@article{6926805,
  abstract     = {{Background: Diabetes has been defined on the basis of different biomarkers, including fasting plasma glucose (FPG), 2-h plasma glucose in an oral glucose tolerance test (2hOGTT), and HbA(1c). We assessed the effect of different diagnostic definitions on both the population prevalence of diabetes and the classification of previously undiagnosed individuals as having diabetes versus not having diabetes in a pooled analysis of data from population-based health examination surveys in different regions. 
Methods: We used data from 96 population-based health examination surveys that had measured at least two of the biomarkers used for defining diabetes. Diabetes was defined using HbA(1c) (HbA(1c) >= 6 . 5% or history of diabetes diagnosis or using insulin or oral hypoglycaemic drugs) compared with either FPG only or FPG-or-2hOGTT definitions (FPG >= 7 . 0 mmol/L or 2hOGTT >= 11 . 1 mmol/L or history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated diabetes prevalence, taking into account complex survey design and survey sample weights. We compared the prevalences of diabetes using different definitions graphically and by regression analyses. We calculated sensitivity and specificity of diabetes diagnosis based on HbA1c compared with diagnosis based on glucose among previously undiagnosed individuals (ie, excluding those with history of diabetes or using insulin or oral hypoglycaemic drugs). We calculated sensitivity and specificity in each survey, and then pooled results using a random-effects model. We assessed the sources of heterogeneity of sensitivity by meta-regressions for study characteristics selected a priori. 
Findings: Population prevalence of diabetes based on FPG- or-2hOGTT was correlated with prevalence based on FPG alone (r= 0 . 98), but was higher by 2-6 percentage points at different prevalence levels. Prevalence based on HbA(1c) was lower than prevalence based on FPG in 42 . 8% of age-sex-survey groups and higher in another 41 . 6%; in the other 15 . 6%, the two definitions provided similar prevalence estimates. The variation across studies in the relation between glucose-based and HbA(1c)-based prevalences was partly related to participants' age, followed by natural logarithm of per person gross domestic product, the year of survey, mean BMI, and whether the survey population was national, subnational, or from specific communities. Diabetes defined as HbA(1c) 6 . 5% or more had a pooled sensitivity of 52 . 8% (95% CI 51 . 3-54 . 3%) and a pooled specificity of 99 . 74% (99 . 71-99 . 78%) compared with FPG 7 . 0 mmol/L or more for diagnosing previously undiagnosed participants; sensitivity compared with diabetes defined based on FPG-or-2hOGTT was 30 . 5% (28 . 7-32 . 3%). None of the preselected study-level characteristics explained the heterogeneity in the sensitivity of HbA(1c) versus FPG. 
Interpretation: Different biomarkers and definitions for diabetes can provide different estimates of population prevalence of diabetes, and differentially identify people without previous diagnosis as having diabetes. Using an HbA(1c)-based definition alone in health surveys will not identify a substantial proportion of previously undiagnosed people who would be considered as having diabetes using a glucose-based test.}},
