Brief report
Prevalence of lower extremity diseases associated with normal glucose levels, impaired fasting glucose, and diabetes among U.S. adults aged 40 or older

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Abstract

Background

Peripheral arterial disease (PAD) and peripheral neuropathy (PN) are serious complications of diabetes, but early detection and intervention may reduce this morbidity. The degree to which PAD and PN develop before diabetes diagnosis has not been established among a representative sample of U.S. adults.

Objective

To compare the prevalence of lower extremity diseases (LEDs) among U.S. adults aged 40 or older with previously diagnosed diabetes, undiagnosed diabetes, impaired fasting glucose, and normal glucose levels.

Research design and methods

We analyzed cross-sectional data of a nationally representative sample of 3607 U.S. adults from the 1999–2004 National Health and Nutrition Examination Surveys (NHANES).

Subjects were divided into four groups on the basis of their fasting plasma glucose (FPG) levels and interview responses: normal glucose levels (FPG < 100 mg/dl), impaired fasting glucose (IFG; FPG 100–125 mg/dl), undiagnosed diabetes (FPG  126 and no self-reported diabetes), and diagnosed diabetes. PN was assessed by monofilament testing at three sites on each foot and defined as ≥1 insensate area. PAD was defined as an ankle-brachial blood pressure index <0.9. Any LED was defined as the presence of PAD or PN or a history of non-healing ulcer or amputation.

Results

The prevalence of PN was lowest among persons with normal glucose (10.5%) and IFG (11.9%) and highest among those with undiagnosed (16.6%) and diagnosed diabetes (19.4%). PAD prevalence was also lowest among persons with normal glucose (3.9%), similar among those with IFG (5.4%), and significantly higher among those with undiagnosed (9.2%) and diagnosed diabetes (7.5%). Any LED was present in about 27% of persons with both undiagnosed diabetes and diagnosed diabetes.

Conclusions

LED prevalence was nearly as high among persons with previously undiagnosed diabetes as among those with diagnosed diabetes, but it was not appreciably higher among persons with impaired fasting glucose than among those with normal glucose levels. These results suggest that LED detection efforts should be focused on persons with diabetes, including those with undiagnosed diabetes.

Introduction

Peripheral arterial disease (PAD) and peripheral neuropathy (PN) are disabling lower extremity disease (LED) complications of diabetes that can lead to non-healing ulcers and amputation [1], [2], [3]. However, both conditions can occur before the diagnosis of diabetes [4], [5], [6], [7], [8], [9] and the degree to which this occurs has implications for how aggressively diabetes and LED screening should be conducted to initiate care to prevent serious complications [10], [11], [12]. We previously reported the prevalence of lower extremity disease in the U.S. population, showing that PAD and PN were each about twice as common among the diabetic population as the non-diabetic population [13]. However, we lacked data to examine the degree to which intermediate steps toward the diagnosis of diabetes, including impaired fasting glucose and undiagnosed diabetes, were associated with LED. In this report, we report findings from the recently available 6 years of the continuous National Health and Nutrition Examination Survey (NHANES) (1999–2004) providing the first opportunity to compare the prevalence of specific LEDs among U.S. adults aged ≥40 years with normal glucose, impaired fasting glucose, and undiagnosed and diagnosed diabetes.

Section snippets

Research design and methods

The NHANES is a continuous, nationally representative cross-sectional survey of the U.S. civilian non-institutionalized population [14], [15], [16]. Nine thousand nine hundred and seventy adults aged ≥40 years agreed to participate in the NHANES surveys, 9145 (92%) of them attended a physical exam, and half were randomly assigned to a morning fasting glucose examination. Of 3896 persons who had the fasting glucose examination, 3607 (93%) underwent a lower extremity disease examination, serving

Results

The mean age of the population was 56.7 years and ranged from 54.6 among persons with normal glucose to 59.9 and 61.6 among those with diagnosed and undiagnosed diabetes (not shown).

The prevalence of PN was lowest among persons with normal glucose levels (10.5%, 95% CI, 8.9–12.1%), similar among those with IFG, 58% higher among those with undiagnosed diabetes (16.6%, 9.6–23.7%), almost twice as high among those with diagnosed diabetes (19.4%, 15.5–23.2%), and higher among persons with diabetes

Discussion

In this nationally representative study of American adults aged 40 years or older, persons with established diabetes had about twice the risk for PN and PAD as those without diabetes and, among those with diabetes, about 1 in 12 have PAD, 1 in 5 have PN, and 1 in 4 have some type of LED. Unexpectedly, however, the prevalence of each LED was as high among persons with previously undiagnosed diabetes as those with diagnosed diabetes.

PAD and PN are each associated with extensive morbidity but are

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    The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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