Diabetes In Older Adults Research Articles

Diabetes Mellitus in Older Adults

The prevalence of diabetes mellitus increases with age and causes significant morbidity and poor quality of life in older adults. To review the current literature on the diagnosis and management of diabetes in the elderly, the relevant manuscripts were identified through a MEDLINE (2000-September 1, 2010) search of the English literature. The key phrase used was diabetes in older adults or diabetes in the elderly. The literature search was limited to core clinical journals that have accessible full texts. A total of 480 manuscripts were reviewed. Managing diabetes in older adults is a challenging task. Some features of the disease are unique to the older patient. Several new antidiabetic agents are now available for clinical use, and yet very few clinical trials have been carried out in this age group. For many older adults, maintaining independence is more important than adherence to published guidelines to prevent diabetes complications. The goals of diabetes care in older adults are to enhance quality of life without subjecting the residents to inappropriate interventions.

Chronic Kidney Disease, Insulin Resistance, and Incident Diabetes in Older Adults

Insulin resistance is a complication of advanced CKD. Insulin resistance is less well characterized in earlier stages of CKD. The response of the pancreatic β cell, effects on glucose tolerance, and risk of diabetes are not clear. The Cardiovascular Health Study included 4680 adults without baseline diabetes. The Chronic Kidney Disease Epidemiology Collaboration creatinine equation was used to obtain the estimated GFR (eGFR). Insulin resistance was evaluated as fasting insulin concentration. The insulin sensitivity index, β cell function, and glucose tolerance were assessed by oral glucose tolerance testing. Incident diabetes was defined as fasting glucose ≥126 mg/dl, nonfasting glucose ≥200 mg/dl, or use of glucose-lowering medications. Mean age was 72.5 years (range, 65-98 years). Mean eGFR was 72.2 (SD 17.1) ml/min per 1.73 m(2). After adjustment, each 10 ml/min per 1.73 m(2) lower eGFR was associated with a 2.2% higher fasting insulin concentration (95% confidence interval [CI], 1.4%, 2.9%; P<0.001) and a 1.1% lower insulin sensitivity index (95% CI, 0.03%, 2.2%; P=0.04). Surprisingly, eGFR was associated with an augmented β cell function index (P<0.001), lower 2-hour glucose concentration (P=0.002), and decreased risk of glucose intolerance (P=0.006). Over a median 12 years' follow-up, 437 participants (9.3%) developed diabetes. eGFR was not associated with the risk of incident diabetes. Among older adults, lower eGFR was associated with insulin resistance. However, with lower eGFR, β cell function was appropriately augmented and risks of impaired glucose tolerance and incident diabetes were not increased.

Total and High-Molecular-Weight Adiponectin and Risk of Incident Diabetes in Older People

OBJECTIVETo delineate the associations of total adiponectin, high-molecular-weight (HMW) adiponectin, and the HMW-to-total adiponectin ratio with diabetes in older adults.RESEARCH DESIGN AND METHODSTotal and HMW adiponectin were measured in a population-based study of older adults. The relations of total adiponectin, HMW adiponectin, and their ratio with incident diabetes (n = 309) were assessed in 3,802 individuals.RESULTSTotal and HMW adiponectin were highly correlated (r = 0.94). Analysis using cubic splines revealed that the associations between total and HMW adiponectin and new-onset diabetes were not linear. Specifically, after adjustment for confounders, there were similar inverse relationships for total (hazard ratio per SD 0.49 [95% CI 0.39–0.63]) and HMW adiponectin (0.42 [0.32–0.56]) with diabetes up to values of 20 and 10 mg/L, respectively, above which the associations plateaued. These associations persisted after adjustment for potential mediators (blood pressure, lipids, C-reactive protein, and homeostasis model assessment of insulin resistance [HOMA-IR]). There was, however, evidence of interaction by HOMA-IR in the lower range of adiponectin, with stronger inverse associations among insulin-sensitive than insulin-resistant participants. HMW-to-total adiponectin ratio showed a linear adjusted association with outcome, but this was abolished by inclusion of mediating variables.CONCLUSIONSIn this older cohort, increasing concentrations of total and HMW adiponectin were associated with comparably lower risks of diabetes, but these associations leveled off with further increases above concentrations of 20 and 10 mg/L, respectively. The more pronounced risk decreases at the lower range among participants without insulin resistance support a role for adiponectin that is independent of baseline hyperinsulinemia, but this will require further investigation.

