Prevalence of

Diagnosed Diabetes,

Undiagnosed

Diabetes, and

Impaired Glucose

Tolerance in Adults

20-74 Years of Age

United States, 1976–80

The total prevalence of diabetes and

impaired glucose tolerance in U.S. adults

aged 20-74 years was obtained from

medical history and oral glucose tolerance

tests. Plasma glucose distributions,

associations with selected medical,

genetic, and clinical characteristics, and

comparisons with prevalence in the 1976

National Health Interview Survey are also

presented.

Data From the National Heatth Survey

Series 11, No. 237

DHHS Publication No. (PHS) 87-1687

U.S. Department of Health and Human

Services

Public Health Service

National Center for Health Statistics

Hyattsville, Md.

February 1987
i

Copyright information

All material appearing in this repon ia in the public domain and may ba

reproduced or copied without parmisaion; citation aa to source,

howaver, ie appreciated.

Suglpated Citation

National Canter for Health Statiatica, W. C. Hadden and M. 1. Harris

Prevalence of diagnoaad dtabataa, undiagnosed diabataa, and impaired

glucoee tolerance in adulta 20-74 yeara of age, Unitad Statea.

1976-SO. V/Id ●nd Health ti?atiatka. Seriaa 11, No. 237. DHHS Pub.

No. (PHS) S7-1 SS7. Public Health service. Washington. U.S.

Government Printing Dffice, Feb. 19S7.

Library of Congmaa Catatogin@n-PuMication Data

Hadden, Wilbur Crana,

The prevalence of dtagnoaed diabetea, undiagnosed

diabataa, ●nd impaired glucoaa tolarance in adulta

20-74 yeara of age, Unitad Stataa. 1976-SO.

(Series 11, Data from the National HA Survey;

no. 237) {DHHS publication; no. {PHS) S7-16S7)

Sibliographv

Supt of Doca no.: HE20.62CW11 J237

1. Diabataa-Unitad Statea-Statiatica. 1. Harria,

Maureen 1. Il. National Canter for Health Statiatica

(U. S.) Il. T*e. fv. ~ Viial and health

atatiatica. Seriaa 11. Data from the national haalth

ohuwey; no. 237. V. Sariax DHHS publication; no.

(PHS) S7-1 SS7. [DNLW 1. Diebataa MeWkua, lnaulinDWarKfWt-w**Unitd Stataa. Z Glucose

Tolerance Teat-United Statee-atatiatiW2 A Ml 4Svk no.237]

RA407.3.M47 m 237 3S2.1’0S73021 8s-60030s

[RA64s.os] [614.6’S46200S73021 ]

ISSN044064ms-s
National Center for Health Statistics

Manning Feinleib, M.D., Dr.P.H., Director

Robert A. Israel, Deputy Director

Jacob J. Feldman, Ph.D., Associate Director for Analysis

and Epidemiology

George A. Schnack, Associate Director for Data Processing

and Services

Alvan O. Zarate, Ph.D., Assistant Director for International

Statistics

Peter L. Hurley, Acting Associate Director for Interview

and Examination Statistics

Stephen E. Nieberdin~ Associate Director for Management

Gail F. Fisher, Ph.D., Associate Director for Program

Planning, Evaluatiofi and Coordination

Monroe G. Sirken, Ph.D., Associate Director for Research

and Methodology

Peter L. Hurley, Associate Director for Vital and Health

Care Statistics

Office of Interview and Examination Statistics Program

Peter L. Hurley, Acting Associate Director

Mary Grace Kovar, Dr.P.H., Special Assistant for Data

Policy and Analysis

Division of Health Examination Statistics

Robert S. Murphy, Director

Catherine E. Woteki, Ph.D., Deputy Director

Kurt R Maurer, ChieJ Survey Planning and Development

Branch

Clifford Johnson, ChieJ Nutrition Statistics Branch

Suzanne Haynes, Ph.D., Chief Medical Statistics Branch

Division of Data Services

James C. Jacks, Ph.D., Director

PlhillipR Beattie, Deputy Director

David L. Larson, ChieJ Health Examination Field

Operations Branch

—

Cooperation of the U.S. Bureau of the Census

Under the legislation estsbliihmg the National Heslth Survey, the Public Heslth

Service is authorized to use, in.sofer se possible, the services or facilities of other Federal,

State, or private agencies.

In accordance with specifications established by the Nationsl Center for Health

Statistics, the U.S. Bureau of the Census participated in the design and selection of the

mmple zmdcurried out the hnusehold irrtemiew stage of the data collection and certain

psrts of the statistics.1 processing

Data Processing and Services Program

George A. Schnack, Associate Director
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I

Highlighta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

Second National Health andNutritionExamination Survey(NHANES II) sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

NHANES H data collection procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

National Health Interview Survey sample design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Data limitations and sources of error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Incomplete coverage of U.S. population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Sampling emor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Nonresponse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Missing data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Reporting error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Othernonsampling error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Method of analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Statistical techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Estimates for the black population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Classification of sample persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevalence of diagnosed and undiagnosed diabetes in the Second National Health and Nutrition Examination Survey

(NHANES II) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison of NHANES II and National Health Interview Survey (NHIS) estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevalence of impaired glucose tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total prevalence of glucose intolerance in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mean plasma glucose levels and percentile distributions in U.S. adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Frequency distribution of plasma glucose values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Use of the fasting plasma glucose value as a screen for undiagnosed diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Association ofdabetes mdIGTwifi me~cdtistoU of brderltie dabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Association of diabetes and IGT with medical history of potential diabetes and with parental history of diabetes . . . . . . . .

Association of diabetes and overweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

12

12

13

13

14

15

16

17

17

18

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

List of detaiIed tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Appendixes

I. Statistical notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

II. Definition of sociodemographic terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

III. Medical history questionnaire items related to diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

...

Ill
List of text figures

1.

2.

3.

4.

5.

Percent of adults aged 20–74 years with medical history of diabetes (NHIS, 1976) and percent with no medical history

of diabetes who had undiagnosed diabetes or impaired glucose tolerance using National Diabetes Data Group criteria

(NHANES II, 1976-80), by race, sex, and age: United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected percentile distributions of fasting, 1-hour, and 2-hour plasma glucose values of the oral glucose tolerance test,

byage United States, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Frequency distributions of fasting 1-hour, and 2-hour plasma glucose values of the oral glucose tolerance test for adults

aged 20–74 years with no medical history of diabetes: United States, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of persons in specific fasting plasma glucose (FPG) groups who are undiagnosed diabetics: United States,

1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected percentile distributions of fasting l-hour, md2-hour plasma @ucosevalues oftieoral glucose tolerace test,

by percent desirableweighti United States, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of text tables

A.

B.

c.

D.

E.

F.

G.

Response rates foradults aged20-74years: Second National Health mdNutfition Exmkation Suwey, l976-8O . . .

Reason for loss oforalglucose tolerance test (OGTT) data for persons with nomedical history of diabetes: Second

National Health and Nutrition Examination Survey, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unweighed number and response rates of sample persons with complete medical history interviews and with classifiable

oral glucose tolerance tests (OGTT’S) and no medical history of dialbetes, by race, sex, and age Second National Health

and Nutrition Examination Survey, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unweighed number of sample persons with no medical history of ciiabetes, by oral glucose tolerance test criteria of the

National Diabetes Data Group and of the World Health Organizatiorx Second National Health and Nutrition Examination Survey, 1976-80. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevalence of diabetes in adults aged 20-74 years, by race, sex, and age United States, 1976-80 . . . . . . . . . . . . . . . . . .

Cumulative percent distribution of adults aged 20–74 years with undiagnosed diabetes, by fasting plasma glucose level

according to criteria of the National Diabetes Data Group and of the World Health Organization United States,

1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prevalence of diabetes in adults aged 20-74 years, by race, sex, and percent desirable weighk United States, 1976–80.. . .

---

. . .

0.0

z

*

#

Symbols

Data not available

Categov not applicable

Quantity zero

Quantity more than zero but less than

0.05

Quantity more than zelro but less than

500 where numbers are rounded to

thousands

Figure does not meet :standard of

reliability or precision

Figure suppressed to comply with

confidentiality requirements

14

15

16

17

19

6

6

7

10

12

17

18
Prevalence of Diagnosed

Diabetes, Undiagnosed

Diabetes, and Impaired

Glucose Tolerance in Adults

20-74 Years of Age

by Wilbur C. Hadden, M. A., Division of Health Examination

Statmtics, National Center for Health Statistics, and

Maureen 1. Harris, Ph. D., M. P. H., National Diabetes Data

Group, National Institutes of Health

Introduction

The hallmak of diabetes and the basis for its diagnosis is

the body’s inability to adequately metabolize glucose circulating in the blood. Elevated blood glucose levels result from either

inadequate production of insulin or impaired effectiveness of

insulin. Both acute and chronic complications can occur. Severe insulin deficiency, or less severe insulin deficiency coupled

with other conditions such as stress, fever, dehydratio~ or acute

myocardial infarction, can cause ketoacidosis which may lead

to coma and a life-threatening crisis. Chronic diabetes is ass~

ciated with vascular and necrologic degeneratio~ and persons

with diabetes are at increased risk of heart disease, blindness,

renrd failure, and inadequate circulation and sensation in peripheral tissues. These latter consequences make diabetics’ feet

highly susceptible to injury, ulceration, gangrene, infection,

and ultimately amputation. Women with diabetes also have

increased risk of stillbirths and congenital malformations in

their children.l Diabetes is the seventh leading cause of death

in the United States,z the leading cause of new cases of blindness in adults,l and the cause of 25 percent of new cases of

end-stage renal disease.3 These direct consequences of diabetes

make it a disease that is costly and difficult to manage. It is

believed, however, that the complications of diabetes are caused

primarily by elevated blood glucose levels and that they can be

avoided in many cases by control of blood glucose and close

medical supervision with appropriate intervention.4

Over the past 25 years, diabetes mellitus has been one of

the conditions included in the National Health Interview Surveys (NHIS’S) and Health Examination Surveys conducted by

the National Center for Health Statistics to assess the health

and disease status of U.S. residents. Because these surveys are

based on national probability samples of the civilian noninstitutionalized U.S. population, they produce estimates of the

prevalence of diabetes in the United States that may be more

valid than those infemed from surveys of diabetes in individual

communities. However, these national surveys have contained

no component to medically veri& that surveyed persons have

diabetes or, with a single exception, to ascertain undiagnosed

cases of diabetes. Also, insulin-dependent and non-insutindependent types of diabetes can only be inferentially differentiated. The exception is the Second National Health and

Nutrition Examination Survey (NHANES II) conducted in

1976–SO in which oral glucose tolerance tests (OGTT’S) were

administered to a representative sample of the civilian noninstitutionalized U.S. population aged 20-74 years.5

OGTT’S conducted under standardized conditions were

included in NHANES II at the request of the National Institute of Arthrhis, Diabetes, and Digestive and Kidney Diseases

(NIADDK) of the National Institutes of Health. Also at the

request of NIADDK, similar medical history questions related

to diabetes were included in NHANES II and in a special

supplemental interview to the 1976 NHIS.6 The impetus for

these requests can be traced to the U.S. National Commission

on Diabetes, a commission constituted by the U.S. Congress in

1975 to formulate a long-range plan to combat diabetes and to

develop specific recommendations for the utilization and organization of national resources. 1The Commission was hampered in its work by the lack of valid data to assess the scope

and impact of diabetes, particularly undetected diabetes, and it

was envisioned that glucose tolerance testing of a sample of the

U.S. population would document the extent of undiagnosed

diabetes and provide important new epidemiologic correlations

on the causes and consequences of diabetes.

The NHIS diabetes supplement and the diabetes component of NHANES II, including the medical history and

the procedure for the OGTT, were designed by NCHS and

NIADDK. NIADDK supported expenses incurred in performing the OGTT% and analyses of plasma glucose, and the

National Diabetes Data Group, NIADDK, supported analyses

of NHANES II diabetes data, providing funds and consultant

services.

Knowledge of the prevalence of diabetes-those cases that

exist in a defined population at a point in time-provides important information that serves several purposes. First, prevalence can be used to estimate the clinical workload, the resources in hospital and outpatient facilities, nutritional and

patient education services, and the number of trained medical

specialists required to provide primary care for diabetics. Second prevalence estimated in groups identified by other variables can be used to assess the risk of developing diabetes, to

explore hypotheses about factors that might cause diabetes,

and to plan programs for control and prevention of diabetes.

Thir~ prevalence data can be used to estimate the impact of

diabetes on society, to place this disease in its proper perspective compared with other competing priorities, and to de1
termine how much of a community’s

applied to its detection and treatment.

resources should be

Prevalence data are

important to clinicians in managing patients, to scientists in

planning research and to public health oficials in developing

programs to promote health in their communities.

This report presents estimates of age-, sex-, and race-specific prevalence of physician-diagnosed diabetes based on

data collected in NHANES II and in the 1976 NHIS. This

report also presents estimated prevalence of undiagnosed diabetes and of impaired glucose tolerance (IGT), based on the

NHANES II OGTT data and using criteria of the National

Diabetes Data Group7 and the World Health 0rganization.8

The estimates based on OGTT data should be interpreted

cautiously because only 43 percent of eligible sample persons

had OGTT results that met the specifications of the NDDG,

and these persons may not be representative of the survey’s

target population. Furthermore, only 350 black persons completed the test. The validity of the estimates presented in this

report depends on an assumption that those sample persons

who dld not complete the OGTT are similar to those who did

witlhrespect to their glucose tolerance. Evidence is presented

that this is a reasonable assumption. Because the black persons

who completed the test lived in only a few communities, the

estimates of their sampling error are probably unreliable.

This report also presents national estimates of the plasma

glucose values of persons with no medical history of diabetes.

It is believed that these data can serve as a national reference

standard against which clinicians can compare the plasma glucose values of their individual patients and medical researchers

can compare the values of their clinical and epidemiologic research populations. Finally, the report presents analyses of

several factors that are thought to be influential in the natural

hi~~to~of diabetes (in addition to age, race, and sex), namely

obesity, parental history of diabetes, and a previous diagnosis

of borderline or potential diabetes,
Highlights

Estimates of the prevalence of diagnosed diabetes (diabetes that was reported by respondents to have been previously

diagnosed by a physician) were 3.4 and 3.0 percent for persons

aged 20–74 years in the civilian noninstitutionalized population of the United States. These estimates are based on data

from the Second National Health and Nutrition Examination

Survey, 1976–80, and the National Health Interview Survey,

1976, respectively.

Estimates for undiagnosed diabetes based on oral glucose

tolerance test results from the Second National Health and

Nutrition Examination Survey, using either National Diabetes

Data Group (NDDG) or World Health Organization (WHO)

criteria, were very similar to each other-3.2 and 3.4 percen4

respectively. These rates were approximately equal to the percent of persons with physician-diagnosed diabetes as reported

in household interviews. In other words, about half the people

with diabetes did not know it

The prevalence of both diagnosed and undiagnosed diabetes increased with age and were higher for black persons

than for white persons. Sex differences were smaller, but at

ages 20-44 years women were more likely than men to have

diabetes.

The prevalence of diabetes increased with level of obesity.

Persons who were 50 percent or more above ideal body weight

had diabetes at five times the rate of persons of ideal weight or

lighter.

Estimates for impaired glucose tolerance using WHO criteria, 11.2 percent, were more than twice those using NDDG

cnteri~ 4.6 percent. This difference is due to WHO criteria

requiring two plasma glucose measures while NDDG criteria

require three.

Using NDDG criteri~ it appears that 11.2 percent of the

U.S. population aged 20–74 years exhibit abnormal glucose

tolerance, either diabetes or IGT. Using WHO criteri~ 18.0

percent were glucose intolerant.

3
Data sources

Second National Health and Nutrition

Examination Survey (N HANES 11)

sample design

The target population of NHANES II was the civilian

noninstitutionalized population of the United States (including

Alaska and Hawaii) aged 6 months-74 years. The NHANES

II sample was a stratified probability sample of this target

population, selected as follows. Areas of the United States,

usually counties, were grouped into 64 categories called strata

with approximately equal populations that were internally as

homogeneous as possible with respect to region, median family

income, and other demographic characteristics that varied with

region. From each stratum, one area was selected by a technique that guaranteed the geographic and socioeconomic diversity of the sample. Within each of the 64 selected areas two

additional strata were created Clusters of eight households

were grouped into segments, and segments were stratitied into

poverty and nonpoverty strata. Poverty segments were located

in census enumeration districts with 13 percent or more of

persons below the poverty level in the 1970 census. Segments

were differentially sampled from these strata at rates determined by a mathematical model to produce a sample of the

required size with minimum variance of the estimated proportion of persons below the poverty level. Within segments, interviewers enumerated household residents and systematically

selected persons into the sample at rates based on age. The

sampling rates of segments and persons were so set that children

aged 6 months-5 years, adults aged 60–74 years, and all

persons living in areas with 13 percent or more of people below

poverty level are overrepresented in the sample.

The total sample size for NHANES II was 27,801 persons aged 6 months-74 years, but this report is based mainly

on a subsample of adults aged 20–74 years who constitute an

“oral glucose tolerance test” (OGTT) or “fasting” subsarnple.

As the sample was selected, alternate sample persons aged 20-

74 years were assigned to a one-half subsample and were asked

to fast ovemigh~ to attend the examination center in the rooming,and, with the exception of diabetics using insulin, to submit

to an OGTT. There were 17,390 persons aged 20–74 years in

the total NHANES H sample and 8,686 persons in the fasting

subsarnple. Additional details of sample design are presented

in appendix I.

NHANES II data collection procedures

NHANES II included a household interview, conducted

by trained U.S. Bureau of the Census interviewers, during which

demographic data (see definitions in appendix II) were obtained

and a detailed medical history was taken. In some cases, sample ~

persons initially refused the interview but later responded when

contacted by National Center for Health Statistics field staff.

Examinations were conducted from February 1976 to

February 1980 by two teams of health professionals working in

three mobile examination centers. Because of limitations in the

heating and cooling systems of these centers, examinations were

scheduled so that sample persons residing in more southern

areas were examined in the winter and sample persons in more

northern areas were examined in the summer. Measurement of

conditions that vary seasonally may therefore be confounded

by ~is design.

NHANES II collected a large amount of data on each

sa~mple person. Data on diabetes used in this report are from

both the medical history interview and the examination, which

provided body measures of height and weight and OGTT data.

Other data collected in NHANES II but not used in thk report

include components of the medical history, body measures

other than height and weight, 24-hour diet recall and dietary

frequency, blood chemistries, urinalysis, electrocardiogram,

chest X-ray, and physician examination data.

Medical history

The presence of physician-diagnosed diabetes in interviewed persons was ascertained from the question, “Do you

have diabetes or sugar diabetes?” Interview confhmation of a

diagnosis of diabetes was attempted by asking those who responded positively “Did a doctor tell you that you had it?”;

99 percent of those responding “Yes” to the first question

responded “Yes” to this followup question (see questionnaire in

appendix III). No proxy responses were allowed. Persons who

responded “Yes” to the question on physician diagnosis of

diabetes or to questions on borderline, potential, or prediabetes

were also queried on use of antidiabetic therapy. These questions elicited information on past use, current use, and duration

of use of insulin, “diabetes pills” (in pretests this was equated

by diabetics to oral antidiabetic medication), and a written diet

for control of diabetes.

Examination

Height was measured with a steel tape attached to a vertical bar. Examinees wore disposable foam rubber slippers and

stood on a level platform with their feet together and their back

and heels against the vertical bar. They were instructed to

“stand up tall” or “stand up real straight” and to “look straight

4
ahead.” A horizontal bar attached perpendicularly to the vertical bar was lowered snugly on the exarninee’s head. In the

same plane as the horizontal measuring bar, a Polaroid cameraa

was attached and used to photograph the examinee’s height

and sample person number. These photographs were read by

NHANES 11 field staff. This technique minimized observer

and recording error by eliminating paralax and created a permanent record of this measurement. Weight was measured on

a Toledo self-balancing scalea that mechanically printed weight

to one-quarter of a pound onto a permanent record The scale

was calibrated at each survey location before the examinations.

OGTT and blood glucose analysis

OGTT’S were administered according to National Diabetes Data Group (NDDG) recommendations,7 which require

the following Subjects fast overnight for 10–16 hours; OGTT’S

are performed in the morning a fasting blood sample is takem

subjects drink flavored water containing 75 grams of glucose or

carbohydrate equivalent and additional blood samples are

taken. The drink used in NHANES II was Glucola,” a colaflavored preparation containing a carbohydrate equivalent of

75 grams of glucose.

Although the NDDG recommends that blood samples be

taken at one-half-hour intervals up to the final 2-hour sample,

in this voluntary survey NHANES II field staff did not attempt

to obtain multiple midtest venipunctures. (The test recommended by the World Health Organization requires only fasting

and 2-hour blood samples.) They did obtain fasting single

midtest, and 2-hour blood samples in 98 percent of OGTT’S in

compliance with NDDG guidelines. More than 95 percent of

all midtest and 2-hour samples were obtained within 5 minutes

of the specitied times, and 99 percent were within 10 minutes.

For pm-poses of classification, the analyses include all midtest

values (range of 20-86 minutes), but only those 2-hour values

that were taken within 105–1 35 minutes after sample persons

drank Glucola were used. For estimating 1- and 2-hour plasma

glucose distribution statistics, all values obtained within 15

minutes of the spechied times were used.