  author       = {{Danaei, Goodarz and Fahimi, Saman and Lu, Yuan and Zhou, Bin and Hajifathalian, Kaveh and Di Cesare, Mariachiara and Lo, Wei-Cheng and Reis-Santos, Barbara and Cowan, Melanie J and Shaw, Jonathan E and Bentham, James and Lin, John K and Bixby, Honor and Magliano, Dianna and Bovet, Pascal and Miranda, J Jaime and Khang, Young-Ho and Stevens, Gretchen A and Riley, Leanne M and Ali, Mohammed K and Ezzati, Majid and Abdeen, Ziad A and Kadir, Khalid Abdul and Abu-Rmeileh, Niveen M and Acosta-Cazares, Benjamin and Aekplakorn, Wichai and Aguilar-Salinas, Carlos A and Ahmadvand, Alireza and Al Nsour, Mohannad and Alkerwi, Ala'a and Amouyel, Philippe and Andersen, Lars Bo and Anderssen, Sigmund A and Andrade Tenesaca, Dolores Susana and Anjana, Ranjit Mohan and Aounallah-Skhiri, Hajer and Aris, Tahir and Arlappa, Nimmathota and Arveiler, Dominique and Assah, Felix K and Avdicova, Maria and Balakrishna, Nagalla and Bandosz, Piotr and Barbagallo, Carlo M and Barcelo, Alberto and Batieha, Anwar M and Baur, Louise A and Ben Romdhane, Habiba and Bernabe-Ortiz, Antonio and Bhargava, Santosh K and Bi, Yufang and Bjerregaard, Peter and Bjorkelund, Cecilia and Blake, Margaret and Blokstra, Anneke and Bo, Simona and Boehm, Bernhard O and Boissonnet, Carlos P and Bovet, Pascal and Brajkovich, Imperia and Breckenkamp, Juergen and Brewster, Lizzy M and Brian, Garry R and Bruno, Graziella and Bugge, Anna and de Leon, Antonio Cabrera and Can, Gunay and Candido, Ana Paula C and Capuano, Vincenzo and Carvalho, Maria J and Casanueva, Felipe F and Caserta, Carmelo A and Castetbon, Katia and Chamukuttan, Snehalatha and Chaturvedi, Nishi and Chen, Chien-Jen and Chen, Fangfang and Chen, Shuohua and Cheng, Ching-Yu and Chetrit, Angela and Chiou, Shu-Ti and Cho, Yumi and Chudek, Jerzy and Cifkova, Renata and Claessens, Frank and Concin, Hans and Cooper, Cyrus and Cooper, Rachel and Costanzo, Simona and Cottel, Dominique and Cowell, Chris and Crujeiras, Ana B and D'Arrigo, Graziella and Dallongeville, Jean and Dankner, Rachel and Dauchet, Luc and de Gaetano, Giovanni and De Henauw, Stefaan and Deepa, Mohan and Dehghan, Abbas and Dhana, Klodian and Di Castelnuovo, Augusto F and Djalalinia, Shirin and Doua, Kouamelan and Drygas, Wojciech and Du, Yong and Egbagbe, Eruke E and Eggertsen, Robert and El Ati, Jalila and Elosua, Roberto and Erasmus, Rajiv T and Erem, Cihangir and Ergor, Gul and Eriksen, Louise and de la Penaa, Jorge Escobedo and Fall, Caroline H and Farzadfar, Farshad and Felix-Redondo, Francisco J and Ferguson, Trevor S and Fernandez-Berges, Daniel and Ferrari, Marika and Ferreccio, Catterina and Finn, Joseph D and Foger, Bernhard and Foo, Leng Huat and Fouad, Heba M and Francis, Damian K and Franco, Maria do Carmo and Franco, Oscar H and Frontera, Guillermo and Furusawa, Takuro and Gaciong, Zbigniew and Galbarczyk, Andrzej and Garnett, Sarah P and Gaspoz, Jean-Michel and Gasull, Magda and Gates, Louise and Geleijnse, Johanna M and Ghasemain, Anoosheh and Giampaoli, Simona and Gianfagna, Francesco and Giovannelli, Jonathan and Gross, Marcela Gonzalez and Rivas, Juan P Gonzalez and Gorbea, Mariano Bonet and Gottrand, Frederic and Grant, Janet F and Grodzicki, Tomasz and Grontved, Anders and Gruden, Grabriella and Gu, Dongfeng and Guan, Ong Peng and Guerrero, Ramiro and Guessous, Idris and Guimaraes, Andre L and Gutierrez, Laura and Hardy, Rebecca and Kumar, Rachakulla