External validation of the KORA S4/F4 prediction models for the risk of developing type 2 diabetes in older adults: the PREVEND study

Recently, prediction models for type 2 diabetes mellitus (T2DM) in older adults (aged≥55 year) were developed in the KORA S4/F4 study, Augsburg, Germany. We aimed to externally validate the KORA models in a Dutch population. We used data on both older adults (n=2,050; aged≥55year) and total non-diabetic population (n=6,317; aged 28-75year) for this validation. We assessed performance of base model (model 1: age, sex, BMI, smoking, parental diabetes and hypertension) and two clinical models: model 1 plus fasting glucose (model 2); and model 2 plus uric acid (model 3). For 7-year risk of T2DM, we calculated C-statistic, Hosmer-Lemeshow χ(2)-statistic, and integrated discrimination improvement (IDI) as measures of discrimination, calibration and reclassification, respectively. After a median follow-up of 7.7years, 199 (9.7%) and 374 (5.9%) incident cases of T2DM were ascertained in the older and total population, respectively. In the older adults, C-statistic was 0.66 for model 1. This was improved for model 2 and model 3 (C-statistic=0.81) with significant IDI. In the total population, these respective C-statistics were 0.77, 0.85 and 0.85. All models showed poor calibration (P<0.001). After adjustment for the intercept and slope of each model, we observed good calibration for most models in both older and total populations. We validated the KORA clinical models for prediction of T2DM in an older Dutch population, with discrimination similar to the development cohort. However, the models need to be corrected for intercept and slope to acquire good calibration for application in a different setting.

Management of Type 2 Diabetes Mellitus in Older Adults

In the near future, the majority of patients with diabetes will be adults aged 65 or older. Unlike young adults with diabetes, elderly diabetic people may be affected by a variety of comorbid conditions such as depression, cognitive impairment, muscle weakness (sarcopenia), falls and fractures, and physical frailty. These geriatric syndromes should be considered in the establishment of treatment goals in older adults with diabetes. Although there are several guidelines for the management of diabetes, only a few are specifically designed for the elderly with diabetes. In this review, we present specific conditions of elderly diabetes which should be taken into account in the management of diabetes in older adults. We also present advantages and disadvantages of various glucose-lowering agents that should be considered when choosing a proper regimen for older adults with diabetes.

PS9 - 48. External validation of the KORA S4/F4 prediction models for the risk of developing type 2 diabetes in older adults: the PREVEND Study

Recently, prediction models for type 2 diabetes mellitus (T2DM) in older adults (aged =55y) were developed in the KORA S4/F4 study, Augsburg, Germany. We aimed to externally validate the KORA models in a Dutch population using the latest standards in prediction research.

Discontinuation of Unnecessary Medications in Older Adults

Identifying and managing the use of medications that may be discontinued is a daunting task for the health care team, especially for the consultant pharmacist. This article discusses a framework to evaluate the risks and benefits of medications. A case-based approach will be employed to demonstrate the application of evidence-based medicine and the challenges that pharmacists face in attempting to discontinue medications in older adults. Medline and Micromedex were used as resources for primary literature as well as drug information. Studies were identified based on their relevance to the case to demonstrate the importance of applying emerging literature and evidence-based medicine. Guidelines on managing osteoporosis as well as diabetes in older adults were used for this case. A structured framework was applied to demonstrate considerations when tackling challenging medication regimens. Patient-centered, individualized medication regimens need to be developed and updated based on the needs of the patient as well as the wishes of the family and caregivers. This is a dynamic process that benefits from the consultant pharmacist, who understands the complexity of the medications and is essential to addressing the use of unnecessary medications.