Venous blood samples were obtained in each venipuncture. Plasma was separated from blood, frozen, and shipped in

Dry Ice to the Centers for Disease Control for analysis. There,

glucose determinations were made by the Clinical Trials Section, Metabolic Biochemistry Branch Clinical Chemistry DiVisiou using a microadaptation of the national glucose reference

method.g This method has been shown to have several desirable

aMention of brand nrune is for the purpose of specific identification of the equip

mentor product used in the survey and does not imply endorsement by the U.S.

Department of Health and Human Services.

properties including reliability, transferability, specificity, and

precision. It has an average bias of less than 2 percent. Further

information on processing of blood samples is presented in

appendix I.

National Health Interview Survey

sample design

The National Health Interview Survey is a continuous

survey, the design of which has been detailed in previous pub

lications.’$10The target population for the National Health

Interview Survey is the civilian noninstitutionalized population

of the United States living at the time of the interview. The

sampling plan follows a multistage probability design that permits continuous sampling such that the sample of households

interviewed each week is representative of the target population and weekly samples are additive over time. The sampling

in 1976 was not designed to oversimple any population subgroup. At the first stage of sampling 376 areas of the country

were selected at the second stage, segments of an expected

four households were selected from each area. The sample

contained approximately 40,000 eligible occupied households

and about 113,000 persons, of whom 69,006 were aged 20–74

years and 2,442 reported a medical history of diabetes. Field

operations of the survey were performed by the U.S. Bureau of

the Census under specifications established by the National

Center for Health Statistics. A special supplement to the household interview contained diabetes-related questions in common

with the medical history interview questions of NHANES II.

Each person 19 years of age and over present at the time of interview was interviewed individually. For adults not present in

the home at the time of interview, information was obtained

from a related household member, such as a spouse or parent.

Spouses provided the majority of proxy responses for adults.II

The presence of physician-diagnosed diabetes in surveyed

persons was ascertained in several sections of the household

interview, spec~lcally, through respondents reporting that

household members had disabilities due to diabetes, a hospital

stay or doctor visit for diabetes, or by responding positively to

the direct questio~ “Do you (or anyone in the household) have

diabetes or sugar diabetes?” Interview confhmation of a diagnosis of diabetes was attempted by asking the perso~ “How

old were you (or the household member) when a doctor told

you that you had it?”; 98 percent responded with an age at

diagnosis to this followup question. Persons who responded

“Yes” to the question on physician diagnosis of diabetes were

also queried on use of antidiabetic therapy, including past use,

current use, and duration of use of insuli~ “diabetes pills,” and

a written diet for control of diabetes.

5
Data limitations and sources

of error

There are many potential sources of limitation or error

during the design, data collection, and processing phases of

surveys. The most important of these for the Second National

Health and Nutrition Examination Survey (NHANES II) are

limitation in the coverage of the U.S. populatio~ sampling

error, nonsampling error, nonresponse, missing data, and reporting error.

Incomplete coverage of U.S. population

Persons in institutional settings such as nursing homes,

long-term care hospitals, and prisons were not included in the

NHANES II and National Health Interview Survey (NHIS)

samples. Consequently, to the extent that persons in institutional settings are part of the U.S. population, the surveys

underestimate the total prevalence of diabetes, The majority of

persons in health care institutions reside in nursing homes and,

from the National Nursing Home Survey, it is estimated that

approximately 60,000 diabetics aged 20–74 years were known

to be in these facilities in 1977.12 They constitute only 1.3

percent of the diagnosed diabetic population estimated from

NHANES II in this report.

Sampling error

Estimates based on sample surveys are subject to several

types of error. These errors may be divided into two general

types-sampling and nonsarnpling errors. The sampling errors

of estimates presented in this report estimate the amount by

which estimates might differ from results that would have been

obtained if another sample had been drawn or a complete

census had been taken using the same instruments, instructions,

interview and examination personnel, and procedures. Because

of the probability design of the survey, it is possible to generalize from the sample to ihe population and to estimate the

potential sampling error. In doing so, however, it is necessary

to assume that those who participated in the survey and completed the procedures are a representative sample; that is, that

those who responded are like those who did not. This assump

tion is discussed further in the following section and in ap

pendix I.

Nonresponse

Response rates to NHANES II for persons aged 20-74

years are presented in tables A, B, and C. In both the total

NHANES 11adult sample and the oral glucose tolerance test

(OGTT) subsarnple, 88 percent of sample persons participated

in the demographic-medical history interview and 68 percent

participated in the examination (table A). Approximately 4

percent of persons in both samples reported a history of physician-diagnosed diabetes. OGTT’S that conformed to National

Diabetes Data Group requirements were obtained from 43

percent of persons in the OGTT subsample, which represents

52 percent of interviewed OGTT subsample persons with no

medical history of diabetes. Reasons for loss of OGTT data

are;summarized in table B. The main reasons were refiml to

participate in the examination component of NHANES H and

not attending the exam center during the morning hours. The

numbers and response rates of sample persons with complete

medical history interviews or classifiable OGTT’S are shown

by age, race, and sex in table C.

One possible source of bias for estimates presented in this

re]portis differential interview and examination nonresponse by

pc,pulation subgroups. A previous analysis of NHANES II

Table A. Response rates for adults aged 20-74 years: Second

National Health and Nutrition Examination Survey, 1976-80

Total sample OGTT1 suhsample

Response category Numbar Percent Number Percent

Sample persons. . . . . . . . 17,390 100.0 8,686 100.0

Interviewed . . . . . . . . . . . 15,357 88.3 7,688 88.5

Medical history of

diabetes . . . . . . . . . . . . . 756 4.3 381 4.4

Examined . . . . . . . . . . . . . 11,860 68.2 5,903 68.0

Classifiable 0GlT2. . . . . . . . . . . . 3,772 43.4

~OGTT = oral glucose tolerance test.

‘Only persons with no medical history of disbetes.

“rable B. Reason for Ioas of oral glucosa tolerence test (OGil_T) data

for persons with no medical history of diabetes: Second National

Health and Nutrition Examination Survey, 1976-80

Reason for loss Number Percent

Interviewed sample persons with no medical

history of diabetes. , . . . . . . . . . . . . . . . . . . . . 7,307 100.0

Refused examination.......,.. . . . . . . . . . . . . . 1,678 23.0

Did not attend morning examination . . . . . . . . . . 877 12.0

DidnOtfast 10-16 hours . . . . . . . . . . . . . . . . . . . 442 6.0

Refused OGTT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 2.4

Missing or incomplete OGTT’S1 . . . . . . . . . . . . . . 360 4.9

Classifiable OGIT’s . . . . . . . . . . . . . . . . . . . . . . . . 3,772 51.6

I Length of fast unknown, technical errors, samples lost, unsuccessful

venipuncture, sample persons became ill, or other reason.

6
Table C. Unweighed number and response rates of sample persons with complete medical history interviews and with classifiable oral

glucose tolerance tests (OGTTS) and no medical history of diabetes, by race, sex, and agrx Second National Health and Nutrition Examination

Survey, 1976-80

Age Age

Total, 20- 20-44 45-54 55-64 65-74 Total, 20- 20-44 45-54

Race and sex 74 years

55-64 65-74

years years years years 74 years years years years years

All racesl

Botn sexes . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes, . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Black

Both sexes . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . .

All racesl

Both sexes......,.........,.. . .

Male, . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Black

Both s.exes . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female. . . . . . . . . . . . . . . . . . . . . . . .

Number with complete interview

15$357 6,531 1,866 3,328 3,632

7,074 3,064 892 1,525 1,593

8,283 3,467 974 1,803 2,039

13,311 5,587 1,613 2,925 3,186

6,167 2,635 787 1,347 1,398

7,144 2,952 826 1,578 1,788

1,762 795 212 364 391

765 354 87 163 161

997 441 125 201 230

Number with classifiable 0GlTs2

3,772 1,608 490 841 833

1,772 740 216 423 393

2,000 868 274 418 440

3,348 1,408 437 753 750

1,585 648 200 383 354

1,763 760 237 370 396

351 159 42 79 71

154 73 14 36 31

197 86 28 43 40

Percent of sample completing intetview

88.3 91.2 86.8 86.0 86.2

87.6 89.7 84.8 85.5 87.5

88.9 92.6 88.8 86.5 85.3

88.1 91.2 87.2 85.9 85.7

87.4 89.5 85.4 85.0 86.9

88.8 92.7 89.1 86.6 84.7

90.1 92.0 85.1 88.1 91.1

89.8 91.9 79.8 B9.1 92.0

90.4 92.1 89.3 87.4 90.6

Percent of sample completing 0GTTs4

43.4 45.0 45.6 44.1 39.1

43.1 42.9 42.1 44.9 42.0

43.7 47.0 48.8 43.2 36.8

44.3 46.2 46.9 45.0 39.5

44.1 43.8 44.1 46.2 42.8

44.5 4B.5 49.6 43.8 36.9

36.5 36.6 36.8 37.4 35.0

35.2 37.2 28.6 35.0 34.4

37.6 36.1 43,1 39.8 35.4

1Includes races other than white or black

‘Only persons with no medical history of diabetes.

3Persons with medical history of diabetes excluded from numerator but included in denominator.

nonresponse showed that the interview nonresponse rates varied

with age, regio~ residence in a standard metropolitan statistical

are% and family size the examination nonresponse rate vaned

with wanting to discuss a health problem with a doctor, work

status, and number of cars owned.ls After comparing NHANES

II and NHIS estimates of several important health measures,

the author of this earlier study concluded that the statistical

weighting procedures (that is, nonresponse adjustments and

poststratilcation) substantially reduced the bias due to differential interview and examination nonresponse rates. These

weighting procedures were also used in this report

However, as noted above, the data for the OGTT study

are subject to even finther nonresponse because of failure to

obtain classifiable OGTT’S for a substantial proportion of the

interviewed and the examined OGTT sample. Details of analyses of the potential magnitude and effect of nonresponse bias

are presented in appendix I. To check for differential nonresponse, estimates of population distributions for various socioeconomic and demographic variables for sample persons who

completed the OGTT were compared with estimates for the

same variables based on the interviewed and the examined

NHANES II samples and the NHIS sample. Only small dtiferences were observed between corresponding estimates, indicating tha~ even though failure to obtain classifiable OGTT’S

was differentially distributed across socioeconomic and demographic subgroups, these differentials were so small they prob

ably did not substantially aHect the estimates presented in this

repoti

To evaluate the effects of nonrespcmaeon health measures,

prevalence estimates based on medical history items related to

diabetes were computed for NHIS and for NHANES II interviewe~ examined and OGTT’-completed groups. Distributions

of heigh~ weight body mass index, diastolic and systolic blood

pressure, and cholesterol were estimated for all examined sample persons, the OGTT-examined subsample, and the OGTTcompleted group. For most items the estimates were very similar, but two potentially important problems were uncovered.

Firs~ a smaller proportion of persons with a medical history of

diabetes participated in the exam or met the requirements for

the OGTT than persons with no history of diabetes. Second, a

larger proportion of persons with a medical history of borderline (59.4 percent) or potential (63.1 percent) diabetes or having

7
a parent with diabetes (58.3 percent) participated in the exam

and met the requirements of the OGTT compared with all

OGTT sample persons with no history of diabetes (50.6 percent) (appendix I, table V).

To estimate the magnitude of potential bias caused by this

higher response of persons having a parent with diabetes or a

history of borderline or potential diabetes, standardized estimates were calculated that is, estimates from the OGTTcompleted group were adjusted to the prevalence of these

background items in the interviewed sample. These adjusted

estimates differed from the survey estimates by only small

amounts, less than 0.4 percen; for any of the detailed sex-age

cells presented in this report (appendix I, table VIII). Thus, it

appears that the differential response rates for these two groups

did not substantially bias prevalence estimates for either the

entire population or its subgroups.

The sensitivity of estimates of unknown diabetes or impaired glucose tolerance to violations of an assumption of independence in two groups—those with and those without either

a medical history of borderline or potential diabetes or a parent

with diabetes— was modeled mathematically. The model showed

that the greater effect on prevalence estimates would be caused

by overresponse or underresponse by persons with no history

of borderline or potential diabetes and whose parents did not

have diabetes. Overestimating or underestimating prevalence

in nonrespondents by 25 percent would cause about a 15 percent error in estimates presented in this report (appendix I,

table IX).

For the 1976 NHIS the noninteniew rate was 3.7 percent. Respondent refusal was 2.1 percenc the remaining 1.6

percent was primarily failure to find an eligible respondent at

home after repeated calls.b

Missing data

Sample persons with missing medical history data were simply

excluded from any analysis or tabulation where appropriate.

For those few examinees with missing height or weight values

were imputed with a regression model based on NHANES I

data using their other body measures, age, race, and sex.

Reporting error

l[n 1962, a study was performed to examine the accuracy

of reporting a diagnosis of diabetes in the National Health

Interview Survey. It was found that about 15 percent of persons

with diabetes on their medical records failed to tell the interviewer that they were diabetiq there was only about 1 percent

overreporting of this disease.’4 It is not known whether similar

levels of reporting error existed 15 years later during NHANES

II. There was no followback to medical records of the 756

persons who reported that they were diabetic in response to the

NHANES II medical history interview.

Other nonsampling error

Every effort possible was made during the design, execution, processing, and analysis of NHANES II to prevent or

minimize nonsampling errors. By thorough training of the staff,

use of mobile examination centers, and careful review of operating procedures, interobserver and interarea variability in the

data were minimized. In editing the NHANES II data, 27

sample persons were identified whose plasma glucose values

appeared to reflect either failure of the participant to fas~ inaccurate labeling of the time the blood sample was taken, or

glucose measurement errors. These persons were excluded from

analyses in this report.

The number of respondents with missing data for any of

the medical history items used in this report was very small.
Method of analysis

Statistical techniques Estimates for the black population

Data from all Second National Health Interview Survey

(NHANES II) interviewed persons aged 20-74 years were

used in this report for prevalence estimates of data from the

medical history interview, most importantly the prevalence of

physician-diagnosed diabetes. For items measured during the

NHANES II examination, most importantly height and weight,

examined persons were used as a base for prevalence estimates.

Estimates of prevalence of undiagnosed diabetes and impaired

glucose tolerance are based ordy on persons for whom classifiable oral glucose tolerance test (OGTT) data were obtained.

Because of the complex sample designs of the National

Health Interview Survey (NHIS) and NHANES II, as well as

the stratification and oversampling of children, of adults aged

60-74 years, and of persons living in poverty areas, weighting

was employed in the calculation of all estimates in this report.

The weights take into account the probability with which persons were drawn into the samples and certain adjustments,

based on the known demographic characteristics of interviewed

or examined persons versus all eligible persons, to minimize

the effects of nonresponse and bias. When summed the weights

of all interviewed or all examined persons closely approximate

the estimated target populations at the midpoint of the survey

periods (March 1, 1978, for NHANES W,July 1, 1976, for

NEns).

There are no formulas for exact measures of sampling error

because of the many complex features of the NHANES II and

NHIS sample designs. Approximations were used in analyses

reported here. They were calculated using a method of Taylor

series linearization of approximate formulas incorporated in

the computer programs SURREGR15 and SESUDAAN.16

Statistical tests were performed with a method of weighted least

squares for multivariate categorical data which produces test

statistics that are asymptotically chi-square. 17The calculations

were made using the computer program GENCAT. 18 This

program makes possible the construction of multivariate tests

of significance that take into account the full covariance matrix

of estimates. These tests have greater statistical power than

testa based on comparisons of paired estimates using the method

for combining estimates presented in appendix I. Thus, analyses using the GENCAT procedures may produce somewhat

different results than comparison of paired estimates using

standard errors shown in the detailed tables. All findings in this

report are statistically significant at levels of probability less

than, usually much less than, 0.05 percent.

Estimates for black persons must be interpreted with caution because of the small number of black people in the sample

and their low (36 percent) OGTT completion rate (table C).

The reliability of estimates as measured by their standard errors

is related to sample size, sample distribution across primary

sampling units, and the magnitude of the estimate. Making

precise estimates for conditions that are as rare as diabetes is

in some subpopulations requires larger samples than the

NHANES II sample of black persons. In this report the estimates for all black persons and sometimes for all black females

or males can be considered reasonably precise, that is, the

standard error of an estimate is less than 30 percent of the estimate itself. But for many estimates, especially those based on

the OGTT results, the sample size is inadequate for precise

estimates. Furthermore, as described in the previous section,

the standard errors presented in this report are also subject to

errov estimated standard errors may not be reliable because of

the small numbers of black persons in certain cells and their

concentration in certain areas of the country.

Despite these limitations, results for black persons are

presented because the prevalence of diabetes and glucose intolerance for black and white persons provides an important

racial comparison, and other studies do not have comparable

data. Although estimates for detailed age and sex groups of

black persons are not individually reliable, they are presented

to demonstrate the variability of the data by age and sex. Other

researchers may fmd these data useful for generating hypotheses

or building their own models. Results for black persons based

on these data must be interpreted cautiously; they should be

replicated in other studies before they are accepted as adequate

national estimates of the prevalence of diabetes and glucose

intolerance for the black population.

Classification of sample persons

In this report, sample persons are classified to the extent

possible according to the system developed by the National

Diabetes Data Group (NDDG).7 This classification has been

endorsed by the American Diabetes Association and the World

Health Association (WHO) Expert Committee on Diabetes

has accepted its substantive recommendations.8 In this system, the main types of diabetes are insulin-dependent diabetes

mellitus (IDDM), non-insulin-dependent diabetes mellitus

(NIDDM), gestational diabetes, and diabetes secondary to other

diseases and conditions. In addition, the NDDG and WHO

9
have defined a category based on the OGTT that is termed

impaired glucose tolerance (IGT) and represents glucose levels

intermediate between those considered diabetic and those considered normaL7,8

Classification of persons with medical history

of diabetes

Persons with a medical history of diabetes were classified

as diabetic based on data obtained in their medical history interview. The interview question did not ascertain the criteria

that physicians used for diagnosis of diabetes ant consequently,

it is not known if reported cases of diabetes met the NDDG or

WHO diagnostic criteria for diabetes. However, data from the

interview indicate that these respondents should be considered

diabetic. Among the 756 NHANES II subjects who indicated

a medical history of physician-diagnosed diabetes, 26 percent

were using insulin and 35 percent were taking oral antidlabetic

medication at the time of the survey. An additional 14 percent

had been given a written diet for control of their diabetes and

were following their diets. The remaining 25 percent were not

following any of these three therapies at the time of the survex

however, virtually all had a history of use of insulin, oral antidiabetic agents, or diet. Similar results on past and current use

of diabetes therapies were reported by participants in the 1976

NHIS.l 1Because these ”therapy histories are consistent with a

diagnosis of diabetes, all persons in NHANES II and NHIS

who reported a physician diagnosis of diabetes have been designated “medical hktory” or” diagnosed” diabetics.

In another study of the validity of classification based. on

medical histories, the medical records of diabetics in the pop

ulation of Rochester, Minnesota, who were diagnosed between

1945 and 1969 were reexamined.19 It was found that approximately 21 percent of diabetics dld not meet the NDDG criteria

at their initial diagnosis, although one-third of these dld meet

the criteria after 10 years duration of diabetes. The diabetic

population of Rochester is primarily diagnosed by elevated

fasting plasma glucose, however, whereas NDDG and WHO

permit diagnosis of diabetes by either elevated fasting plasma

glucose or abnormal OGTT.

Plasma glucose values have not been used in classifying

the 381 medical history diabetics in the fasting subsample.

Because participation in this survey was voluntary, it was considered inappropriate to request that the 75 insulin-taking diabetics in the examined subsample have an OG~, in addition,

the remaining number of persons with a medical history of diabetes who received an OGTT (100 persons) was deemed too

small for valid analysis. Half of these met the NDDG criteria

for diabetes; the other half may not have because they were on

blooc[-glucose-lowering therapies.

The data collected in NHANES II do not permit accurate

differentiation of medical history diabetics into the categories

IDDM and NIDDM. However, an estimate can be made by

assuming that all persons diagnosed as diabetic under the age

of 301years who reported using insulin for the duration of their

diabetes (plus or minus 1 year) had IDDM, and that the remainder had NIDDM. Using these cnteri~ approximately onethird of medical history diabetics aged 20-44 years could be

clamilled as having IDDM. Over age 44 years, less than 2

percent appear to have IDDM. Similar results were found in

the 1976 NHIS.l 1IDDM and NIDDM have not been analyzed

separately in this report.

The category of gestational diabetes diagnosed by an abnom~al OGTT in pregnancy will not be used in this report.

There were 52 pregnant women in the interviewed samplq none

of the 32 who received an OGTT was diabetic.

It cannot be determined how many NHANES II persons

with a medical history of diabetes have diabetes that is secondary to other conditions; in a recent study,lg this catego~ represented only 2 percent of allmedically diagnosed cases of diabetes.

Classification of persons with no medical

history of diabetes

For those persons who did not report a medical history of

diabetes, the diagnostic criteria recommended by NDDG and

WHO were applied to their venous plasma glucose values in

the fasting state and during the OGTT to classify them ns diabetic, IGT, or nondiagnostic (table D). For 3,701 of 3,772

sample persons who met NDDG requirements for conduct of

the OGTT, all three plasma glucose values were obtained.