Hari and He, Jiang and Heidemann, Christin and Hihtaniemi, Ilpo Tapani and Ho, Sai Yin and Ho, Suzanne C and Hofman, Albert and Russo, Andrea RV and Hormiga, Claudia M and Horta, Bernardo L and Houti, Leila and Hussieni, Abdullatif S and Huybrechts, Inge and Hwalla, Nahla and Iacoviello, Licia and Iannone, Anna G and Ibrahim, Mohsen M and Ikeda, Nayu and Ikram, M Arfan and Irazola, Vilma E and Islam, Muhammad and Iwasaki, Masanori and Jacobs, Jeremy M and Jafar, Tazeen and Jasienska, Grazyna and Jiang, Chao Qiang and Jonas, Jost B and Joshi, Pradeep and Kafatos, Anthony and Kalter-Leibovici, Ofra and Kasaeian, Amir and Katz, Joanne and Kaur, Prabhdeep and Kavousi, Maryam and Kelishadi, Roya and Kengne, Andre P and Kersting, Mathilde and Khader, Yousef Saleh and Khang, Young-Ho and Kiechl, Stefan and Kim, Jeongseon and Kiyohara, Yutaka and Kolsteren, Patrick and Korrovits, Paul and Koskinen, Seppo and Kratzer, Wolfgang and Kromhout, Daan and Kula, Krzysztof and Kurjata, Pawel and Kyobutungi, Catherine and Lachat, Carl and Laid, Youcef and Lam, Tai Hing and Landrove, Orlando and Lanska, Vera and Lappas, Georg and Laxmaiah, Avula and Leclercq, Catherine and Lee, Jeannette and Lee, Jeonghee and Lehtimaki, Terho and Lekhraj, Rampal and Leon-Munoz, Luz M and Li, Yanping and Lim, Wei-Yen and Lima-Costa, M Fernanda and Lin, Hsien-Ho and Lin, Xu and Lissner, Lauren and Lorbeer, Roberto and Lozano, Jose Eugenio and Lundqvist, Annamari and Lytsy, Per and Ma, Guansheng and Machado-Coelho, George LL and Machi, Suka and Maggi, Stefania and Magliano, Dianna and Makdisse, Marcia and Rao, Kodavanti Mallikharjuna and Manios, Yannis and Manzato, Enzo and Margozzini, Paula and Marques-Vidal, Pedro and Martorell, Reynaldo and Masoodi, Shariq R and Matsha, Tandi E and Mbanya, Jean Claude N and McFarlane, Shelly R and McGarvey, Stephen T and McLachlan, Stela and McNulty, Breige A. and Mediene-Benchekor, Sounnia and Meirhaeghe, Aline and Menezes, Ana Maria B and Merat, Shahin and Meshram, Indrapal I and Mi, Jie and Miquel, Juan Francisco and Miranda, J Jaime and Mohamed, Mostafa K and Mohammad, Kazem and Mohan, Viswanathan and Yusoff, Muhammad Fadhli Mohd and Moller, Niels C and Molnar, Denes and Mondo, Charles K and Moreno, Luis A and Morgan, Karen and Moschonis, George and Mossakowska, Malgorzata and Mostafa, Aya and Mota, Jorge and Muiesan, Maria L and Muller-Nurasyid, Martina and Mursu, Jaakko and Nagel, Gabriele and Namesna, Jana and Nang, Ei Ei K and Nangia, Vinay B and Navarrete-Munoz, Eva Maria and Ndiaye, Ndeye Coumba and Nervi, Flavio and Nguyen, Nguyen D and Nieto-Martinez, Ramfi SE and Ning, Guang and Ninomiya, Toshiharu and Noale, Marianna and Noto, Davide and Ochoa Avilés, Angélica María and Oh, Kyungwon and Onat, Altan and Osmond, Clive and Otero, Johanna A and Palmieri, Luigi and Panda-Jonas, Songhomitra and Panza, Francesco and Parsaeian, Mahboubeh and Peixoto, Sergio Viana and Pereira, Alexandre C and Peters, Annette and Peykari, Niloofar and Pilav, Aida and Pitakaka, Freda and Piwonska, Aleksandra and Piwonski, Jerzy and Plans-Rubio, Pedro and Porta, Miquel and Portegies, Marileen LP and Poustchi, Hossein and Pradeepa, Rajendra and Price, Jacqueline F and Punab, Margus and Qasrawi, Radwan F and Qorbani, Mostafa and Raitakari, Olli and Rao, Sudha Ramachandra and Ramachandran, Ambady and Ramos, Rafel and Rampal, Sanjay