Plasma omega-3 fatty acids and incident diabetes in older adults

Although long-chain omega-3 fatty acid (n-3 FA) consumption estimated via food-frequency questionnaires has been associated with a higher incidence of diabetes, limited prospective data on diabetes risk are available that use objective biomarkers of n-3 FAs. We sought to examine the relation between plasma phospholipid n-3 FAs and incident diabetes. We prospectively analyzed data in 3088 older men and women (mean age: 75 y) from the Cardiovascular Health Study (1992-2007). Plasma phospholipid n-3 FAs were measured by using gas chromatography, and incident diabetes was ascertained by using information on hypoglycemic agents and serum glucose. We used Cox proportional hazards models to estimate multivariable-adjusted relative risks. During a median follow-up of 10.6 y, 204 new cases of diabetes occurred. In a multivariable model that controlled for age, sex, race, clinic site, body mass index, alcohol intake, smoking, physical activity, LDL cholesterol, and linoleic acid, relative risks (95% CIs) for diabetes were 1.0 (reference), 0.96 (0.65, 1.43), 1.03 (0.69, 1.54), and 0.64 (0.41, 1.01) across consecutive quartiles of phospholipid eicosapentaenoic acid and docosahexaenoic acid (P for trend = 0.05). Corresponding relative risks (95% CIs) for phospholipid α-linolenic acid (ALA) were 1.0 (reference), 0.93 (0.65, 1.34), 0.99 (0.68, 1.44), and 0.57 (0.36, 0.90) (P for trend = 0.03). With the use of objective biomarkers, long-chain n-3 FAs and ALA were not associated with a higher incidence of diabetes. Individuals with the highest concentrations of both types of FAs had lower risk of diabetes.

Memory Impairment and Executive Dysfunction are Associated with Inadequately Controlled Diabetes in Older Adults.

To assess the cross-sectional relationship of glycemic control to memory impairment and executive dysfunction in older adults with diabetes treated at an urban primary care center. As part of a primary care-based cognitive screening program, we identified adults age 65 or older with a diagnosis of diabetes. Glycosylated hemoglobin level (HbA1c) was used to define diabetes as controlled (HbA1c <7) or inadequately controlled(HbA1c ≥ 7). Episodic memory was measured by quartile of free recall scores on the Free and Cued Selective Reminding Test. Executive function was measured using an ordinal composite score derived from animal fluency and months backward. These were the main predictors of diabetic control. The 169 participants with diabetes had a median age of 74. The sample was 38% African American and 42% Latino. One hundred four (61%) had inadequately controlled diabetes. Memory impairment and executive dysfunction were independent predictors of diabetic control after adjusting for age and education. Binary logistic regression models indicated that the odds of inadequately controlled diabetes was higher for patients in the worst quartile of memory functioning compared to patients in higher quartiles of memory functioning (odds ratio = 6.4; 95% confidence interval: 2.3, 17.6). Any level of executive dysfunction increased the odds of inadequately controlled diabetes compared to patients in the best quintile of executive functioning (odds ratio = 3.6; 95% confidence interval: 1.58, 8.35). Memory impairment and executive dysfunction were associated with inadequately controlled diabetes. Though causal inferences are not robust in a cross-sectional study, we suggest that cognitive dysfunction may interfere with diabetes management and that inadequate diabetic control may contribute to cognitive dysfunction.

Perfectionism and other related trait measures as predictors of mortality in diabetic older adults: A six-and-a-half-year longitudinal study

After baseline assessment of health and perfectionism trait measures, 385 diabetic older adults were followed for six-and-a-half years. We hypothesized that the potential for increased stress associated with perfectionism leads to an increased risk of impending mortality for diabetics. Contrary to our hypothesis, mortality risk was 29 percent lower for high scorers on the perfectionism (self-oriented) dimension, compared to low scorers. In contrast, Cox regression analysis showed that high scores on measures of dysfunctional perfectionistic attitudes and dysfunctional dependency, which in many respects parallel the perfectionism (self-oriented) measure, were associated with an increased risk of mortality. Implications of findings are discussed.

The effect of diabetes mellitus on age‐associated lean mass loss in 3153 older adults

Diabetes mellitus may be associated with excessive lean mass loss. Other diabetes-related conditions may also play a role. We assessed body composition changes associated with diabetes in older adults with adjustment for diabetes-related co-morbidities. Three thousand, one hundred and fifty-three community-living adults aged ≥ 65 years were examined for lifestyle factors, diabetes-related medical conditions and body composition by dual energy X-ray absorptiometry at baseline and 4 years later. Body composition changes were compared between participants with diabetes and those without diabetes. Multivariate linear regression was used to examine the relationship between appendicular lean mass loss and confounders. Appendicular lean mass loss in men with diabetes was two times that of men without diabetes (-1.5% in 'no diabetes' vs. -3.0% in 'diabetes') and in women with diabetes was 1.8 times that of those without diabetes (-1.9% in 'no diabetes' vs. -3.4% in 'diabetes') over 4 years. Men with diabetes also had higher total body mass loss and higher total body fat loss than men without diabetes. Women with diabetes had higher total body mass loss but total body fat loss was similar. After adjusting for age, body mass index, diabetes-related conditions, lifestyle factors and total body mass loss, diabetes remained an independent predictor of appendicular lean mass loss in both men and women. Diabetes was associated with higher body mass loss and higher appendicular lean mass loss in older adults. In men, diabetes was also associated with total body fat loss.