There were 71 sample persons for whom one of the OGTT

wdues was missing but whose other values excluded the dlagTable D. Unweighed number of sample persons with no madical history of diabetes, by oral glucose tolerance test critaria of the National

Diabetes Data Group and of the World Health Organization: Second National Health and Nutrition Examination Survey. 1976-80

National Diabetes Data Group

World Health Organization 1 hou~ 200 mg/dl or more 1 houc less than 200 mg/dl

—

Fasting and 2-hour plasma glucose Number of Number of Number of

concentrations Classification persons Classification persons Classification persons

Fasting, 140mg/dl or more..... . . . . . . . . . . . Diabetes 44 Diabetes 44 Diabetes

Fasting, Iesa than 140 mg/dl:

2hour,200mg/dl ormora . . . . . . . . . . . . . . . Diabetes 148 Diabetes 136 Nondiagnostic 12

2hour,140–199 mg/dl . . . . . . . . . . . . . . . . . Impaired glucose 532 Impaired glucose 227 Nondiagnostic 303

tolerance tolerance

2hour, Iessthan 140mg/dl . . . . . . . . . . . . . . Normal 2,991 Nondiagnostic 196 Normal 2,783

Classified with partial data . . . . . . . . . . . . . . . . . Normal 4 Normal or nondiagnostic = 71

Total number of persons . . . . . . . . . . . . . . . . . 3,719 3,772

‘mgldl = milligrams per deciliter.

10
noses diabetes or IGT. For development of WHO estimates,

which require only fasting and 2-hour values, 58 of these could

not be classified because their 2-hour value was missing. The

effect of this was to reduce the sample base for WHO estimates.

Despite the greater complexity of the NDDG system, more

sample persons could be classified because the 1-hour value

could be used to exclude IGT and diabetes. Fifteen persons

were unclassifiable under NDDG criteria because of partial

data that did not exclude diagnoses of diabetes or IGT, but in

the WHO system, which utilizes only the fasting and 2-hour

blood glucose values, five of these persons could be classified.

Only about one-fourth of undiagnosed diabetics could be

class~led as diabetic on the basis of an elevated fasting plasma

glucose (140 milligrams per deciliter or more); the remainder

were classified as diabetic based on their 1- or 2-hour postglucose challenge levels (200 milligrams per deciliter or more)

(table D).

IDDM is a disease with such classic onset and obvious

symptoms that virtually no patients are undiagnosed consequently, no cases of undiagnosed diabetes in NHANES II are

considered to be IDDM.

11
Findings

Prevalence of diagnosed and

undiagnosed diabetes in the Second

National Health and Nutrition Examination

Survey (NHANES 11)

Tables 1–3 present age-, race-, and sex-specific rates of

diagnosed diabetes and undiagnosed diabetes. More detailed

age rates for white persons only are presented in table 4. The

prevalence of physician-diagnosed diabetes (table 1) rose with

age and was higher for black than for white persons. Prevalence

at ages 65–74 years (9.3 percent) was 8.5 times that at ages

20-44 years (1. 1 percent). Prevalence for black persons (5.2

percent) was 1.6 times greater than for white persons (3.2 percent). Prevalence rates for males and females were not statistically different except for white persons aged 20–44 years

and black persons aged 65–74 years.

The prevalence of undiagnosed diabetes as defined either

by the National Diabetes Data Group (NDDG) (table 2) or

the World Health Organization (WHO) (table 3) also rose

with age and was higher for black than for white persons in all

age groups. Using NDDG criteria, the prevalence of undiagnosed diabetes rose from 0.9 percent in the youngest age group

to 8.4 percent in the oldest group. Using WHO criteria, the

rates rose ffom 0.9 to 9.4 percent. Both definitions provided

similar total prevalence rates—3.2 and 3.4 percen$ respectively.

The WHO definition produced slightly higher estimates in age

groups 55 years and over because, although all oral glucose

tolerance tests (OGTT’S) that met the NDDG criteria for diabetes also met the WHO criteria, 12 of 192 that met the WHO

criteria did not meet the NDDG l-hour criteria (table D).

Estimates for individual age groups of black persons were unreliable, although the increase with age was consistent with the

pattern of estimates for white persons. Differences between

male and female rates were statistically significant only for

white persons aged 20–64 years; within this age range undiagnosed diabetes was about 1.5 times more prevalent in females

than males.

Table E presents the sums of NHANES II rates for diagnosed and undiagnosed diabetes using NDDG criteria shown

in tables 1 and 2. These sums represent an estimate of the total

prevalence of diabetes in the United States for persons aged

20–74 years. Because sample persons on which estimates for

undiagnosed diabetes in NHANES II are based are a subset of

sample persons on which estimates for physician-diagnosed

diabetes are based, these estimates are not independent. Because computer programs for estimating their covariances were

unavailable, estimates of standard errors for total prevalence

Table E. Prevalence of diabetes in adults agad 20-74 years, by

race, sex, and age: United States, 1976-80

Age

Total,

20-74 20-44 45-54 55-64 65-74

Race and sex yeers yeers years yeers years

All racesl

Both sexes 6.6

Male . . . . . . . . . . 5.7

Female . . . . . . . . 7.3

White

Bol.h sexes . . . . 6.2

Male . . . . . . . . . . 5.3

Female . . . . . . . . 7.0

Blackz

Both sexes . . . . . 9.6

Male . . . . . . . . . . 8.4

Female . . . . . . . . 10.5

Percent of population

2,0 8.4 12.8

1.5 7.8 9.6

2.5 9.0 15.5

1.6 8.1 11.9

1.0 7.7 9.0

2.2 8.5 14.6

3.1 12.9 20.8

2.7 11.0 14.4

3.5 14.5 25.4

17.7

19.2

16.5

16.9

18.1

16.1

25.8

29.4

23.1

1Includes races other than white or black.

‘Sex and age eatimatea for black peraona are preaentsd for information only.

They are too unreliable to be considered national prevalence estimates.

NOTE Includes both peraona reporting in medical history interview that a doctor

had told them they had diabetea and persona classified diabetic on an oral

glucose tolerance teat using National Diabetes Data Group criteria (ace text

for criteria).

of diabetes in table E could not be calculated. However, the

fact that age and race effects were similar in tables 1 and 2

strongly suggests that the increase in total prevalence with age

and the higher rates for black than for white persons were statistically significant.

The prevalence of diabetes in persons aged 65–74 years

(17.7 percent) was 8.8 times that for persons aged 20-44 years

(2.O percent). Total diabetes was 1.5 times more prevalent for

black than for white persons (9.6 and 6.2 percent respectively).

Relative sex differences shown in table E were smaller than

those in tables 1 and 2 and may not be statistically significant

except for white persons aged 20-44 years; in this group the

prevalence of total diabetes for females (2.2 percent) was greater

than for males (1.0 percent).

Comparison of NHANES II and National

Health Interview Survey (NH IS) estimates

Estimates of previously diagnosed diabetes based on the

1976 NHIS are presented in table 5. Compared to NHANES

II estimates in table 1, there were some differences in the prev12
alence of known diabetes, with estimates from NHANES II

generally being higher than those from NHIS. For example,

3.4 percent of persons aged 20–74 years in NHANES II reported a medical history of diabetes, versus 3.0 percent in

NHIS. For specific race-sex-age groups, the difference between

NHANES II and NHIS varied. Generally, the NHANES II

estimates were 10 percent higher than those of NHIS. These

discrepancies might be partly explained by the different time

periods during which the surveys were conducted. For example,

the 1979-81 NHIS, conducted at the end of NHANES II,

found that 3.3 percent of persons aged 20–74 years reported a

medical history of diabetes.20 However, rates of diabetes in the

individual years of NHANES II did not show an increase in

prevalence between 1976 and 1980. The discrepancy might

also be due to underreporting of diabetes by proxy respondents

in NHIS. Using only self-respondents in NHIS to estimate

diabetes prevalence reduces the difference between the surveys

by about two-thirds. The rest of the difference was probably

due to sampling error and the sum of effects of differences in

interviewers, question context, editing, and processing.

In general, the NHIS estimates of physician-diagnosed

diabetes (table 5) showed the same pattern as the NHANES II

estimates (table 1). As in NHANES II, the prevalence of

known diabetes increased with age and was higher for black

than for white persons in all age groups. Prevalence for the

oldest age group (8.3 percent) was 8.3 times that of the youngest

(1.0 percent). Prevalence for black persons (4.4 percent) was

1.6 times that for white persons (2.8 percent). For white persons aged 20–44 years, the rate for females (1. 1 percent) was

higher than for males (0.7 percent).

It is informative to assess the relative prevalence of diagnosed and undiagnosed diabetes. This could not be done with

NHANES II data alone, as explained earlier. It can be done,

however, by comparing NHANES II estimates with NHIS

estimates.

The prevalence of undiagnosed diabetes in NHANES II

using NDDG criteria (table 2) and WHO criteria (table 3) was

similar to the prevalence of physician-diagnosed diabetes

mea..ured in NHIS (table 5). The only statistically significant

differences between these sets of estimates were sex dHerences

for white persons aged 20–64 years and for black persons aged

20-54 years. In NHANES II, for white persons aged 20-64

years, females had higher rates of undiagnosed diabetes than

males; but in NHIS, females had higher rates than males only

in the age group 20–44 years. For black persons aged 20–54

years there was no sex difference in undiagnosed diabetes in

NHANES II, whereas there was a difference in the prevalence

of diagnosed diabetes in this group in NHIS.

From table 2 it can be seen that 3.2 percent of the U.S.

population aged 20–74 years could be considered to have met

the NDDG criteria for diabetes but had not yet been diagnosed

as diabetic. From table 3 it can be seen that 3.4 percent could

be considered to have met WHO criteria for diabetes. These

rates of undiagnosed diabetes were similar to the rate of diagnosed diabetes ascertained in NHIS (3.0 percent) and indicate

that diabetes may be twice as prevalent in the United States as

the rates found by medical history surveys such as NHIS.

Comparison of NHANES II estimates of known and unknown

diabetes with NHIS estimates of known diabetes shows that

this ratio held across age and race groups.

Prevalence of impaired glucose tolerance

Table 6 presents estimates of impaired glucose tolerance

(IGT) using NDDG and WHO criteriaj and table 7 presents

estimates for white persons by more detailed age groups. Estimates of IGT using WHO criteria were higher than those using

NDDG criteriz often more than twice as high. For all persons,

the prevalence of IGT was estimated at 4.6 percent using

NDDG criteria, and at 11.2 percent using WHO criteria.

The different criteria of NDDG and WHO account for

this difference in prevalence of IGT. Both sets of criteria require

a 2-hour plasma glucose concentration of 140-199 milligrams

per deciliter for definition of IGT. However, WHO criteria

define IGT solely on the basis of this 2-hour value, while

NDDG requires both the 2- and l-hour values of 200 milligrams

per deciliter or morq if the l-hour value is less than 200 milligrams per deciliter, NDDG designates the OGTT as “nondiagnostic,” rather than as IGT. Table D shows that nearly twice

as many persons were classified as IGT by WHO criteria as

by NDDG criteria.

Despite the dtierence in magnitude, the effects of age and

race generally were similar using either NDDG or WHO criteria. IGT increased with age for white persons but not for

black persons (although these data for black persons, like those

in tables 2 and 3, must be interpreted with caution). Using

NDDG criteria, the prevalence of IGT in white persons rose

from 2.0 percent in the youngest age group to 9.5 percent in the

oldest using WHO criteria the increase was from 5.6 to 23.0

percent. A greater proportion of white females than white males

had IGT in the age group 20–44 yearx For white males in this

age group, 1.0 and 4.6 percent had IGT using NDDG and

WHO criteri% respectively, compared with 2.8 and 6.5 percent

for white females. In the age group 55–64 years, white female

rates were lower (5.5 percent) than white male rates (10.1 percent) under the NDDG deftitioq the difference using WHO

criteria was not statistically signitlcant.

Total prevalence of glucose intolerance

in the United States

Table 8 and figure 1 present estimates from NHIS and

NHANES II of the total prevalence of glucose intolerance in

the United States (sum of rates of diagnosed diabetes from the

1976 NHIS and undiagnosed diabetes and IGT using NDDG

criteria from NHANES II). The methcd of calculating standard

errors of estimates in this table is presented in appendix I. These

estimates show that glucose intolerance affected about 11 percent of the total population aged 20–74 years and as many as

26 percent of persons aged 65–74 years. These high rates have

not been reported in white populations, although they have been

found in some American Indian tribes,21Pacific Island populations,22 and Mexican Americans.zs

Interestingly, the black-white differences were not significant when total glucose intolerance was considered. The only

statistically significant sex difference was for white persons

aged 20–44 years where the prevalence of glucose intolerance

13
M = Male

F = Female

W = White

B = Black

❑ Impaired glucose tolerance (NDDG criteria), no history of diabetes

❑ Undiagnosed diabetes [N13DG criteria), no history of diabetes

❑ Medical history of diabetes

VVM WI:

m

B

20–74 years

BM

WF

4

WM

.......

....... .:.:.:.

20-44

years

Age

WF

45-54

years

WM

55-64

vears

65-74

years

Figure 1. Percent of adults aged 20-74 years with medical history of diabetes (N H IS, 1976) and percent with no medical history of diabetes

who had undiagnosed diabetes or impaired glucose tolerance using National Diabates Data Group ( NDDG) criteria (N HANES 11,1976-80), by

race, sex, and age United States

was higher for females (4.6 percent) than for males (2.2 percent). In general, the race and sex differences in previously

diagnosed and unknown diabetes and IGT were in opposite

directions and canceled out when added together in table 8.

Diagnosed diabetes constituted about 30 percent of total glucose intolerance, undiagnosed diabetes contributed about 30

percent, and IGT accounted for about 40 percent, using

NDDG criteria. For black females, however, IGT constituted

only 19 percent. When WHO criteria were used, the percent of

total glucose intolerance accounted for by IGT did not differ

by race or sex.

Mean plasma glucose levels and

percentile distributions in U.S. adults

Tables 9–1 1 show the mean (and standard deviation and

standard error) of fasting 1-hour, and 2-hour plasma glucose

concentrations for adults aged 20–74 estimated from the

NHANES 11 population who did not report a physician-diagnosed medical history of diabetes. More detailed age data for

white persons are shown in table 12.

The mean fasting plasma glucose value showed only a slight

upward trend with agq it rose from 89.5 milligrams per deciliter

14

at ages 20–44 years to 98.1 milligrams per deciliter at ages

65–74 years (table 9). In contrast, the mean 1- and 2-hour

plasma glucose values showed a large increase with age, from

130.1 to 171.0 milligrams per deciliter (table 10) and from

100.0 to 133.4 milligrams per deciliter (table 11), respectively,

Race differences for mean glucose values were not statistically significant for any of the three venipunctures (tables

9--11).

Males had higher l-hour plasma glucose concentrations

than females; the differences averaged about 13 milligrams per

deciliter (table 10). There were other differences between the

sexes in certain groups, but they were so small as to be of little

importance. Males had higher concentrations of glucose in the

fasting venipuncture than females aged 20-44 years (92.2

versus 87.2 milligrams per deciliter) and in white persons aged

65-74 years (99.7 versus 96.8 milligrams per deciliter). At

age 20–44 years, females had higher (102.4 milligrams per

deciliter) concentrations of glucose than males (97.4 milligrams

per deciliter) 2 hours after challenge.

Tables 9– 11 also show the percentile distributions of plasma

gjucose levels by race and sex in the NHANES II population

who reported no medical history of diabetes. The distributions

by age are plotted in figure 2. There was an upward trend with
280

260

240

220

[

200

[

● ,*o**me* *****mm** ● **

%

~

.-0

: 180

&

a

z

160 P

g

s

E 140 D** DO**9*9**80 **O*****

c.-

60

40

20

0

95

90

75

50

25

10

5

Faating

I I I

20-44 45-64 65-74

years years years

1 hour

95

90

75

50

25

10

5

20-44 45-64 65-74

years years years

Age

u

95

D  o** **m ●e00*m9**q Qn

1- ●aAoe@*eo*oo*

I

2 hour

20-44 46-64 65-74

years years years

Figure 2. Selected percentile distributions of fasting, l-hour, and2-hour plasma glucose values of theoral glucose tolerance test by age

Urked States, 1976-80

age in each percentile value for both post-glucose challenge

values. There were nodifferences byraceand only small differences bysex within agegroups.

Adecline ofglucose tolerancewith age has beenshownin

anumber ofcommunity-based studies. In addition, data from

NHANES II provide evidence that this occurs in the general

U.S. population, as shown by the increases in the means and

the percentile values with age. However, whether this phenomenon is a normal physiological process related to aging or

is, in fact, a pathological process related to the increasing prevalence of diabetes is still the subject of debate.

Frequency distribution of plasma

glucose values

Figure 3 illustrates the fkequencydistributions of the fasting

l-hour, and 2-hour plasma glucose values on a base 10 log-

.,

arithmic scale for NH.ANES II sample persons with no medical

history of diabetes. Relatively symmetric unimodal distributions

can be observed. The frequency distributions of glucose tolerance values in most populations have been reported to be

unimodal with skewing toward higher values, especially in older

age groups.24Bimodal distributions that conform to a model of

overlapping Gaussian distributions have been shown in several

populations with high prevalence of diabetes when data from

all persons, diabetics and nondiabetics, are considered together,zl-zs with persons with normal levels constituting the

lower glucose component and diabetics constituting the higher

component. In these bimockd populations, the major contribution to the age-related rise of plasma glucose appears to be

due to the increasing prevalence of diabetes with age. The exclusion of glucose values of persons with a medical history of

diabetes tlom figure 3 may be the reason for unimodality and

the lack of skewness.

15
i

II

II

II

II

II

II

II

] \ Fasting

II

II

II

II

II

II

II

II

II

1;

f

:7

<1,5 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

Iog, o plasma !jlucoaa

50 100 200 250 400 500

Plasma glucosa value in milligrams per deciliter

Figure 3. Frequency distributions of fasting, 1-hour, and 2-hour plasma glucose values of the oral glucose tolarance tast for adults agad

20-74 yaars with no medical history of diebetes United States, 1976-80

Use of the fasting plasma glucose value 2-hour OGTT. In these cases the fasting plasma glucose (FPG)

as a screen for undiagnosed diabetes mightbe used as a proxy for the OGTT if it were sufficiently

smsitive in predicting diabetes. Table 13 presents the percent

In many circumstances, such as community screening for of persons in certain FPG groups who would be considered

diabetes, it maybe impossible or impractical to conduct a full diabetic according to NDDG and WHO criteria. These data

16
are illustrated in figure 4, which shows that below an FPG

value of 110 milligrams per deciliter, only a small percent of

persons were diabetic. Above this value, the percent who were

diabetic at each FPG value steadily rose, up to the value of

140 milligrams per deciliter, the level that both NDDG and

WHO consider to be diagnostic of diabetes. No clear break in

the curve is see% although the “yield” of diabetics rose with

FPG, there was still a large proportion of persons in each FPG

group, even at the highest FPG value (135–139 milligrams per

deciliter), who were not shown by the OGTT to be diabetic.

Hence, using FPG as a screen for diabetes has a high falsepositive rate if a cutoff below 140 milligrams per deciliter is

chosen.

This situation is explored further in table F in which the

cumulative percents of all persons with undiagnosed diabetes

(according to either elevated FPG or abnormal OGTT) are

displayed by FPG values. About half of the undiagnosed diabetics had FPG values less than 120 milligrams per deciliter,

which is 20 milligrams per deciliter below the NDDG and

WHO fasting criterion for diabetes (140 milligrams per deciliter

or greater). Based on this criterion, only about 26–28 percent

were diabetic. The remaining 72–74 percent were diabetic

based on their abnormal OGTT results. Thus the conclusion

is that FPG lacks sensitivity in detecting undiagnosed dia80

70

60

m 50

c

0

2

0

; 40

30

20

10

A

/

A

A

A

n.

<80 85- 95- 105- 115- 125- 135-

89 99 109 119 129 139

FPG value in milligrams per deciliter

Figure 4. Percent of persons in specific fasting plasma glucose

(FPG) groups who are undiagnosed diabetics United States,

1976-80

Table F. Cumulative percent distribution of adults aged 20-74

years with undiagnosed diabetes, by fasting plasma glucose level

according to criteria of the National Diebetes Data Group and of the

World Health Organization: United States, 1976-80

National Diabetes World Health

Data Group Organization

Fasting plasma glucose Ievefl criteria criteria

Total . . . . . . . . . . . . . . . . . . . . . . .

80mg/dl or more . . . . . . . . . . . .

85mg/dl or more . . . . . . . . . . . .

90mg/dl or more . . . . . . . . . . . .

95mg/dl or more . . . . . . . . . . . .

100mg/dl or more . . . . . . . . . . .

105mg/dl or more, . . . . . . . . . .

llOmg/dl or more . . . . . . . . . . .

115mg/dl or more . . . . . . . . . . .

120mg/dl or more . . . . . . . . . . .

125mg/di or more . . . . . . . . . . .

130mg/dl or more . . . . . . . . . . .

135mg/dl or more . . . . . . . . . . .

140mg/dl or more . . . . . . . . . . .

180mg/dl or more . . . . . . . . . . .

200mg/dl or more . . . . . . . . . . .

Cumulative percent distribution

100.0 100.0

97.1 97.3

95.5 95.8

93.3 93.2

89.8 89.0

82.7 80.5

76.2 72.6

65.3 62.3

57.3 54.7

52.6 50.2

44.2 42.3

39.9 38.3

35.1 33.7

27.9 26.4

11.7 11.1

10.2 9.7

‘mgldl = milligrams per decileter.

