Value of risk stratification to increase the predictive validity of HbA1c in screening for undiagnosed diabetes in the US population

J Gen Intern Med. 2008 Sep;23(9):1346-53. doi: 10.1007/s11606-008-0661-6. Epub 2008 Jun 10.


Background: Opportunistic screening using hemoglobin A1c (HbA1c) may improve detection of undiagnosed diabetes but remains controversial.

Objective: To evaluate the predictive validity of HbA1c as a screening test for undiagnosed diabetes in a risk-stratified sample of the US population.

Design: Weighted cross-sectional analysis of diabetes risk factors, HbA1c, and fasting plasma glucose (FPG) in National Health and Nutrition Examination Survey (NHANES), 1999-2004.

Subjects: Six thousand seven hundred and twenty-three NHANES participants from morning examination session, aged > or = 18 years and without prior physician-diagnosed diabetes.

Measurements: HbA1c and undiagnosed diabetes defined by FPG > or = 7.0 mmol/l (126 mg/dl).

Results: The estimated prevalence of undiagnosed diabetes in the US population was 2.8% (5.5 million people). HbA1c had strong correlation with undiagnosed diabetes, with an area under the receiver-operating characteristic curve of 0.93. Independent predictors of undiagnosed diabetes were older age, male sex, black race, hypertension, elevated waist circumference, elevated triglycerides, and low high-density lipoprotein cholesterol. We derived a risk score for undiagnosed diabetes and stratified participants into low (0.44% prevalence), moderate (4.1% prevalence), and high (11.1% prevalence) risk subgroups. In moderate and high risk groups, a threshold HbA1c value > or = 6.1% identified patients requiring confirmatory FPG; HbA1c < or = 5.4% identified patients for whom diabetes could be reliably excluded. Intermediate HbA1c (5.5-6.0%) may exclude diabetes in moderate, but not high risk groups).

Conclusions: Risk stratification improves the predictive validity of HbA1c in screening for undiagnosed diabetes in the US population. Although opportunistic screening with HbA1c would improve detection of undiagnosed diabetes, cost-effectiveness studies are needed before implementation of specific screening strategies using HbA1c.

Publication types

  • Research Support, Non-U.S. Gov't
  • Validation Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Blood Glucose / analysis*
  • Diabetes Mellitus / diagnosis*
  • Diabetes Mellitus / epidemiology
  • Female
  • Glycated Hemoglobin / analysis*
  • Health Status Indicators
  • Humans
  • Male
  • Mass Screening*
  • Middle Aged
  • Nutrition Surveys
  • Predictive Value of Tests
  • Prevalence
  • United States / epidemiology


  • Blood Glucose
  • Glycated Hemoglobin A