Association Between Adiposity in Midlife and Older Age and Risk of Diabetes in Older Adults

Although adiposity is a well-known risk factor for type 2 diabetes among young and middle-aged adults, the relationship between diabetes and measures of body composition in older adults is unclear. Several measures of body composition change with aging. These changes include increased body mass index (BMI) and fat mass, loss of muscle mass, redistribution of adipose tissue, and height shrinkage. Because there is a high prevalence of obesity and diabetes in older aging adults, it is important to clarify the relationship between adiposity, changes in parameters of body composition, and diabetes risk in this population. This prospective population-based study investigated the relationship between measures of overall body fat and fat distribution, changes in these measures, and the risk of incident type 2 diabetes in a population of 4193 men and women aged ≥65 years. This investigation is part of the Cardiovascular Health Study, a large population-based study of older ambulatory, noninstitutionalized adults. Anthropometric data on body composition measures and bioelectrical impedance data on fat mass were collected at baseline and anthropometric measurements repeated 3 years later. The presence of diabetes was defined by use of insulin or oral hypoglycemic agents, or a fasting glucose level ≥126 mg/dL. The participants were followed for a median of 12.4 years (range, 0.9-17.8 years). Of the 4193 participants, 2457 were women and 1736 were men. Over the 12.4-year follow-up, there were 339 new cases of diabetes (7.1/1000 person-years). Comparison of the hazard ratios for women in the highest quintile of baseline measures of adiposity with those in the lowest showed that the following were strongly related to the risk of type 2 diabetes: BMI at baseline (adjusted hazard ratio [aHR], 3.7; 95% confidence interval [CI], 2.3-6.2), BMI at 50 years of age (aHR; 3.2; 95% CI, 1.9-5.5), weight (aHR, 3.5; 95% CI, 2.1-5.7), fat mass (aHR, 3.3; 95% CI, 2.0-5.6), waist circumference (aHR, 3.6; 95% CI, 2.2-6.0), waist-hip ratio (aHR, 1.9; 95% CI, 1.1-3.2), and waist-height ratio (aHR, 3.6; 95% CI, 2.2-5.9). There was no significant statistical interaction with stratification of the data by gender or race. Stratification by age, however, showed that the HRs in participants aged ≥75 years were about half as large as those in patients aged 65 to 74 years. Compared to participants whose weight remained stable (±2 kg) throughout the study period, those with the greatest weight gain (9 kg or more) from 50 years of age to baseline had a nearly 3-fold greater risk of developing type 2 diabetes during follow-up (aHR, 2.8; 95% CI, 1.9-4.3). Between baseline and the third annual visit, participants with a greater than 10-cm increase in waist size had an increased risk of developing type 2 diabetes (HR, 1.7; 95% CI, 1.1-2.8) compared to those with a gain or loss of 2 cm or less. These findings show that measures of overall and central adiposity and weight gain are strongly associated with the risk of incident type 2 diabetes in both men and women during middle age and after the age of 65 years.

Association of blood lactate with type 2 diabetes: the Atherosclerosis Risk in Communities Carotid MRI Study

Background Accumulating evidence implicates insufficient oxidative capacity in the development of type 2 diabetes. This notion has not been well tested in large, population-based studies.Methods To test this hypothesis, we assessed the cross-sectional association of plasma lactate, an indicator of the gap between oxidative capacity and energy expenditure, with type 2 diabetes in 1709 older adults not taking metformin, who were participants in the Atherosclerosis Risk in Communities (ARIC) Carotid MRI Study.Results The prevalence of type 2 diabetes rose across lactate quartiles (11, 14, 20 and 30%; P for trend <0.0001). Following adjustment for demographic factors, physical activity, body mass index and waist circumference, the relative odds of type 2 diabetes across lactate quartiles were 0.98 [95% confidence interval (CI) 0.59–1.64], 1.64 (95% CI 1.03–2.64) and 2.23 (95% CI 1.38–3.59), respectively. Furthermore, lactate was associated with higher fasting glucose among non-diabetic adults.Conclusions Plasma lactate was strongly associated with type 2 diabetes in older adults. Plasma lactate deserves greater attention in studies of oxidative capacity and diabetes risk.