NOTE See text for criteria defining diabetes.

Association of diabetes and IGT with

medical history of borderline diabetes

Borderline diabetes is a term that NDDG recommended

be abandoned.7 It has been applied in the past by physicians to

patients who had some impairment of glucose tolerrmce that

might classify the person as being between normal and clearly

diabetic. In table 14, borderline diabetes is related to the glucose tolerance status of the NHANES II population. The percent of persons with a history of borderline diabetes increased

as the severity of glucose intolerance increased from normal, to

diabetes with no medical history, to diabetes with a medical

history (and presumably longer duration of hyperglycemia than

diabetes with no medical history). The percent of persons with

IGT who had a history of borderline diabetes was between, but

not statistically ditTerent from, the percent with undiagnosed

diabetes and the percent with normal glucose tolerance. These

findings are consistent with previous studies showing that diabetes tends to arise more frequently among persons who already

have some impairment of glucose tolerance.2*’25

Association of diabetes and IGT with

medical history of potential diabetes

and with parental history of diabetes

Numerous studies, most notably a study of concordance

for diabetes in identical twins,zbhave strongly implicated genetic

factors in the etiology of diabetes. In the past, genetic or other

factors in a person’s medical history, including a family history

of diabetes, that placed a person at a higher risk of developing

diabetes may have resulted in a diagnosis of potential diabetes,

a term no longer recommended for use.

Table 14 presents the prevalence of two genetic indicators—

previous diagnosis of potential diabetes and parental history of

17
diabetes-in the NHANES II population divided into diabetes

status groups. The rates for a previous diagnosis of potential

diabetes were equal among persons with normal glucose tolerance, IGT, and undiagnosed diabetes, but higher among persons with a medical history of diabetes. Persons with a medical

history of diabetes or IGT were more likely to report a parental

history of diabetes than persons with normal glucose tolerance,

and the difference between undiagnosed diabetics and those

with normal glucose tolerance approached statistical significance @ = 0.11 ). The percent of persons with undiagnosed

diabetes who reported a parental history of diabetes was not

statistically significantly different from the percent reported by

either diagnosed diabetics or persons with IGT. These findings

support the importance of genetics in the etiology of diabetes,

although it is likely that the lower rate of parental diabetes in

persons with normal glucose tolerance was partly due to their

being significantly younger and their parents not having developed diabetes yet.

Association of diabetes and overweight

To assess obesity, body mass index (BMI)27was calculated

which is weight (in kilograms) divided by height (in meters)

squared. This ratio was then converted to percent desirable

weight (PDW). Of the overweight indexes that utilize height

and weight, BMI has the highest correlation with independent

measures of obesity, such as skinfolds or body density .27Other

analysts have found that an index of weight divided by height

to the 1.5 power has a lower correlation with height for females,

which indicates that it may be preferable to BMI.28 However,

height squared has been used in this report to be consistent

with other studies on diabetes. Although BMI adjusts weight

for differences in height the interpretation of specific BMI

values differs by sex. For example, 120 percent of PDW calculated from the Metropolitan Life Jn.surance medium-frame

tables as adapted by an international expert committee29 corresponds to a BMI of 27 for males but only 25 for females. To

compare overweight-related sex differences, BMI was converted

to PDW by multiplying BMI by 4.76 for females and 4.39 for

males, These multipliers were obtained from the international

committee’s table of recommended weightin relation to height.29

Percent desirable weight also has a moderate nonlinear relationship with age.28

Table 14 shows the percent of persons in each diagnostic

group who were 20 percent or more over ideal body weight,

which is equivalent to 120 percent of PDW. Over half of diagnosed diabetics were overweight by this criterion. Over half of

persons with undiagnosed diabetes and IGT were also overweight, whereas only one-third of persons with normal glucose

tolerance were 20 percent or more over ideal body weight.

Obesity has repeatedly been linked with NIDDM and with

insulii resistance leading to high blood glucose levels;30’31and,

anecd!otally,about 80 percent of diagnosed diabetics are thought

to be overweight. However, weight loss is a treatment for diabetes, and it is possible that the rate of only 55.6 percent was

due to diabetics maintaining more normal weight levels than

expected. Another explanation could be differential mortality

wherein very overweight diabetics die at a rate greater than less

overweight diabetics. This hypothesis cannot be tested fi’om

the NHANES II cross-sectional data.

In table G, the relationship between diabetes and overweight is explored by race, sex, and PDW groupings. Tables

15 and 16 present these data for persons with and without a

medical history of diabetes. The prevalence of diabetes rose

with PDW for those with and those without a medical history

of diabetes, but differences by race and sex were insignificant

or inconsistent. Consequently, the only correlate of diabetes

prevalence in table G was overweight. The prevalence of diaTable G. Prevalence of diabetes in adults aged 20-74 years, by race, sex, and parcant desirable weight: Unitad States, 1976-80

Percent desirable weightl

Less than 150 or

Race and sex 100 700-109 110-119 120-134 135-149 higher

All racesz Percent of population

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 4,(Q 4.6 7.7 10.2 20.6

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 4.4 5.3 6.9 8.6 13.3

Female, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 3.6 3.8 8.4 11.0 22.4

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 3.5 4.5 7.3 10.4 19.3

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,5 3.2 5.2 6.2 8.6 11.0

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 3.7 3,6 8.4 11.5 21.3

Black3

Both aexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7 7.0 6.6 9.7 10.1 24.5

‘Male, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 10,4 5.1 12.6 9.1 28.4

Female, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.0 3.1 7.0 8.3 10.5 24.4

1Percent desirable weight ia an index of weight adjusted for height equal to k times weight divided by height aquared, where k k 4.39 for males and 4.76 for females.

‘Includes races other than white or black.

3Sex and age estimates for black persona are presented for information only. They are too unreliable to be considered national prevalence estimates.

NOTE Includes both persons reporting in medical history interview that a doctor had told them they had diabetes or sugar diabetes and persons classified diabetic on

an oral glucose tolerance test using National Diabetea Data Group criteria (ace text for criteria).

18
300

280

260

240

220

c.-

80

9m*m**. ***. m.. m● ****9*4

● a*m***m O* OOmm. m● **.*. ) ‘5

60

40 t

Fasting

()~

90 100 110 120 130 140 150 160

r

1

1 hour

II I I 1 I I I

[

90 100 110 120130 140150 760

Percent desirable weight

95

90

● *m*m***a*m**** ● * ● .*

J

75

9** ● *mOes***m ● ***.*

*

50

10

- ~25

5

1

2 hour

II I I I 1 I I I

90 100 110 120 130 140150 160

Figure 5. Selected percentile distributions of fastina, l-hour, and2-hour plasma glucose values of theoral glucose tolerance test by percent

desirable weight: United Statas,1976-80

betes for those at least 1!4 times desirable weight (20.6 percent)

was 5.7 times the prevalence for those less than desirable weight

(3.6 percent).

Table 17 presents, for reference purposes, the estimated

percent distribution of all civilian noninstitutionalized persons

inthe IJnited States aged20-74years by PDW class. In table

18, the relationship of the fasting and 2-hour glucose levels to

PDW is presented for persons with no medical history of diabetes. The percent of persons with FPG 140 milligrams per

deciliter or greater was not clearly related to PDW. The percent

with FPG 115 milligrams per deciliter or greater showed an

upward trend with increasing PDW value, from 2 percent in

the less than desirable weight group to 15 percent in the most

overweight. The percent of persons with 2-hour values of 200

milligrams per deciliter or greater or 140– 199 milligrams per

deciliter also showed an upward trend with increasing PDW.

Because the 2-hour value of 200 milligrams per deciliter is

highly correlated with the diagnosis “diabetes” and the 2-hour

value of 140-199 milligrams per deciliter approximates the

diagnosis “IGT,” the trend in table 18 is to be expected in light

of the trend seen in table G. Other investigators have also

demonstrated this apparent loss of glucose tolerance with increasing overweight.32,33

This phenomenon of decreasing glucose tolerance with increasing overweight is clearly illustrated in table 19 and figure

5, where a distinct rise in mean fasting, 1-hour, and 2-hour

post-glucose challenge values occurred with increasing PDW.

Table 20 shows that these increases occurred in each age group.

19
Discussion

The Second National Health and Nutrition Examination

Survey (NHANES II) is the first national study to rigorously

investigate the prevalence of diabetes and impaired glucose

tolerance using oral glucose tolerance tests (OGTT’S) and

classification criteria of the National Diabetes Data Group

(NDDG) and the World Health Organization (WHO). The

sample was so designed tha~ after weighting and other statistical

adjustments, it would be representative of the civilian noninstitutionalized population of the United States during 1976–80.

In the execution of the study, however, there was substantial

nonresponse to the household medical history interview, to the

physical examination, and to the OGTT. Because of this nonresponse, it is possible that response bias affected the estimates

presented in this report. Analysis of the NHANES 11 clata

suggeststhat such effects were not substantial, but this evidence

is of necessity inconclusive. Estimates for black persons based

on NHANES II data are particularly problematical. The

sample size for black persons was small, and this was compounded by such low OGTT response rates that the estimates

for black persons should be interpreted as preliminary or exploratory. Rates should be investigated in other studies in which

the number of black sample persons is larger.

Based on the NHANES II medical history, 3.4 percent of

adults aged 20-74 years had been previously diagnosed by a

physician as having diabetes. This estimate is slightly larger

than an estimate from the 1976 National Health Interview

Survey (NHIS), 3.0 percent, probably because NHANES II

relied on self-reported medical hktories whereas NHIS a&

cepted proxy respondents. (In the 1976 NHIS, estimates using

self-respondent data are higher than estimates from combined

self-respondents and proxy respondents.)

Based on NHANES II OGTT results, the prevalence of

undiagnosed diabetes was 3.2 percent using NDDG criteria

and 3.4 percent using WHO criteria in adults aged 20–74 years

in 1976–80.

The NDDG and WHO criteria for classifying and diagnosing diabetes and glucose intolerance’,s were based on prob

abilities of developing complications of diabetes (that is, retinopathy and nephropathy) assessed in population-based

prospective studies. These criteria have become widely accepted internationally, and NHANES II is the first national

study in which these criteria have been used. Consequently,

the results of NHANES II may serve as a reference against

which researchers and clinicians can compare their subjects

and patients.

The prevalence of a medical history of physician-diagmosed

diabetes has been documented in many studies of U.S. communities34 and in the NHIS, which has been continuous since

1958. However, it is difiicult to compare the NHANES II

estimates for diabetes with those of earlier studies because

there was no generally accepte~ standard deftition of diabetes

and because of differences in measurement and methodology.

The NHANES II estimates of previously diagnosed diabetes

are similar to an estimate ffom the Health Insurance Study

(2.7 percent of persons aged 14-64 years) conducted in several

U.S. communities in the midseventies.35 They are higher than

rates reported in earlier community studies reviewed in Wes~34

but this is to be expected because the prevalence of diabetes in

the United States has been increasing as documented by NHIS

since 1958.20

In a study in Oxford, Massachusetts, in 1946-47 the

prevalence of known diabetes was found to be 0.77 percent for

persons aged 14-75 years, and diabetes was discovered in

0.88 percent using both hyperglycemia and glycosuria to define

diabetes. In this study if hyperglycemia had been the only criterion used, 2.7 percent would have been classified as newly

dkcovered diabetics.3e In another study in Massachusetts, the

Framingham heart study, which began in 1948, the prevalence

of diabetes was 1.9 percent, and approximately half of these

were newly diagnosed at study examinations.37 In a study in

Baltimore in 1953–56, 58 percent of persons classified as

diabetic were not previously aware that they had diabetes.38 In

Sudbury, Massachusetts, in 1964, 1.4 percent of persons over

14 years of age reported a medical history of diabetes and 1.2

percent were newly diagnosed on the basis of a diagnostic

OIGTT.S9In Tecumseh, Michigan, in the early sixties, known

diabetes was found in 2.5 percent of persons aged 20 years and

over, and 5.3 percent were found to be hyperglycemic 1 hour

after a 50-gram oral glucose challenge.40 At about the same

time, 1960–62, the National Health Examination Survey estimated that 1.8 percent of the U.S. population aged 18–-14years

had known diabetes and, with a 50-grarn glucose challenge, 1.9

percent were hyperglycemic.41 A study of adults agecl 30–95

years in Rancho Bernardo (a predominantly white, uppermiddle-class community in California) in 1972-74 found 4.5

percent prevalence of known diabetes and 2.9 percent unknown

diabetes based on fasting plasma glucose concentrations of 140

milligrams per deciliter or more.42

NHANES II was not designed to assess the prevalence of

diabetes in Hispanic Americans, but three studies of Mexican

Americans in Texas found that the prevalence of diabetes was

‘higherfor this group than for white Americans generally. In

20
Laredo in 1979, 14.5 percent of Mexican-American adults aged

45–74 years had known diabetes, and 2.4 percent were found

to be diabetic with fasting plasma glucose concentrations of

140 milligrams per deciliter or more.43 In samples of persons

aged 25–64 years from three San Antonio neighborhoods in

1979-81, diabetes was found in 6.5 percent of white Americans

and in 15.5 percent of Mexican Americans.M In 1981 diabetes

was found in 7.9 percent of a sample of persons aged 15 years

and over from the urban areas of Starr County 6.4 percent

were previously known and 1.5 percent were determined by an

OGTT with NDDG criteria after preliminary screening.45

In general, using various criteria and methods to define

diabetes, these earlier studies found the prevalence of undiagnosed diabetes to be about equal to or even greater than that of

known diabetes.36The NHANES II data continue to document

this one-toone ratio, even though the NDDG criteria are far

stricter than earlier criteria for diagnosing diabetes. The ratio

holds not only for all adults, but also for all age and race groups.

For all adults the ratio of known diabetes (3.4 percent) to unknown diabetes (3.2 percent) was 1.1. For white persons the

ratio was 1.1 and for black persons, 1.2. For the youngest age

group, persons aged 20–44 years, it was 1.2, and for the oldest,

persons aged 65–74 years, 1.1. It would appear that a large

reservoir of undiagnosed diabetes still persists in the United

States.

Impaired glucose tolerance (IGT) is a new diagnostic

category suggested by NDDG and WHO in 1979 for the purpose of eliminating the label “diabetes” from persons formerly

termed “borderline” or “chemical” diabetics. The prevalence

found in NHANES II indicates that IGT is a significant category in terms of numbers of people. Using NDDG criteri~ 4.6

percent of adults aged 20–74 years had IGT, using WHO criteri~ 11.2 percent had it. The clinical significance of IGT has

not been fully investigated From earlier studies it appears that

persons with IGT progress to overt diabetes at about four times

the rate of persons with normal glucose tolerance.4c~47However,

many persons with IGT remain in this class for years, or return

to normal glucose tolerance. Although IGT does not appear to

be associated with development of the microvascular complications characteristic of diabetes, it does seem to be associated

with increased rates of macrovascular disease.25 Major discrepancies exist between the IGT rates obtained from NDDG

criteria and those from WHO criteria. Differences between

criteria are still unresolved by these organizations. Most preferable would be criteria that define an impaired glucose tolerance

catego~ that is predictive of complications, but the NHANES

II cross-sectional data are not ideal for this purpose. Rather,

prospective studies are needed to assess the significance of

IGT in populations.

21
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Lcmcet 1(7902)300-302, 1975.

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Diabetes mellitus in Tecumseh, Michigam Prevalence, incidence, and

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23
List of detailed tables

1. Percent of persons, standard error of percent, and number

of interviewed persons aged 20-74 years reporting in a

medical history interview of the Second National Herdth

and Nutrition Examination Survey that a doctor had told

them they had diabetes or sugar diabetes, by race, sex, and

age United States, 1976 -80...... . . . . . . . . . . . . . . . . . . . .

2. Percent of persons, standard error of percent, and number

of examined persons aged 20–74 years classified undiagnosed d]abetic by oral glucose tolerance test (OGTT) using

National Diabetes Data Group criteria, by race, sex, and

age: United States, 1976 -80 . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Percent of persons, standard error of percent, and number

of examined persons aged 20–74 years classified undiagnosed diabetic by oral glucose tolerance test (OGTT) using

World Health Organization criteria, by race, sex, and age:

United States, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Percent and standard error of percent of white adults aged

20-74 years with diabetes, by previous diabetes status,

sex, andage United States, 1976-80 . . . . . . . . . . . . . . . . . .

5. Percent and standard error of percent of adults aged 20-74

years with medical history of diabetes as reported in the

National Health Interview Survey, by race, sex, and age

United States, 1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. Percent and standard error of percent of adults aged 20-74

years with impaired glucose tolerance, by criteria of the

National Diabetes Data Group and of the World Health

Organization, race, sex, and age United States, 1976-80 . . .

7. Percent and standard error of percent of white adults aged

20-74 years with impaired glucose tolerance, by criteria of

the National Diabetes Data Group and of the World Health

Organization, sex, and age United States, 1976 -80......

8. Percent and standard error of percent of adults aged 20-74

years with diabetes or impaired glucose tolerance, using

National Diabetes Data Group criteria, by race, sex, and

age United States, 1976 -80 . . . . . . . . . . . . . . . . . . . . . . . . . .

9. Mean fasting plasma glucose concentration, standard deviation, standard error, and selected percentiles of the oral

glucose tolerance tests of adults aged 20-74 years with no

medical history of diabetes, by race, sex, and age United

States, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10. Mean 1-hour plasma glucose concentration, standard deviation, standard error, and selected percentiles of the oral

glucose tolerance tests of adults aged 20-74 years with no

medical history of diabetes, by race, sex, and age: United

States, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11. Mean 2-hour plasma glucose concentration, standard deviation, standard error, and selected percentiles of the oral

glucose tolerance tests of adults aged 20-74 years with no

mledical history of diabetes, by race, sex, and age: United

States, 1976 -80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12. Mean plasma glucose concentration, standard deviation,

25

stsndard error, and selected percentiles of the oral glucose

tolerance tests of white adults aged 20–74 years with no

medical history of diabetes, by fasting 1-hour, and 2-hour

wmipunctures, sex, and age United States, 1976–80 . . . . .

13. Percent of adults aged 20-74 years with no medical history

26

of diabetes, by level of fasting plasma glucose, who would

be classified as having diabetes or impaired glucose tolerance, by criteria of the National Diabetes Data Group

and of the World Health Organization United States,

1976 -80.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14. Percent, standard error of percent, and median age of adults

27 aged 20-74 years with medical history of borderline diabetes, potential diabetes, a parent with diabetes, or 120 percent or more of desirable weight, by diabetes status: United

28 States, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15. Percent and standard error of percent of adults aged 20-74

years reporting in a medical history interview that a doctor

had told them they had diabetes or sugar diabetes, by race,

29 sex, ad percent deskable weighb lJnited States, 1976-80 . . .

16. Percent and standard error of percent of adults aged 20-74

years classhled undiagnosed diabetic by oral glucose tol-

. lerance test using National Diabetes Data Group criteria,

30 by race, sex, and percent desirable weiglk United States,

1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17. Percent distribution of adults aged 20-74 years by percent

desirable weigh~ according to race and sex United States,

31 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18. Percent and standard error of percent of adults aged 20-74

years with no medical history of diabetes and with abnormal

fasting or 2-hour plasma glucose concentrations, by veni31 puncture, sex, and percent desirable weighti United States,

1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19. Mean plasma glucose concentration, standard deviation,

standard error, and selected percentiles of the oral glucose

tolerance tests of adults aged 20-74 years with no medical

32 history of diabetes, by venipuncture and percent desirable

weighti United States, 1976 -80... . . . . . . . . . . . . . . . . . . . .

20. Mean fasting and 2-hour plasma glucose concentrations of

the oral glucose tolerance tests of adults aged 20-74 years

with no medical hktory of dlabete~, by percent desirable

33 weight and age United States, 1976–80 . . . . . . . . . . . . . . . .

34

35

37

37

38

38

39

39

40

40

24
Table 1. Parcent of persons, standard arror of percent, and numbar of interviewed parsons agad 20-74 yeers reporting in a medical history interview of tha Sacond National Haalth and

Nutrition Examination Survay that a doctor had told them they hed diabatea or sugar diabates, by race, sex, and agrx Unitad Statea, 1976-80

Age

Total,

Age

Total,

Age

Total,

20-74 20-44 45-54 55–64 65-74 20-74 20-44 45-54

Race and sex

55-64 65-74 20-74 20-44 45-54

years years years

55-64

years

65-74

years years years years years years years years years years years

All racasl Percent of rzooulation . . Standard arror of percent Number of interviewed oersona

Both sexes . . . . . . . . . . . . . . . . . . . . . . . 3.4 1.1 4.3

,.

6.6 9.3 0.14 0.11 0.53 0.66 0.45 15,357

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9 0.6 4.3 5.6 9.7 0.25 0.12

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8

0.82

1.5

0,64 0.71

4.3 7,4 8.9

7,074

0.24 0.22 0.67 1.10 0.56 8,283

White

Both sexas . . . . . . . . . . . . . . . . . . ... ,, 3.2 1.0 4.2 6.0 8.9 0.16 0.12 0.55 0.58 0.49 13,311

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 0.5 4.5 5.3 9.1 0.27 0.15

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 1.4

0.92 0.66 0.78 6,167

3.9 6.6 8.8 0.23 0.22 0.60 0.91 0.64 7,144

Bleck2

Both sexes . . . . . . . . . . . . . . . . . . . . . . . 5.2 2.2 5.7 13,1 13.6 0.49 0.58 1.46 2.65 1.35 1,762

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5 *1.8 “3.6 9.2 17.2 0.60 0.63 * 1.48

Female . . . . . . . . . . . . . . . . . . . . . . . . ,. 5.9 *2.6 “7.5

2.55 2.87

16.3

765

10,8 0.99 1.00 *2.33 *4.03 1.51 997

6,531

3,064

3,467

1,866

892

974

5,587

2,635

2,952

795

354

441

1,613

787

826

212

87

125

3,328

1,525

1,803

2,925

1,347

1,578

364

163

201

3,632

1.593

2,039

3,186

1,398

1,788

391

161

230

1]nclude~ races other than white or black.