and Rathmann, Wolfgang and Redon, Josep and Reganit, Paul Ferdinand M and Rigo, Fernando and Robinson, Sian M and Robitaille, Cynthia and Rodriguez, Laura A and Rodriguez-Artalejo, Fernando and Rodriguez-Perez, Maria del Cristo and Rojas-Martinez, Rosalba and Romaguera, Dora and Rosengren, Annika and Rubinstein, Adolfo and Rui, Ornelas and Ruiz-Betancourt, Blanca Sandra and Rutkowski, Marcin and Sabanayagam, Charumathi and Sachdev, Harshpal S and Saidi, Olfa and Sakarya, Sibel and Salanave, Benoit and Salonen, Jukka T and Salvetti, Massimo and Sanchez-Abanto, Jose and Nunes, Renata and Santos, Rute and Sardinha, Luis B and Scazufca, Marcia and Schargrodsky, Herman and Scheidt-Nave, Christa and Shaw, Jonathan E and Shibuya, Kenji and Shin, Youchan and Shiri, Rahman and Siantar, Rosalynn and Sibai, Abla M and Simon, Mary and Simons, Judith and Simons, Leon A and Sjostrom, Michael and Slowikowska-Hilczer, Jolanta and Slusarczyk, Przemyslaw and Smeeth, Liam and Snijder, Marieke B and Solfrizzi, Vincenzo and Sonestedt, Emily and Soumare, Aicha and Staessen, Jan A and Steene-Johannessen, Jostein and Stehle, Peter and Stein, Aryeh D and Stessman, Jochanan and Stockl, Doris and Stokwiszewski, Jakub and Strufaldi, Maria Wany and Sun, Chien-An and Sundstrom, Johan and Suriyawongpaisal, Paibul and Sy, Rody G and Tai, E Shyong and Tarawneh, Mohammed and Tarqui-Mamani, Carolina B and Thijs, Lutgarde and Tolstrup, Janne S and Topbas, Murat and Torrent, Maties and Traissac, Pierre and Trinh, Oanh TH and Tulloch-Reid, Marshall K and Tuomainen, Tomi-Pekka and Turley, Maria L and Tzourio, Christophe and Ueda, Peter and Ukoli, Flora M and Ulmer, Hanno and Valdivia, Gonzalo and Van Valkengoed, Irene GM and Vanderschueren, Dirk and Vanuzzo, Diego and Vega, Tomas and Velasquez-Melendez, Gustavo and Veronesi, Giovanni and Verschuren, Monique and Vioque, Jesus and Virtanen, Jyrki and Visvikis-Siest, Sophie and Viswanathan, Bharathi and Vollenweider, Peter and Voutilainen, Sari and Wade, Alisha N and Wagner, Aline and Walton, Janette and Mohamud, Wan Nazaimoon Wan and Wang, Ming-Dong and Wang, Ya Xing and Wannamethee, S Goya and Weerasekera, Deepa and Whincup, Peter H and Widhalm, Kurt and Wiecek, Andrzej and Wilks, Rainford J and Willeit, Johann and Wojtyniak, Bogdan and Wong, Tien Yin and Woo, Jean and Woodward, Mark and Wu, Aleksander Giwercman and Wu, Frederick C and Wu, Shou Ling and Xu, Haiquan and Yang, Xiaoguang and Ye, Xingwang and Yoshihara, Akihiro and Younger-Coleman, Novie O and Zambon, Sabina and Zargar, Abdul Hamid and Zdrojewski, Tomasz and Zhao, Wenhua and Zheng, Yingfeng}},
  issn         = {{2213-8587}},
  journal      = {{LANCET DIABETES & ENDOCRINOLOGY}},
  keywords     = {{SYSTEMATIC ANALYSIS,INSULIN-RESISTANCE,CONSENSUS STATEMENT,WORLDWIDE STANDARDIZATION,CARDIOVASCULAR-DISEASE,GLYCATED HEMOGLOBIN,FASTING PLASMA-GLUCOSE,HEMOGLOBIN A(1C) MEASUREMENT,TOLERANCE TEST,SCREENING-TEST}},
  language     = {{eng}},
  number       = {{8}},
  pages        = {{624--637}},
  title        = {{Effects of diabetes definition on global surveillance of diabetes prevalence and diagnosis : a pooled analysis of 96 population-based studies with 331288 participants}},
  url          = {{http://doi.org/10.1016/S2213-8587(15)00129-1}},
  volume       = {{3}},
  year         = {{2015}},
}

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