Egg consumption and risk of type 2 diabetes in older adults

Type 2 diabetes (T2D) remains an important public health issue in the United States. There are limited and inconsistent data on the association between egg consumption and fasting glucose or incident diabetes. We assessed the association between egg intake and incident diabetes in older adults. In this prospective study of 3898 men and women from the Cardiovascular Health Study (1989-2007), we assessed egg consumption by using a picture-sorted food questionnaire and ascertained incident T2D annually by using information on hypoglycemic agents and plasma glucose. We used Cox proportional hazards models to estimate adjusted relative risks. During a mean follow-up of 11.3 y, 313 new cases of T2D occurred. Crude incidence rates of T2D were 7.39, 6.83, 7.00, 6.72, and 12.20 per 1000 person-years in people who reported egg consumption of never, <1 egg/mo, 1-3 eggs/mo, 1-4 eggs/wk, and almost daily, respectively. In multivariable-adjusted models, there was no association between egg consumption and increased risk of T2D in either sex and overall. In a secondary analysis, dietary cholesterol was not associated with incident diabetes (P for trend = 0.47). In addition, egg consumption was not associated with clinically meaningful differences in fasting glucose, fasting insulin, or measures of insulin resistance despite small absolute analytic differences that were significant. In this cohort of older adults with limited egg intake, there was no association between egg consumption or dietary cholesterol and increased risk of incident T2D.

Association between adiposity in midlife and older age and risk of diabetes in older adults.

Adiposity is a well-recognized risk factor for type 2 diabetes among young and middle-aged adults, but the relationship between body composition and type 2 diabetes is not well described among older adults. To examine the relationship between adiposity, changes in adiposity, and risk of incident type 2 diabetes in adults 65 years of age and older. Prospective cohort study (1989-2007) of 4193 men and women 65 years of age and older in the Cardiovascular Health Study. Measures of adiposity were derived from anthropometry and bioelectrical impedance data at baseline and anthropometry repeated 3 years later. Incident diabetes was ascertained based on use of antidiabetic medication or a fasting glucose level of 126 mg/dL or greater. Over median follow-up of 12.4 years (range, 0.9-17.8 years), 339 cases of incident diabetes were ascertained (7.1/1000 person-years). The adjusted hazard ratio (HR) (95% confidence interval [CI]) of type 2 diabetes for participants in the highest quintile of baseline measures compared with those in the lowest was 4.3 (95% CI, 2.9-6.5) for body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]), 3.0 (95% CI, 2.0-4.3) for BMI at 50 years of age, 4.2 (95% CI, 2.8-6.4) for weight, 4.0 (95% CI, 2.6-6.0) for fat mass, 4.2 (95% CI, 2.8-6.2) for waist circumference, 2.4 (95% CI, 1.6-3.5) for waist-hip ratio, and 3.8 (95% CI, 2.6-5.5) for waist-height ratio. However, when stratified by age, participants 75 years of age and older had HRs approximately half as large as those 65 to 74 years of age. Compared with weight-stable participants (+/-2 kg), those who gained the most weight from 50 years of age to baseline (> or = 9 kg), and from baseline to the third follow-up visit (> or = 6 kg), had HRs for type 2 diabetes of 2.8 (95% CI, 1.9-4.3) and 2.0 (95% CI, 1.1-3.7), respectively. Participants with a greater than 10-cm increase in waist size from baseline to the third follow-up visit had an HR of type 2 diabetes of 1.7 (95% CI, 1.1-2.8) compared with those who gained or lost 2 cm or less. Among older adults, overall and central adiposity, and weight gain during middle age and after the age of 65 years are associated with risk of diabetes.