2Sex and age estimates for black paraons are presented for information only. They sre too unreliable to ba considered national pravalenca estimates,
Table 2. Percent of parsona, standard error of percant, and number of examined persons aged 20-74 yeara classified undiagnosed diabetic by oral glucose tolerance tast (OGll_) using

National Diabates Data Group criteria, by race, sax, and age United Statea, 1976-80

Age Age

Total, Total,

Age

20– 74

Total,

20-44 45-54 55-64 65-74 20-74

Race and sex

20–44 45-54 55-64 65-74 20– 74 20-44 45–54

years years years years

55–64

years years

65– 74

years years years years years years years years years

All races] Percent of population Standard error of percent Number of examined persons

Both sexes . . . . . . . . . . . . . . . . . . . . . . . 3.2 “0.9 4.2 6.2 8.4 0.35 0.31 0.81 1.03 0.85 4,044 1,636 524 928 956

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 ‘0.8 “3.6 4.0 9.5 0.41 0.39 1.28

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 “1.0 4.7 8.1 7.6 0.42 0.38 1.14

White

8oth sexes . . . . . . . . . . . . . . . . . . . . . . . 3.0 “0.7 4.0 5.9 8.0 0.38 0.31 0.90

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 “0.5 ‘3.2 3.8 3.0 C!.36 0.27 1.25

.03 1.42 1,889

.68 0.89 2,155

.24 0.85 3,570

.00 1.38 1,678

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 “0.8 4.6 7.9 7.3 0.52 0.40 1.25 2.08 0.95 1,892

Blackz

Both sexes . . . . . . . . . . . . . . . . . . . . . . . 4.4 “0.9 *7.2 *7.7 *1 2.3 0.91 0.68 * *3.75 *3.94 397

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . “4.0 “1.0 *7.5 *5.2 *12.2 1.72 “0.98 *

* *

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6 “0.9 “7.0

176

*9.1 *1 2.3 1.35 *0.91 * *“4.50 221

747 232 464 446

889 292 464 510

,429 465 827 849

652 214 418 394

117 251 40s ~~~

166 47 91 93

76 16 41 43

90 31 50 50

1Includes races other than white or black.

‘Sex and age estimates for black persona are presented for information only. They are too unreliable to be considered national prevalence estimates.

NOTE Undiagnosed diabetea defined as meeting diagnostic criteria for diabetes without medical history of diabetes. Refer to text for National Diabetes Data Group criteria for classifying results of OGTT’S.
Table 3. Percent of paraona, standard error of percent, and number of examined parsons aged 20-74 yaars classified undiagnosed diabetic by oral glucose tolerance test (OGIT) using

World Health Organization criteria, by rata, sex, and egw United Statas, 1976-80

Age

TotaL

Age

Total,

Age

Total,

20-74 20-44 45-54 55-64 65-74 20–74 20-44 45-54 55-64

Race and sex

65-74 20– 74 20-44

years years years

45-54 55-64 65– 74

years years years years years years years years years years years years

All racesl Percent of population Stsndard error of percent Number of examinad persons

Both sexes . . . . . . . . . . . . . . . . . . . . . . . 3.4 “0.9 4.2 6.8 9,4 0.35 0.35 0.81 1.11 0.99 3,991 1,607 518 922 944

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0 “0.9 *3.6 4.3 10.4 0.41

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9

0.48

‘1.0

1.28 1.06

4.8 9.0

1.60 1,872

8.5

741

0.43 0.41

231 458

1.15 1.76

442

0.93 2,119 866 287 464 502

White

Both sexas . . . . . . . . . . . . . . . . . . . . . . . 3.2 “0.7 4.0 6.5 9.0 0.38 0.35 0,91 1.31 0.89 3,526 1,406 459 821 840

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 “0.5 *3.3 4.1 10.0 0.36 0.42 1.25 1.03 1.57

Female . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7 “0.8 4.8

1,664

8.6 8.2

649

0.53

213

0.42 1.26

412

2.14

390

1.09 1,862 757 246 409 450

Black2

Both sexes . . . . . . . . . . . . . . . . . . ,., ., 4.7 *1.O *7.2 *9,4 *12.8 0.99 0.69 * *4.29 *4.33 389 161 47 91

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . *4. 1

90

“1.0 *7.5 *5.4 *1 2.2 1.74 *1.01 *

* *

Female . . . . . . . . . . . . . . . . . . . . . . . . ., 5.1 80.9 *7.1 *11.6

173 73

*13.3 1.37

16 41 43

‘0.93 *

* *

216 88 31 50 47

1Includes races other then white or bkjck.

2Sex and age estimet.es for black persons ere presented for information only. They are too unreliable to be considered national prevalence est(metes.

NOTE Undiagnosed diabetes defined as meeting diagnostic criteria for diabetes without medical history of diabetes. Refer to text for World Health Organization criteria for classifying rasu[ta of OGTT’S.
Table 4. Percent and standard error of percent of white adults aged 20-74 years with diabetes, by previous diabetes status, sex, and age

United States, 1976-80

Age

Total,

Previous diabetes 20-74 20–24 25-29 30-34 35-39 40–44 45-49 50-54 55-59 60-64 65-69 70-74

status and sex years years years years years years years years years years years years

All diabetics

Both sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

Medical history of

physician-diagnosed

diabetes!

Both sexes.,.....,..

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

No medical history

of diabetesz

Both sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

All diabetics

Both sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

Medical history of

physician-diagnosed

diabeteal

Both sexes . . . . . . . . . .

Male, . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

No medical history

of diabetesz

Both sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

6.2

5.3

6.9

3.2

2.8

3.6

3.0

2.5

3.4

. . .

. . .

---

0.16

0.27

0.23

0.38

0.36

0.52

0.9

0.0

1.7

“0.4

0.0

“0.7

“0.5

0.0

*1.O

---

. . .

---

0.16

0.’32

0.53

0:94

1.3

0.9

1.7

‘1.0

“0.4

“1.7

“0.3

“0.5

0.0

.-.

---

. . .

0.34

0.22

0.65

0.28

0.54

. . .

1,3

1,4

1,2

“0.7

“0.4

*0.9

“0.6

“1.0

“0.3

. . .

. . .

.-.

0.25

0.31

0.41

0.34

0.67

0.32

Percent of population

1.8 3.7 7,2 9.0

0.7 2.7 5.5 9.9

2.8 4.5 8.8 8.2

1.6 1.6 3.0 5.3

“0.7 ‘1.5 *2.6 6.3

2.5 *1.7 3.4 4.3

“0.2 “2.1 4.2 *3.8

0,0 *1.2 *2,8 *3.6

*0.4 *2.8 “5,4 *3.9

Standard error of percent

. . . . . . ..- . . .

. . . . . . . . . . . .

-- --- ..- -..

0.41 0.47 0.59 0.83

0.44 0.63 0.87 1.59

0.70 0.52 0.76 0.89

0.19 1.57 1.24 1.32

1.16 1.64 1.88

0;36 2.04 1.90 2.05

10.3

5.8

14.1

4.8

*3.2

6.2

*5.5

“2.6

*7.9

. . .

. . .

-..

0.83

1.03

1.37

2.20

1.47

3,81

13.8

12,5

15.1

7.3

7.5

7.2

6.5

5.0

7.9

. . .

. . .

. . .

0.60

0.88

0.88

1.17

1.38

1.67

16.1

16.9

15.4

8.3

7.5

8.8

7.8

9.4

6.6

-..

..-

..-

0.70

0.99

0.85

1.06

2.10

1.43

18.0

19.5

16.9

9.8

11.2

8.8

8.2

8.3

8.1

.-.

..-

..-

0.83

1.49

0.90

1.55

2.06

1.90

1Reportsd in medical history interviaw thst a doctor had told them they had diabetes or sugar diabetes.

‘Diagnosis based on oral glucose tolerance teat using National Diabetes Data Group criteria in persona without medical history of diabetes.

28
Table 5. Percent and standard error of percent of adults aged 20-74 years with medicaI history of diabetes as reportad in the National Health

Interview Survey, by race, sex, and age: United States, 1976

Age Age

Tote/, TotaL

20-74 20-44 45-54 55-64 65-74 20-74 20-44 45-54

Race and sex

55-64 65-74

years years years years years years years years years years

All racest Percent of population Standard error of percent

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0 1.0 3.8 5.5 8.3 0.08 0.05 0.18 0.22 0.32

Male. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 0.8 3.7 5.7 7.9 0.11 0.07

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0.27

3.2

0.30

1.2 3.9

0.47

5.4 8.7 0.11 0.08 0.24 0.29 0.44

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 0.9 3.5 5.2 7.9 0.08 0.05 0.20 0.22 0.33

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7 0.7 3.5 5.5 7.5 0.11 0.07

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

0.27

3.0 1.1

0.32

3.4

0.49

4.9 8.3 0.10 0.07 0.26 0.30 0.46

Black

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4 1.4 7.1 8.8 12.0 0.27 0.20 0.72 0.87 1.32

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6 0.9 5.9 7.5 10.9 0.35 0.27

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.9

0.98 1.16

1.7

2.13

8.1 9.9 12.8 0.40 0.28 1.06 1.30 1.37

1Includes races other than white Or black.

29
Table 6. Percent and standard error of percent of adults aged 20-74 years with impaired glucose tolerance, by criteria of the National Diabetes

Data Group and of the World Health Organization, race, sez and age: United States, 1976-80

Age Age

Total, Total,

20-74 20-44 45-54 55–64 65-74 20-74 20-44 45-54 55-64 65-74

Criteria, race, and sex Vears years years years years Vears years Vears years years

NATIONAL DIABETES DATA

GROUP CRITERIA

All racesl

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blackz

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WORLD HEALTH ORGANIZATION

CRITERIA

All racesl

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexea. . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Blackz

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of population Standard error of percent

4.6

4.6

4,7

4.6

4.4

4.7

3.8

5.9

*2.3

11.2

10.3

12.0

10.7

10.2

11.1

12.7

11.3

13.6

2.1

*1.2

2.B

2.0

“1.0

2.8

*1.2

*1.4

*1.1

6.4

4,7

7.8

5.6

4.6

6.5

10.3

*4.7

14.2

7.0

7.3

6.7

6.3

6.3

6.2

*1O.7

*18.B

*5.1

14.8

13.1

16.3

13.6

12.6

14.5

*1 7.0

*1 8.8

*1 5.8

7.4

9.8

5.2

7.7

10,1

5.5

*4.5

“7.0

“3.1

15.1

17.2

13.4

1!5.3

17.2

13.7

14.4

“18.6

12.2

9.2

8.9

9.4

9.5

9.0

9.9

*3.4

“5.4

*1.9

22.8

22.8

22.7

23.0

22.8

23.0

*14.5

*22.6

*8.2

0.39

0.58

0.67

0.42

0.61

0.68

0.82

1.18

1.24

0.52

0.72

0.97

0.57

0.76

1.03

2.15

2.02

2.70

0.39

0.39

0.70

0.38

0.34

0.73

0.84

*1 .30

“1.11

0.59

0.69

0.98

0.64

0.72

1.05

1.97

*1 .80

*2.98

0.93

1.65

1.4B

1.04

1.79

1.15

*

*

*

1.4B

2.09

2.52

1.50

2.25

2.38

*

*

*

0.91

1.44

1.24

0.98

1.48

1.43

*2.19

*

*

1.23

1.67

1.89

1.28

1.79

2.04

*2.24

*

*

0.85

1.60

1.15

0.87

1.55

1:20

“2.09

*

*2.22

1.70

2.05

2.59

1.65

2.04

2.55

*4.93

*

*

1Includes races other than white or black.

‘Sax and age estimates for black persons are presented for information only. They sre too unreliable to be considered national prevalence estimates.

NOTE See text for criteria defining impaired glucose tolerance,

30
Table 7. Percent and standard error of percent of white adults aged 20-74 years with impaired glucose tolerance, by criteria of the National

Diabetes Deta Group end of the World Health Organization, sex, and age United States, 1976-80

Age

TotaL

20-74 20-24 25-29 30-34 35-39 40–44 45-49 50-54 55-59 60-64 65-69 70-74

Criteria and sex years years years years years years years years years years years years

National Diabetes

Data Group criteria

Bc!th sexes . . . . . . . . . .

Mi~le . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

World Heslth

Organization criteria

Both saxes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

National Diabetes

Data Group criteria

Bolh sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

World Health

Organization criteria

Both sexes . . . . . . . . . .

Male . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . .

4.6

4.4

4.7

10.7

10.2

11.1

0.42

0.61

0.68

0.57

0.76

1.03

‘0.4

*1.O

4.0

*5.5

*2.7

0.30

0.68

. . .

1.17

2.26

1.18

“1.7

“0.4

*3.1

*3.6

*1,5

*6.O

0.82

0.41

1.66

1.21

0.92

2.34

*1.8

*1.3

*2.1

5.4

“3.7

6.6

0.67

0.97

1.06

1.15

1.53

1.70

Percent of population

*2.9 *3.5 6.3 6.2

“0.7 *1.8 *7.8 “5.0

“4.7 “5.0 “5.0 7.4

7.5 8.9 13.9 13.2

*6.6 7.3 14,5 10.9

8.3 “10.3 13.4 15.5

Standard error of percent

1.04 1,07 1.87 1.10

0.72 1.34 2.62 2.09

1.71 2.38 2.53 1.45

1.80 1.71 2.61 1.92

2.89 1.91 3.36 2.85

2.45 3.50 3.53 3.28

6.8

*8.8

*5.1

14.0

16.4

11.9

1.72

2.85

2.34

2.36

3.56

3.35

8.8

11.5

6.1

16,9

18.0

15.9

1.06

1.62

1.60

1.30

1.89

2.30

12.0

9.3

14.2

22.8

20.7

24.5

1.28

2,09

1.78

1.78

2.88

2.95

5.8

8.5

*3.7

23.0

25.8

20.9

1.05

2.39

1.24

2.58

3.21

3.18

NOTE See text for criteria defining impaired glucose tolerance.

Table 8. Percent and standard error of percent of adults aged 20-74 years with diabetea or impaired glucose tolerance, using National

Diabetes Data Group criteria, by race, sex, and age United States, 1976-80

Age Age

Total, Tota[

20-74 20-44 45-54 55-64 65-74 20-74

Race and sex

20-44 45–54 55-64 65-74

years years years years yearn years years years years years

All races! Percent of population Standard error of percent

Both sexes. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8 4.0 15.0 19.1 25.9 0.52 0.45 1.24 1.39 1.32

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.1 2.8 14.6 19.5 26.2 0.78 0.55 2.11 1.76 2.15

Female . . . . . . . . . . . . . . . . . . . . . . . . .,, . . . . 11.4 5.0 15.3 18.7 25.7 0.70 0.81 2.07 1.76 1.48

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.4 3.5 13.7 18.8 25.4 0.56 0.47 1.34 1.55 1.38

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.6 2.2 13.0 19.3 25.4 0.77 0.46 2.22 1,92 2,17

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 4.6 14.3 18.4 25.4 0.69 0.79 1.89 2.00 1.45

81ack2

Both eexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.5 *3.5 25.0 21.0 27.6 1.11 1.31 *

*4.9 *4.4

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.5 ‘3,3 32.1 *19.7 28.5 1.81 *1.6 * * *

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.8 *3.8 20.3 22.1 27.0 1.48 *1.5 * * *5.3

llncludes races other than white or black.

‘Sex and age estimates for black persons are presented for information only. They are too unreliable to be considered national prevalence eatlmatea.

NOTE Sumof(a) percent ofpersons with medical hiato~of diabetes estimated from the National Health Interview Survey, 1976, and(b) percent ofpersonawlthno

medical history of diabetes but with diabetes or impaired glucose tolerance based on oral glucose tolerance tests according to National Diabetes Data Group cntena

estimated from the Second National Health and Nutrition Examination Survey, 1976-80.

31
Table9. Mean fasting plaama glucose concentration, standard deviation, standard error, andselected parcentilas of theoral glucose tolerance

tests ofadults aged 20-74years with nomedical histo~ of diabetes, by race, sex, and age United States, 1976-80

Percentile

Standard Standard

Race. sex, and age

—

Mean deviation error 5th 10th 25th 50th 75th 90th 95th

ALL RACES1

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

W+ ITE

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years...............,.. . . . . . . . . . . . . . . . . . . .

45-64 years...............,.. . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BLACK2

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64. years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

89.5

96.8

98.1

92.2

97.9

99.8

87.2

95.9

96.8

89.3

96.8

9B.1

91.9

98.1

99.7

87.1

95.5

96.8

89.8

97.5

97.2

94.1

95.7

98.5

86.7

98,7

96.5

10.8

19,3

19.0

9.0

16.5

20.6

11.6

21.7

17.9

10.1

19.5

19.4

8.4

16.8

20.9

11.0

21.9

18.4

16.3

19.8

16.2

12.2

12.8

18.9

1B.6

24.1

16.5

Concentration in milligrams per deciliter

0.34

0.79

0.70

0.33

0.74

0.99

0.46

1.19

0.83

0.34

0.90

0.78

0.31

0.78

1.01

0.46

1.40

0.95

1.28

*1 .35

*1 .80

*1 .34

*1 .60

*

*1 .B7

*2.31

“3.17

77

81

82

80

83

83

75

80

81

77

81

82

80

83

83

76

80

81

75

81

*

*

*

*

*

*

*

79

84

84

83

85

87

78

83

83

80

84

84

83

85

87

78

83

83

78

82

86

80

82

*

76

82

*

84

89

89

87

90

91

82

87

88

84

89

89

87

90

91

B2

87

88

83

89

88

88

89

90

BO

89

88

88

94

94

91

95

96

86

93

94

88

94

94

91

95

96

86

93

94

88

94

94

92

96

96

84

92

91

94

101

102

97

103

103

92

99

101

94

101

102

97

103

103

92

99

101

95

102

103

98

104

101

89

102

105

100

111

112

102

112

115

97

108

111

100

110

112

102

112

115

97

108

111

103

111

112

106

10B

*

97

128

*

104

119

125

106

117

‘129

102

120

121

104

118

123

105

118

125

101

118

121

110

130

*

*

*

*

*

*

*

1Includes races other than white or black.

‘Sex and age estimates for black persons are presented for information only. They are too unreliable to be considered national prevalence estimates.

32
Table 10. Mean l-hour plasma glucose concentration, atandard deviation, atandard error, andselected percentiles of theoral glucose tolerance

tests of adults aged 20-74years with nomedical histo~ of diabetes, byrace, sex, and age United States, 1976-80

Percentile

Standard Standard

Race, sex, and age Mean deviation error 5th 10th 25th 50th 75th 90th 95th

ALL RACES!

8oth sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WHITE

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years....,........,.,,. . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 yaars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BLACK2

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 yeare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130.1

161.0

171.0

136.0

168.7

179.0

125.2

154.2

164.7

129.3

161.2

171.0

135.6

168.6

178.3

123.9

154.4

165.1

129.7

59.1

66.6

31.9

70.7

79.3

128.0

151.5

158.4

43.5

56.5

58.4

45.0

54.8

61.6

42.5

58.3

56.5

42.1

56.8

58.3

43.2

55.2

60.6

41.0

58.6

57.3

52.5

60.8

61.9

54.6

56.8

71.8

54.5

67.2

59.0

Concentration in milligrams per deciliter

1.10

1.90

1.82

1.74

2.30

2.98

1.51

2.77

2.47

1.37

2.20

1.85

1.72

2.54

2.97

1.72

3.19

2,61

3.38

“4.41

“8.70

“5.78

*6.86

*

*5.22

“8.02

*11.04

71

86

95

74

94

97

70

82

92

71

86

92

76

94

95

70

84

90

73

77

*

*

*

*

*

*

*

80

99

110

85

108

119

77

93

103

80

100

109

85

109

119

77

95

102

81

89

113

78

107

*

81

79

*

101

122

132

105

133

140

96

115

125

102

122

132

106

132

140

96

115

126

97

118

123

98

138

141

97

112

117

125

155

164

131

166

172

120

147

159

125

155

165

131

166

172

118

148

159

119

157

155

122

180

160

119

143

144

155

193

203

162

199

207

148

183

197

153

193

204

161

198

207

147

185

198

155

189

193

156

207

206

149

171

180

185

231

237

188

237

247

176

223

230

183

231

235

187

236

242

175

222

231

179

230

265

199

239

*

170

225

*

208

255

275

214

262

291

197

248

257

203

253

266

210

263

285

196

246

257

232

267

*

*

*

*

*

*

*

1Includes races other than whits or black.

2Sax pnd age estimatea for black per~on~ are presented for information only. They are too unreliable to be considered national Prevalence estimates.

33
Table 11. Mean 2-hour plasma glucose concentration, standard deviation, standard error, and selected percentiles of the oral glucose tolerance

tests of adults aged 20–74 years with no medical history of diabetes, by race, sex, and age: United States, 1976-80

Percentile

Standard Standard —

Race, sex, and age Mean deviation error 5th 10th 25th 50th 75th 90th 9!5th

ALL RACESl

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WHITE

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Msle

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BLACK2

Both sexes

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-44 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.1

119.0

133.4

97.4

116.0

133.9

102.4

121.6

133.1

99.0

118.0

132.B

97.1

115.3

133.2

100.7

120.6

132.4

102.6

126.1

137.4

95.5

124.8

140.1

107.7

126.9

135.5

30.6

51.7

58.5

29.1

4B. I

62.9

32.4

55.6

56.3

28.7

52.3

59.3

2B.2

48.9

64.3

29.5

56.1

56.7

40.0

53.9

59.3

26.9

44.3

60.8

47.7

61.4

63.8

Concentration in milligram per deciliter

0.75

1.67

1.94

1.20

2.29

3.27

1.12

2.62

2.33

1,07

2.20

2.14

1.25

2.55

3.50

1.43

2.94

2.61

2.41

*4.89

*7.83

*2.25

*6.31

*

“3.60

“6.70

*9.86

63

66

72

60

62

72

66

70

72

63

64

71

61

62

70

65

69

71

59

74

*

*

*

*

*

*

*

71

75

80

67

70

79

72

79

80

70

74

79

67

69

78

72

76

80

71

81

96

69

79

*

74

81

*

81

90

97

81

88

95

82

91

99

81

90

95

81

87

94

82

91

97

82

95

106

83

101

106

82

95

106

96 113 132 152

109 135 170 209

122 154 199 240

94 111 125 ‘144

108 133 166 ’191

119 154 207 243

98 115 136 156

109 136 177 222

124 154 196 232

96 111 129 146

107 133 169 205

121 154 196 234

94 111 125 140

106 132 166 189

117 153 206 257

96 113 133 152

107 135 175 222

124 154 195 231

94 116 148 156

115 147 179 215

123 149 239 *

93 108 126 *

116 149 167 *

127 156 * *

99 128 155 *

113 147 202 *

114 140 * *

1 Includes races other than white or black.

‘Sex and age estimstea for black persons are presented for information only. They are too unreliable to be considered national prevalence estimatea.

34
Table 12, Mean plasma glucose concentration, standard deviation, standard error, and selected percentiles of the orai 91ucose tolerance tests

of white adults aged 20-74 years with no medical history of diabetes, by fasting, 1-hour, and 2-hour venipunctures, sex, and agtx

United States, 1976-80

Percentile

Standard Standard

Venipuncture, sex, and age Mean deviation error 5th ?Oth 25th 50th 75th 90th 95th

FASTING

Both sexes

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f?5-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years . . . . . . . .. d. . . . . . . . . . . . . . . . . . +........

30-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . .

65-69 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 HOUR

Both sexes

20-24 yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years................,.. . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years.......,,......,,.. . . . . . . . . . . . . . . . . . .

50-54 years................<.. . . . . . . . . . . . . . . . . . .

55-59 years............,,..,.. . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

86.6

87.7

89.4

90.7

93.9

95.1

96,1

97.8

98,3

98.7

97.3

89.2

90.3

92.7

93.1

96.1

96.4

97.9

97.8

100.7

100.3

98.9

84.5

85.1

87.1

88.6

92.0

94.0

94.4

97.9

96.0

97.4

96.0

119.5

124.5

128.9

137.4

141.5

153.6

159.4

164.1

169.3

171.8

169.9

124.7

126.7

140.0

139.5

155.4

163.9

168.0

166.0

177.9

178.1

178.7

8.3

7.9

8.9

9.8

16.2

17.6

15.8

27.8

15.6

21.5

16.5

6.8

7.2

9.4

8.2

11.4

20.9

18.6

74.3

14.6

25.1

14.5

8.9

8.0

8.1

10.8

19.4

15.1

13.1

37.2

16,7

18.8

18.5

38.4

40.2

42.0

41.5

.54.0

58.6

55.7

63.2

52.6

60.3

57.3

40.4

42.6

42.8

44.0

50.6

60.6

61.1

53.7

52.5

65.2

57.5

Concentration in milligrams per deciliter

0.45

0.43

0.51

0.61

1.64

1.31

1,12

2.17

0.74

1.13

0.83

0.51

0.56

0.94

0.68

1.20

1.89

1.56

1.27

0.92

1.81

1.12

0.66

0.66

0.62

0.84

2.12

1.75

1.35

4.07

1.13

1.20

1.22

2.58

2.05

2.44

2.79

4.77

3.51

3.59

4.35

2.43

2.56

2.92

3.50

3.46

3.49

3.46

4.87

5.46

6.14

4.43

3.01

4.26

5.09

77

76

79

78

79

81

81

81

83

82

82

79

80

81

82

*

*

80

83

86

82

84

76

74

77

76

78

79

81

79

81

82

80

68

71

71

76

76

76

88

95

95

90

100

67

71

80

76

*

*

80

95

100

91

114

78

79

81

80

82

83

83

84

86

84

84

82

82

85

83

88

85

84

85

88

86

88

77

76

79

79

80

82

82

83

84

84

83

75

80

80

89

84

88

97

107

108

102

114

79

80

99

87

100

109

105

110

118

115

121

82

83

84

85

87

88

88

89

90

89

90

85

85

87

88

91

89

90

91

92

90

92

80

81

83

83

84

86

86

88

88

87

88

95

98

104

110

107

113

122

127

136

131

132

97

103

114

111

129

122

131

134

142

139

144

86

87

88

91

92

93

94

93

95

94

94

89

90

92

92

95

94

94

95

98

95

96

84

85

86

89

88

92

94

92

93

94

93

118

119

124

135

136

148

152

155

165

164

166

122

120

137

139

153

162

162

163

177

169

175

91

92

94

96

98

98

101

101

104

103

101

93

95

97

99

101

101

101

105

106

103

104

89

89

91

95

95

97

98

98

101

103

99

140

147

152

164

172

178

192

190

199

207

196

147

148

159

170

181

180

197

195

211

209

206

95

97

100

103

104

108

113

108

113

114

110

98

100

103

103

105

108

114

110

114

116

114

93

95

97

100

103

106

108

104

110

112

110

164

177

182

187

198

229

227

236

232

242

232

177

178

193

188

203

234

229

241

242

253

234

98

101

106

105

110

112

119

116

121

125

121

99

102

108

106

*

*

119

116

128

130

122

96

98

100

105

112

115

118

121

118

122

117

181

198

207

208

223

249

265

249

252

263

268

187

198

223

210

*

*

284

255

271

289

283

35
Table 12. Mean plaama glucose concentration, standard deviation, standard error, alnd selected percentiles of the oral glucose tolerance tests

of white adults aged 20-74 years with no medical history of diabetes, by fasting, 1-hour, end 2-hour venipunctures, sex, and age

United States, 1976-80—Con.

Percentile

Standard Standard

Venipuncture, sex, and age Mean deviation error 5th 10th 25th 50th 75th 90th 95th

1 HOUR—Con.

Female

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–69yesrs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 HOUR

Both sexes

20-24 yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-29 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years..............,,.. . . . . . . . . . . . . . .

40-44 years.........,.....,,. . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50–54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–69 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70–74yeers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25–29 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 years....,.....,,...,.. . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40–44 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25–29 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30-34 yeara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40-44 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50-54 yeara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 years, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115.4

122.2

120.8

135.6

129.5

144.2

151.6

162.5

160.9

166.8

162.5

96.4

96.9

98.9

100.1

104.9

113.5

113,2

121,8

125.1

131.9

134.0

95.1

94.9

98.1

96.7

102.7

111.0

112.7

115.7

123.2

132.7

133.9

97.3

99.1

99.4

103.1

106.9

115.8

113.7

127.3

126.9

131,2

134.1

37.6

40.1

40.9

40.6

55.0

58.8

52.9

73.8

53.1

58.1

58.5

24.7

25.5

26.8

27,7

44.2

46.0

50.2

64.6

50.2

63.4

55.4

25.4

25.6

26.6

28.7

42.0

48.2

58.5

43,5

48.7

71.1

57.2

25,0

26.8

27.8

27.5

47.3

46.6

45.1

81.0

52.9

59.2

55.7

Concentration in milligrams per daciliter

3.21

3.33

3.17

3.54

6.04

5.46

4.92

7.74

3.65

3.59

3,56

1.51

‘1.60

‘1.73

2.04

4.03

2.48

3.30

5.50

2.21

3.03

3.25

1.83

2.01

2.16

2.90

4.04

4.07

5.44

4.04

2.67

4.96

4.94

2.04

2.80

2.22

2.22

5.46

3.70

4.99

9,28

3.18

3.80

3.64

68

70

68

76

72

67

90

91

93

89

95

63

62

65

65

62

65

58

66

71

68

77

60

62

63

56

*

*

57

61

67

70

60

68

62

66

72

62

63

68

71

73

67

80

74

81

72

92

78

82

95

106

102

99

110

69

68

72

73

69

75

68

74

80

77

82

65

67

71

65

70

69

63

70

79

77

80

74

70

73

75

67

76

72

79

80

77

83

90

95

94

109

96

106

114

125

129

126

125

82

80

83

83

81

87

86

91

95

93

102

81

77

84

79

81

82

82

95

94

91

102

82

81

82

85

82

90

90

91

96

94

101

114

118

115

133

119

139

144

151

153

159

160

94

96

95

95

99

103

105

108

115

119

125

93

95

95

93

99

101

105

113

112

115

124

95

98

96

99

98

104

105

106

116

121

125

136

145

145

161

163

175

181

188

191

206

184

108

111

110

114

117

127

126

135

141

152

157

107

110

110

111

114

127

126

135

141

151

161

108

112

110

115

122

129

126

136

143

153

155

157

173

173

185

187

222

217

233

226

232

226

123

124

128

134

152

169

186

167

189

195

199

121

120

125

130

133

155

166

159

190

207

196

126

131

130

137

160

174

166

184

189

194

200

174

197

191

204

214

241

242

249

247

256

265

138

138

14.6

147

167

194

185

206

224

257

227

140

130

137

146

*

*

187

171

216

270

226

133

142

147

151

172

209

178

258

226

230

231

36
Table 13. Percent of adults aged 20-74 years with no medical history of diabetes, by level of fasting plasma glucose, who would be classified

as having diabetes or impaired glucose tolerance, by criteria of the National Diabetes Data Group and of the World Health Organization:

United States, 1976-80

Diabetesz Impaired glucose tolerance

National Diabetes World Health National Diabetes World Health

All Data Group Organization Data Group Organization

Fasting plasma glucose levelT adults criteria criteria criteria criteria

Less than 80mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80-84 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85-89 mg/dl, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

90-94 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95-99 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100-l 14mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115-139 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140mg/dl or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100-104 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105-109 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110-l 14mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115-l 19mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

120-124 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

125-129 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130-134 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

135-139 mg/dl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.1

14.5

21.2

22.4

15.7

14.9

3.2

0.9

7.9

4.8

2.1

1.3

0.7

0.6

0.2

0.4

1.3

0.4

0.4

0.5

1.5

5.7

31.0

100.0

2.7

7.4

12.6

12.9

37.7

24.0

75.2

60.7

Percent of population

1.4

0.4

0.4

0.7

1.9

6.2

31.3

100.0

3.6

7.5

12.6

12.9

36.9

24.0

75.2

65.0

1.4

1.0

1.9

2.8

4.4

13.0

28.6

. . .

9,6

11.9

28.1

27.8

35.9

33.6

17.6

15,6

9.0

3.5

5.8

9.2

15.1

24.1

36.6

. . .

20.7

24.7

35.3

40.3

39.6

46.2

17.6

15.6

‘mg/dl= milligrams per deciliter.

2see text fOr ~ritsria defining diabetes and impaired 91WCEe tolerance.

Table 14. Percent standerd error of percent, andmedien ageofadults aged 20-74years with medical histo~of borderline diabetes, potential

diabetes, aparent with diabetes, or120percent ormoreof desirable weight bydiabetes status United States, 1976-80

120 percent 120 percent

Parent or more of Parent or more of

Borderline Potential with desirable Borderline Potential with desirable Median

Diabetes status diabetes diabetas diabetes weighrl diabetes diabetes diabetes weightl age

Percent of population Standard error of percent Years

Total. 20-74 years. . . . . . . 3.5 2.1 16.4 33.8 0.16 0.14 0.49 0.76 41.0

Medical history of

diabetes,, . . . . . . . . . . . . 36.2 8,7 34.3 55.6 2.37 0.99 2.15 2.25 58.1

No medical history of

diabetes:

Undiagnosed

diabetes3 . . . . . . . . . . . . 14.2 2.6 26.5 63.0 2.50 1.23 4.35 5.50 57.1

Impaired glucose

tolerance . . . ...<.... 7.6 2,2 28.2 53.1 2.16 1.10 3.39 4.10 54.0

Norm,al glucose

tolerance. . . . . . . . . . . . . 2.6 2,5 17.0 33.6 0.33 0.35 0.71 0.99 40.0

1Percent desirable weight ia an index of weight adjusted for height equal to k times weight divided by height squared, where k is 4.39 for males and 4.76 for females.

2Reported in medical history intetview that a doctor had told them they had diabetes or sugar diabetes.

3Baaed on oral glucose tolerance teat using National Diabetes Data Group criteria.

37
Table 15. Percent and standerd error of percent of edults aged 20-74 years reporting in medical history interview thet a doctor hed told them

they had diabetes or sugar diabetea, by race, sex, and percent desirable weight United States, 1976-80

—

Percent desirable weightl

—

Less Less

than 1oo– 170- 120– 135- 150 or than 1oo- 710- 120- 135- 150 or

Race and sex 100 109 119 734 149 greater 700 109 119 134 149 greater

All racesz

Both sexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . .

Black3

Both sexes . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . .

Percent of population Standard error of percent

2.0

2.2

1.7

1.B

2.0

1.6

*3.7

*3.5

“4.0

2.4

2.1

2.7

2.4

2.1

2.8

*2.2

*2.7

*1.6

2.3

2.7

1.B

2.3

2.5

2.0

*3.1

“5.1

“1.0

4.0

3.2

4.7

3.B

3.3

4.2

“4.B

*2.7

*6.2

4.9

4.1

5.3

4.7

4.0

5.2

*6.6

*5.6

“7.1

9.2

8.8

9.3

8.4

“6.1

8.9

13.1

25.3

“11.0

0.25

0.40

0.30

0.24

0.46

0.28

1.38

1.09

*3.19

0.30

0.52

0.51

0.32

0.53

0.58

0.98

*1 .51

0.78

0.32

0.47

0,49

0.32

0.44

0.55

1.01

*1 .90

“0.75

0.41

0.58

0.68

0.47

0.63

0.74

1.48

*1 .68

2.05

0.65

0.80

0.88

0.72

0.93

1.01

2.01

*

*2.69

1.19

1.93

1.41

1.26

1.88

‘1.43

3.02

*

3.32

1Percent desirable weight is an index of weight adjusted for height equal to k times weight divided by height squared, where k is 4.39 for males and 4.76 for femalea.

21ncludes racea other than white or black.

3Estimatea for black males and black females are presented for informaticm only. They are too unreliable to be considered national prevalence estimates.

Table 16. Percent and standard error of percent of adults aged 20-74 years classified undiagnosed diabetic by oral glucose tolerance test

using National Diabetes Data Group criteria, by race, sex, and percent deairabk weight United Statas, 1976-80

Percent desirable weightl

Less Less

than 1oo- 110- 120- 135- 150 or than t oo- 110- 120- 135- 150 or

Race and sex 100 709 T19 134 149 greater 100 109 119 134 149 ,greater

All races2

Both sexes . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . .

Black3

Both sexes . . . . . . . . . . . . . . . . . . . . . . .

Percent of population

1.6 *1.6 2.3 3.7 5.3 11.4

*2.1 *2.3 2.6 3.7 *4.5 *4.5

“1.1 *0.9 1.9 3.8 5.7 13.1

1.8 ‘1.0 2.2 3.5 5.7 10.9

*2.4 *1.2 2.7 2.9 “4.6 *4.9

*1.2 ‘0.9 1.6 4.1 *6.3 12.3

0.0 *4.7 “3.5 “4.8 “3.5 *11.3

0.0 “7.6 0.0 *9.9 *3.6 ‘3.0

“0.0 *1.5 *5.9 *2.1 *3.4 “13.4

Standard error of percent

0.44 0.54 0.44 0.59 1.31 1.84

0.71 0.94 0.76 0.65 2.00 2.32

0.58 0.44 0.49 0.86 1.64 2.12

0.50 0.36 0.44 0.68 1.50 2.30

0.84 0.46 0.79 0.48 2.23 2.85

0.63 0.46 0.39 1.16 1.94 2.67

*3.87 *2.12 *2.40 * . . . *5.24

. . .

*6.B6 --- * * *

* * . . .

“1.58 * *

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . .

1Percent desirable weight is an index of weight adjuated for height equal to k times weighi. divided by height squared, where k ia 4.39 for males and 4.76 for felmalea,

21ncludes races other than white or black.

3Estimatea for black males and black females are presented for information only. They are ‘too unreliable to be considered national prevalence estimates.

NOTE Undiagnosed diabetea defined as meeting diagnostic criteria for diabetes with no medical history of diabetes. Refer to text for National Diabetea Data Group

criteris for classiwng results of oral glucose tolerance tests.

38
Table 17. Percent distribution of adults aged 20-74 years by percent desirable weight, according to race and sex United States, 1976-80

Percent desirable weight~

All Less than 150 or

Race and sex adults 100 100-109 110-119 720-734 135-749 greater

All races2 Percent distribution

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . 100.0 24.0 22.4 19.8 17.6 8.3 7.9

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 25.3 24.3 23.1 18.0

Female . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.2

100.0 22.9

3.0

20.6 16.8 17.2 10.2 12.4

White

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . 100.0 23.9 23.1 20.3 17.6 8.0 7.2

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100.0 24.0 24.7 23.9 18.5

Female . . . . . . . . . . . . . . . . . . . . . . . . . . .

6.2

100.0 23.8

2.8

21.6 17.1 16.5 9.7 11.3

Bleck3

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . 100.0 22.3 16.2 16.5 19.5 10.9 14.6

Male . . . . . . . . . . . . . . . . . . . . . . . . . ,.. . 100.0 31.4 20.8 18.6 16.8

Female . . . . . . . . . . . . . . . . . . . . . . . . . . .

7.6

100.0 14.9

4.8

12.5 14.8 21.7 13.5 22.6

1Percent desirable weight is an index of weight adjusted for haight aqual to k times weight divided by height squared, where k is 4.39 for males and 4.76 for femalea.

‘Includes races other than white or black.

3Estimates for black males and black females are presented for information only. They are too unreliable to be considered national preva[e”ce estimates.

Table 18. Percent and standard error of percent of adults aged 20-74 years with no medical history of diabetes and with abnormal fasting or

2-hour plasma glucose concentrations, by venipuncture, sex, and percent desirable weight United States, 1976-80

Percent desirable weight2

Venipurrcturel and sex

Less Less

than 1oo- 1 fo- 120– 135- 150 or than 1oo- 110- 120- 135- 150 or

100 109 119 134 149 greater 100 109 119 134 149 greater

FASTING

140 mg/dl or more

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . .

Male. . . . . . . . . . . . . . . . . . . . . . . . . . . . ,.

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Both sexes

Male . . . . .

Female . . .

15 mg/dl or more

. . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . ...!. . . . . . . . .

2 HOUR

200 mg/dl or more

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . .

Male. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140-199 mg/dl

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of population

“0.3 *0.1 *4.9

“0.5

*0. I

2,0

*2.2

*1,8

1.6

*2.2

*1.1

5.6

6.0

5.3

‘0.3

*1.8

*2.1

*1.4

*1.7

*2.5

*1.O

8.5

7.0

9.9

80.9 “0.7

*1.3 “0.9

80.4 ‘0.5

4.2 4.0

6.3 4.0

*1.7 4.1

2.5 4.1

2.9 3.7

2.1 4.4

11.4 14.5

10.1 13.5

13.0 15.4

*1.7

*1.7

*1,7

6.4

*7.7

%7

6.0

*4.4

6.9

20.6

29.3

15.6

*2.9

*5.3

15.1

*14.4

15.2

13.0

*5.1

14.8

23.5

*22.2

23.8

Standard error of Dercent

0.09

0.18

. . .

0.56

0.86

0.69

0.58

0.99

0.47

1.28

1.10

2.09

,.–

0.25

0.52

0.07

0.57

0.80

0.80

0.45

0.71

0.61

0.81

1.04

1.16

0.34

0.50

0.30

0.86

1.60

0.62

0.46

0.83

0.53

1.44

1.58

2.31

0.25

0.39

0.33

0.68

0.83

0.89

0.52

0.66

0.74

1.26

2.15

1.75

0.81 1.77

1.45 1.96

0.97 1.97

1.30 2.93

2.50 5.41

1.82 2.95

1.47 1.92

2,05 2.71

1.87 2.19

2.39 2.77

5.66 7.07

2.60 3.24

1m!;/dl = milligrams per deciliter.

2Percent desirable weight is an index of weight adjusted for height equal to k timss weight divided by height squared, where k is 4.39 for males and 4.76 for females.