Low-intensity physical activity is associated with reduced risk of incident type 2 diabetes in older adults: evidence from the English Longitudinal Study of Ageing

We examined whether small amounts of low-intensity physical activity were associated with reduced risk of developing type 2 diabetes in a national sample of people aged 50 years and over. The sample comprised 7,466 individuals (55.9% women) free from self-reported doctor-diagnosed diabetes and was prospectively followed for a mean of 45.3 months. Baseline self-reported physical activity was categorised as physical inactivity, low- and vigorous/moderate-intensity physical activity at least once a week. Cox proportional hazard regression was used to model the association between baseline physical activity and incident type 2 diabetes. Vigorous/moderate-intensity physical activity at least once a week was associated with reduced risk of type 2 diabetes (HR 0.64, 95% CI 0.43-0.95, p = 0.026) but low-intensity physical activity at least once a week was not (HR 0.87, 95% CI 0.58-1.30, p = 0.497) after adjustment for all covariates. However, age-stratified analysis showed that low-intensity physical activity at least once a week was associated with reduced risk of type 2 diabetes for those aged 70 years and over (HR 0.53, 95% CI 0.28-1.02, p = 0.059), but not for those aged 50 to 59 years (HR 1.09, 95% CI 0.52-2.29, p = 0.828) or those aged 60 to 69 years (HR 1.15, 95% CI 0.55-2.41, p = 0.715) after adjustment for all covariates. Compared with physical inactivity, any type of physical activity was associated with reduced risk of type 2 diabetes in adults aged 70 years and over, while in adults aged 50 to 69 years, physical activity needed to be vigorous/moderate in intensity to be associated with reduced risk of type 2 diabetes.

Type 2 diabetes and hypertension in older adults: a case study

The management of long-term conditions in the older adult population can be challenging and complex. After examining the literature and exploring some common issues, this article uses a reflective case study to demonstrate key findings in the management of hypertension and diabetes in an older adult that can be used to support effective interventions and positive outcomes.

Mad Dogs and Englishmen Go Out in the Midday Sun

Mad Dogs and Englishmen Go Out in the Midday Sun

Assessing prediction of diabetes in older adults using different adiposity measures: a 7 year prospective study in 6,923 older men and women

Aims/hypothesisThe aim of this study was to examine whether waist circumference (WC) or WHR improve diabetes prediction beyond body mass index in older men and women, and to define optimal cut-off points.MethodsIn this prospective study, non-diabetic men (n = 3,519) and women (n = 3,404) aged 60–79 years were followed up for 7 years. There were 169 and 128 incident cases of type 2 diabetes in men and women, respectively.ResultsBMI, WC and WHR all showed strong associations with incident type 2 diabetes independent of potential confounders. In men, the adjusted relative risks (top vs lowest quartile) were 4.71 (95% CI 2.45–9.03) for BMI, 3.53 (95% CI 1.92–6.48) for WC and 2.76 (95% CI 1.58–4.82) for WHR. For women, the corresponding relative risks were 4.10 (95% CI 2.16–7.79), 12.18 (95% CI 4.83–30.74) and 5.61 (95% CI 2.84–11.09) for BMI, WC and WHR, respectively. Receiver-operating characteristic curve analysis revealed similar associations for BMI and WC in predicting diabetes in men (AUC = 0.726 and 0.713, respectively); WHR was the weakest predictor (AUC = 0.656). In women, WC was a significantly stronger predictor (AUC = 0.780) than either BMI (AUC = 0.733) or WHR (AUC = 0.728; p < 0.01 for both). Inclusion of both WC and BMI did not improve prediction beyond BMI alone in men or WC alone in women. Optimal sensitivity and specificity for the prediction of type 2 diabetes was observed at a WC of 100 cm in men and 92 cm in women.Conclusions/interpretationIn older men, BMI and WC yielded similar prediction of risk of type 2 diabetes, whereas WC was clearly a superior predictor in older women.

A1C and Diabetes Diagnosis: The Rancho Bernardo Study

OBJECTIVETo examine the sensitivity and specificity of A1C as a diagnostic test for type 2 diabetes in older adults.RESEARCH DESIGN AND METHODSCross-sectional study of community-dwelling adults without known diabetes who had an oral glucose tolerance test and A1C measured on the same day.RESULTSMean age of the 2,107 participants was 69.4 ± 11.1 years; 43% were men. Based on the American Diabetes Association (ADA) criteria, 198 had previously undiagnosed type 2 diabetes. The sensitivity/specificity of A1C cut point of 6.5% was 44/79%. Results were similar in age- and sex-stratified analyses. Given the A1C cut point of 6.5%, 85% of participants were classified as nondiabetic by ADA criteria.CONCLUSIONSThe limited sensitivity of the A1C test may result in delayed diagnosis of type 2 diabetes, while the strict use of ADA criteria may fail to identify a high proportion of individuals with diabetes by A1C ≥6.5% or retinopathy.