39
Table 19. Mean plasma glucose concentration, standard deviation, standard arror, andselected percentiles of theoral glucose tolerance tests

of adults aged 20-74 years with no medical history of diabatas, byvenipuncture and lpercent desirable weight United States, 1976-80

Percentile

Standard Standard

Venipuncture andpercent desirable weightl Mean deviation error 5th 10th 25th 50th 75th 90th 95th

Fasting

Lass than 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100-109 ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110-119 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-134 . . . . . . . . . . . . .

35-149 . .,, . . . . . . . . .

500r higher, . . . . . . . . .

essthan 100, . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . .

hour

. ...,.. . . . . . . . . . . . . . . .

100-109 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110-119 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

120-134 ...,.....,,.......,.. . . . . . . . . . . . . . . . . . .

135-149 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1500r higher . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 hour

Less than 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100-109 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

110-119 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

120-134 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

135-149 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1500r higher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

88.8

90.8

93.2

94.8

96.5

102.9

130.8

138.4

145,7

151,1

160,0

176.2

98.4

102.4

108.9

116.5

124.7

141.0

Concentration inmilligrams per deciliter

9.5 0.34 77

10.9 0.52 78

15.2 0.54 79

14.2 0.46 81

17.5 0.93 81

32.6 2,46 79

47.6 1.98 71

50.4 2.48 73

51.5 2.10 77

51.5 1.58 80

54.0 3.10 85

68.3 4.05 102

32.8 1.30 60

34.8 1.72 62

42.7 1.61 63

44.7 ‘1.78 71

51.9 :3.03 70

70.3 4.67 79

79

80

81

83

84

82

78

81

92

93

101

113

67

69

73

76

81

85

83

84

86

88

89

90

97

105

113

115

125

136

80

82

85

90

96

101

88

90

91

93

94

96

124

130

139

146

156

165

94

97

101

108

113

122

93

96

98

99

101

106

158

168

173

182

188

207

109

115

122

131

143

165

98

103

105

106

111

126

188

209

206

216

226

256

129

141

153

162

181

222

104

108

112.

112

118

139

214

230

235

235

243

289

155

161

168

190

204

268

lPercent desirable weight issnindex ofweight adjusted forheight equal toktimes weight divided by height squared, where kis4.39for males and4.76forfemalea.

Table 20. Mean fasting and 2-hour plasma glucose concentrations of the oral glucose tolerance tests of adults aged 20-74 years with no

medical history of diabatea, by percent desirabla weight and age United Statas, 1976-80

Age

Total, 20-44 45-54 55-64 65-74

Venipuncture and percent desirable weightl 20-74 years years years years years

Total . . .

Less than

100-109

110–119

Festing Concentration in milligrams per deciliter

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92.93 89.52 96.02 97.80 98.12

Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88.77 87.28 90.98 92.01 94.09

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90.83 88.49 92.39 95.29 95.09

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93.25 89.88 95.61 97.35 97.29

20-134 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94.77 91.18 96.64 97.43 102.29

35-149 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96.52 92.21 97.06 102.57 99.58

500rgreater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102.92 95.97 112.36 109.86 102.36

2 hour

10.08 100.06 114.84 123.78 133,44

98.44 93.77 104.90 107.49 11 “7.41

02.37 94.65 107.56 113.67 12’1.93

08.86 100.84 108.49 117.45 131.78

16.48 105.18 119.84 126.62 142.70

135-149 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124.73 114.23 114.63 141.78 148.45

1500r greater . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.00 120.79 156.46 163.40 151.26

1Percent desirable weight is an index of weight adjuated for height equal to k times weight divided by height squared, where k is 4.39 for males snd 4.76 for famalss.

40
Appendixes

Contents

I. Statistical notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Survey design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Estimationprocedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Nonresponse bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard deviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Standard errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Datalimitations andreliability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Combining and comparing estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analytic methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

II. Definition ofsociodemographic terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

III. Medical history questionnaire items relatedto diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

List of appendix tables

I.

IL

III.

Iv.

v.

VI.

VII.

VIII.

Ix.

x.

Sample sizeandpercent responseoftotalsarnple and oral glucosetolerance test(OGTT) subsample, bydemographic

group: SecondNational Health andNutrition Examination Survey (NHANESII),1976-80 . . . . . . . . . . . . . . . . . . . . .

Numberofexamined persons inoralglucose tolerancetestsubsarnple andestimatedpopulation, by race, sex, andage:

Second National Health andNutrition Examination Surevy, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent distribution ofpopulation estimated from National Health Interview Survey (NHIS, 1976) and Second National Health and Nutrition Examination Survey(NHA.NES 11,1976–80)by demographic groups, accordingtototal

sample andoral glucosetolerance test(OGTT) subsample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of adults aged 20–74years by health status, body mass index, selected medical conditions, and diabetes

therapy as reported in medical history interview National Health Interview Survey (NHIS),1976, and SecondNational Health andNutrition Examination Survey (NHANES II), 1976-80.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Number andpercent distribution oforal glucose tolerance test (OGTT) subsample persons byOGTT response, accordingto selected medical history items: Second National Healt,hand Nutrition Examination Survey, 1976-80 . . . .

Mean and selected percentiles of height, weight body mass index, systolic and diastolic blood pressure, and serum

cholesterol, by selected samples: Second National Health and Nutition Exmination Sumey, 1976–80 . . . . . . . . . . . .

Percent bias forselected respondent-nomespondent prevalence ratios andselected response rate~ Second National

Health and Nutrition Examination Survey, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Potential bimkestimated percent prevalence ofunda~oseddabetes andimpaired glucose tolerance due to overresponse bypersons withmeticd tisto~ofborderlke orpotentid tiabetes orap~entwith dabetes: Second National

Health and Nutrition Examination Survey, 1976-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sensitivity of estimated prevalence of undiagnosed diabetes or impaired glucose tolerance to response selection bias

kpersons wifiorwitiout me&cd tisto~ofkrderlke orpotentid tiabetes orap~entwiti &abetes: Second National

Health and Nutrition Examination Survey, 1976–80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent andstandard error ofpercent of adults aged 20–74 years with diabetes-sum ofknown diabetes estimated

from the National Health Interview Survey (1976) and unknown diabetes estimated from the Second National Health

and Nutrition Examination Survey (1976 –80)—by race, sex, and age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42

42

42

44

49

49

50

50

50

52

53

43

44

45

46

47

47

48

49

49

51

41
Appendix I

Statistical notes

This report is based on data collected in the Second National Health and Nutrition Examination Survey (NHANES

II) from February 1976 to February 1980. NHANES II, conducted by the National Center for Health Statistics (NCHS),

was a survey of the civilian noninstitutionalized U.S. population

(including Alaska and Hawaii) 6 months-74 years of age.

Both interview and examination procedures were used to collect

a broad spectrum of demographic, socioeconomic, and morbidity data and related medical and nutritional information.

During household interviews, demographic, socioeconomic,

and certain medical history data were obtained for sample persons. Dietary interview, medical examination, and related clinical tests and procedures were performed in specially designed

mobile examination centers transported to each sample location

to provide standardized conditions and equipment.

Survey design

NHANES II utilized a stratified, multistage probability

sample design. In hierarchical order, the three stages of sample

selection were primary sampling units (PSU’S), segments, <and

sample persons. From the PSU’S of the National Health Interview Survey (NHIS), another major survey program of the

National Center for Health Statistics, 461 PSI-J’Swere formed

in the first design stage. These PSU’S are counties, or groups of

small contiguous counties, or, in some New England States,

areas defined by minor civil divisions. The PSU’S were stratiled

into 64 strata on the basis of region, population size, median

income, and other social and demographic characteristics that

varied with region. One PSU was selected from each stratum

using a modltied Goodman-Kish controlled selection technique.48These 64 counties or areas were the geographic locations visited by a mobile examination center during the survey

period.

The U.S. Bureau of the Census had the major responsibility

for selecting households and sample persons within each of the

PSU’S. The second stage of the design consisted of selection of

segments (clusters of eight households) within enumeration

districts (EDs). An ED is a geographical area that contains

approximately 300 housing units. Two sampling frames of

housing units were used to select the sample within each of the

PSU’S. The list frame consisted of all housing units located in

the 1970 Census of the Population. A new construction flame

supplemented the list frame and contained all new housing

units built since 1970.

NOTE: A list of referencesfollowsthe text.

ED’s within each PSU were stratified into poverty and

nonpoverty strata. The poverty strata contained ED’s with 13

percent or more of persons below the poverty level; the nonpoverty strata contained EDs with less than 13 percent of

persons below the poverty level, as determined from the 1970

census. To oversarnple persons with low incomes, segments

were drawn from the poverty strata with an average of 2.3

times the probability that segments were drawn from the nonpoverty strata. Sampling fractions were determined within

PSU’S by a mathematical model to ensure an adequate and

manageable sample size and to minimize the variance of the

estimated proportion of persons below the poverty level. To

ensure sampling reliability, clusters of 16 listed addresses were

drawn from the sampling frames and then systematically sub

sampled at a rate of 1 out of 2 to produce a final segment of 8

household address listings.

At the third stage of sampling the interviewer made a list

of all eligible sample persons within the selected households.

Using instructions and a worksheet in the interview folder, the

interviewer selected sample persons to be examined so that

approximately one person per sample household was selected

and younger and older age groups were oversampled. Persons

were selected at the following sampling rates:

Age Rate

6months-5 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3/4

6-59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1/4

60-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3/4

For each sample person selected who agreed to participate

in NHANES II, the interviewer did a medical history interview

and.telephoned the field ofllce to make an appointment for an

examination. The field ofilce staff assigned alternate persons

ages 20–74 years to an oral glucose tolerance test (OGTT)

subsample. It is this subsample that is the primary data. base

for this report. The sample size and response rates by several

demographic variables are shown in table I. A more complete

description of the survey design is included in Vital and Health

Statistics, Series 1, No. 15.5

Estimation procedures

Because the design of NHANES II is a complex, multistage probability sample, national estimates are derived through

a multistage estimation procedure. The procedure has three

basic components: (a) Inflation by the reciprocal of the probability of selection, (b) adjustment for nonresponse, and (c)

42
Table 1. Sampla size and percent response of total sample and oral glucose tolerance test (OG~ subsample, by demographic group: Second

National Health and Nutrition Examination Survey (NHANES 11),1976-80

Total adult NHANES IIsampla OGTTsubsampla OGTT-completed

Sample

group as percent

Sample OGTT of examhrad

Demographic group size Interviewed Examined size Interviewed Examined completed subsample~

Total . . . . . . . . . . . . . . . . . . . . . . . .

Region

Northeast, . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . .

Residence

Outside standard metropolitan

statistical area . . . . . . . . . . . . . . .

inside standard metropolitan

statistical area . . . . . . . . . . . . . . .

Segment type

Nonpoverty . . . . . . . . . . . . . . . . . .

Poverty . . . . . . . . . . . . . . . . . . . . . .

Age

20-44 years . . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . .

Sex

Male . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . .

Race

White and another . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . .

Family income group2

Less than $6,000 . . . . . . . . . . . . .

$6,000-$ 9,999 . . . . . . . . . . . . . .

$10,000-$ 14,999 . . . . . . . . . . . .

$15,000-$ 24,999 . . . . . . . . . . . .

$25,0000 r more . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . .

Number Percent Number

17,390

4,295

4,577

4,576

3,942

7,265

10,125

8,663

8,727

7,161

2,149

3,B6B

4,212

8,074

9,316

15,435

1,955

3,289

3,737

3,195

3,893

2,101

1,175

88.3

84.1

89.4

90.8

88.9

92.6

85.3

86.2

90.5

91.3

86.B

86.1

B6.2

87.7

88.9

88.1

90.2

95.9

94.5

94.3

94.9

93.9

. . .

68.2

62.2

6B.6

69.4

73.0

73.1

64.8

66.9

69.5

73.2

67.6

66.1

62.1

69.4

67.2

68.2

68.3

72.5

70.5

73.9

76.2

72.3

. . .

8,686

2,149

2,263

2,290

1,964

3,627

5,059

4,358

4,328

3,570

1,075

1,909

2,132

4,114

4,572

7,724

962

1,644

1,845

1,585

1,962

1,056

574

Percent

8B.5

84.4

89.7

90.9

89.1

92.5

B5.7

86.3

90.8

91.1

86.1

86.5

87.3

87.9

89.1

88.3

90.5

96.0

94.7

93.9

95.1

93.8

,..

68.0

63.1

68.4

68.6

72.0

72.4

64.8

66.9

69.0

72.1

65.9

67.1

62.9

69.2

66.9

68.1

67.2

71.6

69.5

73.8

76.3

72.1

. . .

44.6

38.7

46.3

42.2

51.8

48.3

41.9

44.7

44.5

44.7

47.1

45.8

42.0

44.5

44.7

45,4

3B.1

43.5

44.4

48.5

52.5

50.1

. .

65.6

61.4

67.6

61.5

72.0

66.7

64.7

66.8

64.4

62.0

71.5

68.3

66.9

64.3

66.8

66.7

56.8

60.7

63.9

65.6

68.8

69.5

. . .

‘ Ir,cludes 75 dlabet!cson insulinexemptedfromthe 0G7T.

Zunknown income imputedfrom segment type and education for interviewed and examined SUNeV Pa~iCiPanW.

poststratfication by age, sex, and race. A brief description of

each component is as follows: .

● Injlation b-y the reciprocal of the probability of selection

The probability of selection is the product of the probabilities of selection ffom each stage of selection in the design—

PSU, segment, sample person, and subsample.

. Ar#ustment for nonresponse. Estimates are inflated by a

multiplication factor that brings estimates based on examined persons up to a levelthat would have been achieved

if all sample persons had been examined. Nonresponse

adjustment factors were calculated by dividing the sum

of the reciprocals of the probability of selection for all selected sample persons within each of five income groups

(less than $6,000, $6,000-$9,999, $10,000-$14,999,

$15,000-$24,999, and $25,000 or more), three age groups

(6 months-5 years, 6-59 years, and 60-74 years), four

geographic regions, and within or outside a standard metm

politan statistical area (SMSA) by the sum of the recip

rocals of the probability of selection for examined sample

persons in the same income, age, regio~ and SMSA groups.

. Poststratl@ation by age sex and race Estimates are ratio

adjusted within each of 76 age-sex-race cells to independent estimates, provided by the U.S. Bureau of the

Census, of the population as of Mach 1, 1978, the ap

proximate midpoint of the survey. The ratio adjustment

used a multiplication factor in which the numerator was

the estimated U.S. civilian noninstitutionalized population

and the denominator was the sum of the weights adjusted

for nonresponse for examined persons. This ratio estirna43
tion process brings the population estimates into close

agreement with the U.S. Bureau of the Census estimates

of the civilian noninstitutionalized population of the United

States, and in general reduces sampling errors of NHANES

II estimates. The number of sample persons and the pop

ulation estimates for the fasting (OGTT) subsample are

shown in table II.

Nonresponse bias

The three major categories of nonresponse in NHANE S

II are (a) household interview nonresponse, (b) examination

nonresponse, and (c) item nonresponse. Household interview

nonresponse occurred when a household medical history questionnaire was not completed Examination nonresponse occurred when those sample persons who responded to the

household interview did not come to the examination center for

an examination. Item nonresponse occurred when sample persons dld not complete some portion of either the household

interview questionnaire or the examination. Intense efforts

were undertaken during NHANES II to develop and implement

procedures and inducements that would reduce all types of

nonresponse and thereby reduce the potential for bias in the

survey estimates. These procedures are discussed in Vital and

Health Statistics, Series 1, No. 15.5

In NHANES II the total sample size aged 6 months-74

yeas was 27,801; of these sample persons, 25,286 (91 percent)

were interviewed and 20,322 (73 percent) were examined. In

the OGTT subsample there were 8,686 persons; 7,688 (89

percent) were interviewed and 5,903 (68 percent) were exNOTE: A list of references follows the text.

amined. Response rates in the OGTT sample were lower than

those for the total sample because the former was limited to

adults, and adults had lower response rates than children. The

response rates to the interview and the examination for adults

in the tc)talsample and the OGTT subsample were very similar

(table I).

In addition to interview and examination nonresponse,

there was substantial (23 percent) item nonresponse for the

OGTT. The main reasons for item nonresponse to the OGTT

were Siimpk persons not attending the examination center in

the morning (11 percent), failiig to comply with the instructions

to fast (5 percent), or refusing to participate in the OGTT (2

percent). Other reasons (6 percent) included sample persons

being (or becoming) ill and technical errors in test administration, laboratory analysis, and data processing.

The high level of nonresponse to the OGTT brings into

question the validity of national estimates of glucose intolerance

based on NHANES II OGTT data. For persons in the OGTT

subsarnple, it cannot be determined whether the glucose tolerance of those completing the OGTT was similar to the glucose

tolerance of those who did not complete it. However, analyses

presented below using interview and examination data that

might serve as proxies for glucose tolerance data indicate that

potential bias introduced by nonresponse to the OGTT is not

substantial.

A previous analysis of nonresponse to the interview showed

that nonresponse was associated with age, region, residence in

an SMS& and family size.13Response to the examination was

associated with wanting to discuss a health problem with a

doctor, work status, and number of cars owned These items did

not appear to be related to health outcome variables. Some of

this previous analysis is repeated and extended in this appendix.

Table 11. Number of examined persons in oral glucose tolerance teat subsample and estimated population, by race, sex, and age Second

Nationel Health and Nutrition Examination Survey, 1976-80

All races~ White Black

—

Sample Population in Sample Population in Sample Population in

Sex and age persons thausands2 persons thousands2 persons thousands2

Both sexes

Total, 20-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 years....,....,....,.. . . . . . . . . . . . . . . . . . . . . . . . . . .

55–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male

Total, 20–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female

Total, 20-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-44 years .,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 years . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65–74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5,903 133,606 5,145 116,698 646 13,682

2,574 75,728 2,204 65,092 307 8,374

708 23,032 624 20,335 71 2,260

1,281 20,350 1,131 18,324 135 1,761

1,340 14,496 1,186 12,948 133 1,289

2,846 63,612 2,486 56,003 305 6,103

1,245 36,593 1,069 31,703 143 3,702

329 11,115 297 10,012 29 1,045

656 9,608 579 8,682 70 802

616 6,298 541 5,608 63 556

3,057 69,994 2,659 60,696 341 7,580

1,329 39,136 1,135 33,390 164 4,673

379 11,918 327 10,324 42 1,216

625 10,743 552 9,643 65 959

724 8,199 645 7,341 70 733

‘ Includes races other than white and black.

‘Estimated population as of the midpoint of the survey, March 1, 1978.

44
Table I shows that unweighed response rates varied by

several socioeconomic and demographic variables. In table HI,

however, the weighted population percent distributions for the

interview and examination groups were similar both to each

other and to those of the NHIS. The OGTT-completed group

was more weste~ female, and white than the target population.

However, the general overall agreement between the distributions suggests that the weighting procedure described above

(“Estimation procedures”) substantially compensated for possible response bias associated with these variables. The remaining differences were small and should not substantially

affect estimates presented in this report.

In table IV prevalence estimates of selected health variables on different NHANES II samples are compared with

similar variables from NHIS. Overall, the estimates were quite

similar, especially considering differences in survey design and

administration, question content and context, and survey duration. In particular it is reassuring that the distribution of reported

body mass index, an important item in analyses in this repoz

was not affected by subsampling and nonresponse. The only

item for which there was a striking difference is the estimate for

hypertension; some of this dMerence may be due to increasing

awareness of hypertension during the period of the NHANES

II survey, and some of it may be due to underreporting of hypertension in NHIS by proxy respondents. All NHANES II data

on adults are self-reported

Some of the differences in table IV may, however, be due

to response bias. In particular, OGTT completion rates were

lower than average for persons who reported they had been

told by a doctor they had diabetes, especially ifthey were taking

diabetes pills. For this reason, and because insulii-using diabetics were ineligible for the tes~ OGTT data on persons with

a medical history of diabetes are not analyzed in this report.

Response rates were higher than average for persons with no

medical history of diabetes who reported their parents had diabetes or who had been told that they had borderline or potential

diabetes (table V). The effect of Werential response rates in

persons with and without a medical history of diabetes is lessened

Table III. Percent distribution of population astimated from National Haalth Interviaw Survey (NH IS, 1978) and Sacond National Health and

Nutrition Examination Survey (N HANES 11,1976-80) by demographic groups, according to total sample and oral glucose toleranca tast (OG~

subsample

NHANES II

Total sample, 0G17 subsample, 0G17subsample,

Demographic group NHIS interviewed examined 0G17completed

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Region

Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Residence

Outside standard metropolitan statistical area. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Inside standard metropolitan statistical area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Segment type

Nonpoverty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Povertv . . . . . . . . . . . . . . . . . .. c.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Age

20-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex

Race

White and all other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Family income group

Less than $6,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$6,000-$ 9,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$10,000-$ 14,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$15,000-$ 24,999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$25,000 and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100.0

23.1

24.8

24.7

27.4

31.1

68.9

. . .

. . .

56.3

17.4

15.5

10.8

46.9

53.1

90.7

9.3

13.4

13.2

17.5

25,6

20.8

9.6

I 00.0 100.0 100.0

23.0 23.4 22.3

24.6 24.3 24.7

25.6 25.8 24.0

26.8 26.4 29.0

37.1 36.9 37.3

62.9 63.1 62.7

65.7 65.B 66.5

34.3 34.2 33.5

56.7 56.7 54.1

17.2 17.2 18.5

15.2 15.2 16.1

10.8 10.8 11.3

47.6 47.6 45.9

52.4 52.4 54.1

B9.8 89.8 91.0

10.2 10.2 9.0

14.5 14.5 13.5

20.2 20.6 20.0

18.3 18.7 18.B

27.3 27.5 28.6

15.4 15.1 16.0

4.3 3.7 3.1

45
Table IV. Percent of adults aged 20-74 yaars, by haalth status, body mass indax, selected madical conditions, and diebatea tharapy as

raported in madical histo~ interviaw National Health Interview Survey (N HIS), 1976, and Second National Health and Nutrition Examination

Suwey (N HANES Il), 1976-60

NHANES II sample

0G771 0G17

subsample, subsample,

Variable NHIS Intervie wad Examined examined OG 77 completed2

Health status3

Excellent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Very good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Good . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Poor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Body mass index4

Less than 23kg/m2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23-27 kg/m2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

More than 27kg/m2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Unknown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Selected medical conditions

With hospital stay inpast12 months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rheumatic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heart murmur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Heart attack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other heart troubla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hardening of arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Hypartension6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cataract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Glaucoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Currently smokes cigarettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cannot read newspaper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mother with diabetea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Father with diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oiabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Borderline diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prediabatea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Potential diabetas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trouble hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Therapy for diabetes

Taking inaulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Taking diabetes pills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44.3

40:(;

11.5

3.7

0.4

35.6

44.3

18.2

1.9

% 2.2

. . .

. . .

2:8

4.4

1.9

1.0

15.8

2.4

(3.8

34..9

1.7

9.7

6.3

3.0

2.0

().1

0.8

77.3

21.3

41.9

Parcant of total population

27,5 27.1 27.0

26.B 27.3 28.6

28.2 27.9 27.0

12.4 12.5 12.2

5.1 5.0 5.2

0.1 0.1 0.1

32.9 32.3 32.5

44.3 45.1 44.5

21.2 21.1 21.3

1.6 1.5 1.6

14.1

0.7

7.4

0.9

3.0

5.0

2.4

1.5

24.6

2.7

0.8

37.8

1.2

10.3

6.9

3.4

2.3

0.1

1.3

8.9

13.7

0.7

7.6

0.9

3.0

5.3

2.5

1.5

24.6

2.8

0.8

37.0

1.1

10.4

7.0

3.3

2.5

0.2

1.4

9.3

14.0

0.8

6.3

1.0

3.0

5.2

2.5

1.5

24.9

2.8

0.9

36.8

1.0

10.4

6.8

3.3

2.8

0.1

1.4

9.1

Percent of parsons with known diabetes

26.1 25.6 30.5

35.2 33.8 30.4

26.5

29.2

27.9

11.8

4.5

0.1

32.0

44.7

21.8

1.5

13.7

0.6

7.B

1,0

3.0

5.1

2.2

1.4

24.3

2.9

0.8

34.7

1.0

11.5

7.7

2.9

3.2

0.2

1.8

9.2

22:4

10GIT = oral glucose tolwance teat

‘Includes 75 diabetics on insulin exempted from OGTT.

3~HlS 6atimate~ based on data collected in 1978.

4Aa reported by respondent in intewiew; weight in kilograms divided by height in m6tera squared.

5Baaed on data col16cted in 1978.

6Mea5ured with I question in NH IS, 2 queationa in NHANES Il.

7From National Center for Health Statiatica, P. W. Rica: Hearing ability of persona by aociodemographic and health characteriatica. Vita/ mrd He8/th Statistics, %riea

10, No. 140. DHHS Pub. No. (PHS) B2-1 568. Public Health Service. Washington, US. Government Printing Office, Aug. 1982.

in thk report by presentin~ where possible, estimates that are

based on data for all interviewed persons rather than just

OGTT sample persons.

To explore firther the effects of differential nonresponse

on estimates, the distributions of height, weight, body mass

index, systolic and diastolic blood pressure, and cholesterol

were estimated for the total examined sample, the OGTT subsample, and the OGTT-completed group (table VI). As with

the interview items, there were only small differences, which

suggests that response status was unrelated to these health

measures.

Evidence from earlier studies similar to NHANES II also

suggests no substantial nonresponse bias. An analysis of data

on examined and nonexamined (but interviewed) persons in

the fust 35 stands of NHANES I (conducted in 1971-72)

found that the two groups were quite similar with respect to

certain health characteristics.49 A separate study of examined

and nonexamined persons in NHANES I found no differences

between the two groups with respect to health-related variakdes.5’JA study of factors relating to response in Cycle I of the

National Health Examination Survey of 1960-62 found that

36 percent of nonexamined persons viewed themselves as being

in excellent health, compared with 31 percent of examined

persons.51A self-appraisal of being in poor health was made by

—

NOTE: A list of referencesfollowsthe text.

46
Table V. Number and percent distribution of oral glucose tolerance test (OGIT) subsample persons by OGIT response, according to selected

medical history items Second National Health and Nutrition Examination Survey, 1976-80

Interviewed

0GT7subsample OG17 Not Examined in Improper

Selected medical history items persons complated examined afternoon fast Rafused Other

Number Percent distribution

Total. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,688 49.4 23.2 12.0 6.0 2.5 6.9

Diabetes

Taking insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tsking diabetes pills . . . . . . . . . . . . . . . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100

154

127

. . . 25.0 75.0

27.3 36.4 14;3 5:8 4:5 11.7

42.5 22.0 17.3 7.1 4.7 6.3

No diabetes

Totisl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7,307

224

31

141

711

409

50.6 23.0 12.0 6.0 2.4 5.9

59.4 19.2 9.8 3.6 0.9 7.1

51.6 25.8 12.9 9.7

63.1 22.0 9.2 2:1” 0:+ 2.8

58.1 20.8 9.6 5.6 1.7 4.2

58.9 21.0 9.0 6.4 2.0 2.7

borderline diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . .

Prediabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Potential diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mother with diabetes . . . . . . . . . . . . . . . . . . . . . . . . .

Father with diabetes . . . . . . . . . . . . . . . . . . . . . . . . . .

Table W. Mean and selected percentiles of height, waight, body mass indax, systolic and diastolic blood pressure, and serum cholesterol,

by salected samplee: Second National Health and Nutrition Examination Survey, 1976-80

Percentile

Variablel and sample Maan 10th 25th 50th 75th 90th

Height

Examined, full sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGIT subsample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OCiTT completed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Weight

Examined, full sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGll_ subsample, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OGTTcompleted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8ody maas

Examined, full sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGTTsubsample ...,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OGTT completed, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Systolic blood pressure

Examined, full aample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGTT subsample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OGIT’ completed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Oiastolic blood pressure

Examined, full sample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGTT subsample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OGTT completed. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Serum cholesterol

Examined, full sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Examined, OGTTsubsample, .,,... . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OGTTcompleted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Centimeters

168,3 156.0 161.0 167.9 175.5 181.4

181.4

181.7

91.9

92.2

92.5

31.5

168.4

168.3

775.7

175,6

156.2

155.9

161.2 168.0

161.0 187.9

Kilograms

60.5 70.2

60.2 70.5

60.1 70.7

71.8

71.9

72,0

53.3

53.2

53.1

81.3

81.4

81.6

Indexz

21.9 24.6

21.9 24.5

22.0 24.7

25.3

25.3

25.4

20.0

19.9

20.0

27.7

27.8 31.4

27.8 31.6

Millimeters of mercury

110.5 124.1

110.4 122.3

110.3 122.2

126.4

125.4

124.8

102.3

100.5

100.4

140.1 155.7

138.2 153.0

136.8 150.9

Millimeters of mercury

80.6

80.0

79.3

66.4

66.0

64.5

70.4 80.3 90.2 98.5

90.1 98.2

90.0 96.3

70.3 80.2

70.3 80.2

Milligrams per deciliter

179.5 208.5

178.6 206.1

179.3 208.3

213.2

211.2

213.1

156.4

156.2

156.9

242.8 277.2

241.0 274.2

243.6 276.9

‘ OGiT = oral glucose tolerance test.

‘Body mass index is weight in kilograms divided by height in meters squared.

47
5 percent ofnonexamined persons andby6 percent of those

who were examined. In a different study of the National Health

Examination Survey of 1960–62,52 comparisons between two

extreme groups-those who participated in the survey with no

persuasive effort and those who participated only after a great

deal of persuasive effort-indicated that differences between

the two groups generally had little effect on estimates based on

numerous examination and questionnaire items. This was interpreted as evidence that no large bias existed between the

two groups and was offered as further support for the belief that

there is little bias introduced to the findings because of differences in health characteristics between examined and nonexamined persons.

The validity of the estimates and analyses in this report

rests on an assumption that the glucose tolerance status of

sample persons participating in the OGTT did not differ from

that of sample persons not participating. The importance of

this assumption is illustrated in table VII. This table models

the dependence of the results of the survey on the response rate

and the prevalence of the attribute being estimated in respondents and nonrespondents. The model is based on the following

equatiorx

where t=

p=

~=

~=

t=pr+(l –p)s

true prevalence

proportion of sample responding

prevalence rate estimated based on respondents

prevalence rate in nonrespondents

This equation shows that true prevalence is the sum of prevalence in respondents and nonrespondents weighted by the

proportions of respondents and nonrespondents. IfB is the ratio

of prevalence in nom’espondents to prevalence in respondents

(w+), then

t=pr+(l –p)Br

=r(p+B-Bp)

NOTE: A list of references follows the text.

Tabla V1l. Percent bias for selected respondent-nonrespondent

prevalence ratios and salactad rasponse rates: Second National

Health and Nutrition Examination Survey, 1976-80

Ratio of prevalence rate

for nonrespondents to Percent of population responding

prevalence rate for

respondents 40 percent 45 percent 50 percent

0.50. . . . . . . . . . . . . . . . 43 38 33

0.75 . . . . . . . . . . . . . . . . 18 16 14

0.90 . . . . . . . . . . . . . . . . 6 6 5

1.00 . . . . . . . . . . . . . . . . o 0 0

1.10 . . . . . . . . . . . . . . . . -6 –5 –5

1.25 . . . . . . . . . . . . . . . . –13 –12 –11

1 ,50 . . . . . . . . . . . . . . . . –23 –22 –20

and the percent bias is

loo(r– f) = 100(1 –p– B+pB)

t p+ B–pB

The numbers in table VII were obtained by substituting

values forp and B in the above equation. The table shows that

bias is related to both differential response and response rate.

There is no bias when prevalence is equal in both respondents

and n~onrespondents. With differential response the percent bias

is higher at lower response rates. With only 45 percent response,

if the prevalence in nonrespondents were 25 percent lower, or

higher, than in respondents, the survey estimate would be 16

percent overestimated, or 12 percent underestimated.

M was shown earlier (table V) that persons with a parent

with diabetes or a medical history of borderline or potential

diabvtes had higher OGTT completion rates than persons

without these attributes; the rates of unknown diabetes and

impaired glucose tolerance (IGT) are higher for persons ‘with

these attributes than without them. To estimate the impact of

higher response rates in these higher prevalence groups, adjusted estimates of undiagnosed diabetes or IGT were calculated by direct standardization of estimates based on the

OGrT-completed group to estimates based on the entire interviewed sample. Two categories were used in the calculation:

Persons with a history of borderline or potential diabetes or a

parent with diabetes, and persons without these backgrounds.

The category-specific rates of undiagnosed diabetes or IGT in

the OGTT-completed group were multiplied by the proportion

of the population in each category estimated using all interviewed persons. The sum of these two quantities is the adjusted

estimate and is the prevalence that would have been found had

the prevalence of the attributes among members of the OCiTTcompleted group been the same as in the interviewed sample.

These adjusted estimates are compared in table VIII with estimates based on the OGIT-completed group used in this re:port.

The adjusted estimate for total prevalence was about 0.1 percent lower than the survey estimate, and the difference was less

than 0.4 percent for any age-sex cell, indicating only a very

small bias in estimates for either the entire population or for

subgroups.

Even though bias due to dtierential response rates between

population subdomains does not appear to be a substantial

problem, the estimates based on the NHANES 11 OGTT data

may still be subject to response bias. Because there were no

glucose tolerance data on nonrespondents, it is impossible to

test this assumption directly. To evaluate the potential impact

of clifferential response, a sensitivity analysis was based on the

following modek

t=pr+qs+ab

wh~eret = true prevalence

p = proportion of sample responding

r = prevalence of undiagnosed diabetes or IGT in responding sample

48
Table VI il. Potential bias in estimated percent prevalence of

undiagnosed diabetes and impaired glucose tolerance due to

ovarresponse by persons with medical history of borderline or

potential diabetes or a parent with diabetea: Second National Health

and Nutrition Examination Survey, 1976-80

Survey Adjusted

Sex and aga estimate estimatel Difference

Total . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years. , . . . . . . . . . . ,.. .

45-54 years, . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . .

Female

20-44 years . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . .

Total . . . . . . . . . . . . . . . . . . . . . .

Male

20-44 years . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . .

Female

20-44 yeara . . . . . . . . . . . . . . . .

45-54 years . . . . . . . . . . . . . . . .

55-64 years . . . . . . . . . . . . . . . .

65-74 years . . . . . . . . . . . . . . . .

Percent with undiagnosed diabetes

3.208 3.139 0.069

0.627 0.832 –0.005

3.553 3.613 –0.060

3.997 3.886 0.111

9.478 9.264 0.214

0.978 0.891 0.087

4.700 4.655 0.045

8.061 8,025 0.036

7.607 7.301 0.306

Percent with impaired

glucose tolerance

4.642 4.542 0.100

1.197 1.193 0.004

7.273 6.956 0.317

9.836 9.653 0.183

8.857 8.791 0.066

2.839 2.705 0.134

6.709 6.540 0.169

5.239 5.227 0.012

9.384 9.603 0.219

lAdjustment msdebydirect standardization tocatsgwiesin interviewed sample.

q= proportion of sample not responding who have a

parent with diabetes or a history of borderline or

potential diabetes

s = prevalence of undiagnosed diabetes or IGT in q

a = proportion of sample not responding who do not have

a parent with diabetes or a history of borderline or

potential diabetes

b = prevalence of previously undiagnosed diabetes or

IGT in r

In table IX, p,c q,and a were estimated from NHANES

II data. Values for the differences between r ands and between

r and b were assigned as shown in the row and column labels.

The cells show the resulting values for t. The stronger effect on

the estimates would be caused by error in estimating the prevalence of unknown diabetes or IGT in the group without a

history of borderline or potential diabetes and whose parents

did not have diabetes because this is the larger group (about 80

percent of the population). Overestimating or underestimating

the prevalence of diabetes or IGT in these nonrespondents by

25 percent would cause about a 15-percent error in the survey

estimates.

In addition to these analyses of response bias, there reTable IX. Sensitivity of estimated prevalence of undiagnosed

diabetes and impaired glucose tolerance to response selection bias

in persons with or without medical history of borderline or potential

diabetes or a parent with diabetes Second National Health and

Nutrition Examination Survey, 1976-80

Percent

difference

between Percent difference between

prevalence for prevalence for respondents and

respondents and nonrespondents without

nonresponden ts medical history

with medical

history –25 –To o 10 25

Percent with undiagnosed diabetes

-25 . . . . . . . . . . . 2.8 2.9 3.1 3.2 3.4

–lo . . . . . . . . . . . 2.9 3.0 3.1

0

3.3 3.4

. . . . . . . . . . . 2.9 3.1 3.2 3.3

10” : . . . . . . . . . . .

3.5

3.0 3.1 3.3 3.4 3.6

25 . . . . . . . . . . . . 3.1 3.2 3.4 3.5 3.7

Percent with impaired glucose tolerance

-25. . . . . . . . . . . 4.0 4.3 4.4 4.6 4.8

-lo . . . . . . . . . . . 4.1 4.4 4.6

0

4.7 5.0

. . . . . . . . . . . 4.2 4.5 4.6 4.8

70” : . . . . . . . . . . .

5.1

4.3 4.6 4.7 4.9 5.2

25 . . . . . . . . . . . . 4.4 4.7 4.9 5.0 5.3

mains the possibility of bias caused by an association among

glucose tolerance status, response status, and some unanalyzed

or unmeasured variable. Given the information, the assumption

that the glucose tolerance status of those who did not participate

in the OGTT was like that of those who did seems reasonable.

Accepting this assumption makes it possible to use these data

to make prevalence estimates for previously undiagnosed diabetes and to explore the association of diabetes status with

other variables.

Standard deviations

Sample standard deviation is the square root of sample

variance. It is a measure of the dispersion of sample observations about the sample mean. If observations are normally distributed, the standard deviation is usefhl in describing how an

individual observation compares with the sample meam One

standard deviation above and below the mean includes approximately 68 percent of observation two standard deviations,

approximately 95 percent and 2% standmd deviations, approximately 99 percent.

Standard errors

Because the statistics presented in this report are based on

a sample, they may differ from the figures that would have been

obtained if a complete census had been taken using the same

survey instruments, instructions, interview and examination

persomel, and procedures. The probability design of this survey permits the estimation of standard errors that are appropriate for the estimates shown in this report using the assump

tions about nonresponse presented above.

Standard error is primarily a measure of sampling variability, that is, the variation that might occur by chance because only a sample of the population is surveyed. As calculated

for this repo~ the standard error also reflects part of the varia49
tion that arises in the measurement process. It does not include

estimates of any bias that might be contained in the data. The

chances are about 68 out of 100 that an estimate based on a

sample using the same procedures and instruments would differ

from the value obtained from a complete census by less than

the standard error. The chances are about 95 out of 100 that

the difference would be less than twice the standard error and

about 99 out of 100 that it would be less than 2% times as

large. Estimates of sampling variability in this report were

calculated using a Taylor series linearization method. 15The

variances of statistics me approximated using the first two terms

of a Taylor series expansion. If the higher order terms of the

expansion are negligible and the sample is of a reasonable size

for the domains of interest, then the approximation provides

reliable variance estimates.

It should be noted that estimates of standard errors are

themselves subject to errors that may be large if the number of

sample persons on which an estimate is based is small or if

these persons are concentrated in a few strata. To make estimates of standard errors, PSU’S must be paired. If there were

sample persons in fewer than 12 pairs of PSU’S, the standard

error estimates may be unstable. In the detailed tables of this

report these estimates are presented with an asterisk. If there

were sample persons in fewer than six pairs of PSU’S, the

estimates of standard errors were considered too unstable to

present in the detailed tables and only the asterisk is shown. In

this report estimates for age-sex specific groups of black persons

meet these criteria for instability. They are based on relatively

small numbers of sample black persons who were concentrated

in relatively few strata. In an effort to improve the estimates of

standard errors, different schemes for collapsing strata were

tried. Each decreased only moderately the concentration of

black persons in a few strata and produced substantially the

same estimates of variance as the full strata scheme, so the

latter was used for analysis in this report.

Data limitations and reliability

The criteria for reliability of estimates shown in this report

consisted of the following (a) That the sample size on which

the estimated means or percents were based be at least 30

persons and (b) that the estimated coefficient of variation (that

is, the standard error of the estimate divided by the estimate)

be less than 30 percent. Thus, if the sample size was too small

or if the variation too large, an asterisk was placed next to the

value in the table. Such estimates are considered neither precise

nor stable enough to meet reliability standards. However, the

values are shown to give an impression of the observed distribution and to permit users to combine data into useful categories. For percentile distributions, if there were fewer than

100 sample persons in a subdomain, the estimated 5th and

95th percentiles were replaced with an asterisk if there were

fewer than 50, the 10th and 90th were also replaced.

Combining and comparing estimates

Estimates presented in the detailed tables of this report

may be combined or compared by adding, subtracting, or calcuNOTE: A list of references follows the text.

50

Iating weighted estimates using the population estimates shown

in table II.

The standard error of a sum or difference of estimates cnn

be calculated as follows. Let S be the standard error of a sum,

and S[ and Sz the standard errors of estimates Xl and Xz, then

s = [s;+ s; + 2 Cov(x1,x2)]l/2

The formula for the standard error of a difference is the

same, except that the covariance term must be subtracted. If

estimates Xl and Xz are independent, then their covariance is

zero and the third term within the radical can be ignored. Indepeniience can be assumed for most of the estimates in this

report, but for certain ones that are of particular interest, independence cannot be assumed.

The hypothesis that hvo proportions are equal can be tested

with a statistic that has a standard normal distribution obtained

by dividing the difference of the proportions by the standard

error of the difference.

The estimates in tables E and G, the total prevalence of

diabetes by age and percent desirable weight, are sums of estimates based on those NHANES II sample persons who re

sponcled in the interview and those in the OGTT subsample

who completed the OGTT. One estimate in the sum is thus

based on a sample that is a subset of the sample base for the

other estimate in the sum. The two components of the sum are

not independent, and it cannot be assumed that their covariances are zerq thus variances for the sums cannot be calculated.

It is possible, however, to make alternate estimates for

table E, total prevalence of diabetes, for which standard errors

can be calculated by combining the estimates for undiagnosed

diabetes based on NHANES II in table 2 with the estimates

for diagnosed diabetes based on NHIS in table 5. In the body

of the report estimates from NHANES II are compared with

those from NHIS and shown to be only slightly larger. The

PSUr’S for NHANES II were constructed from the PSU% for

NHIJS but, because there is a minuscule probability that the

same local areas or sample people were in both surveys, it is

reasonable to assume that the covariance of estimates based on

these two surveys is negligible. These alternate estimates for

the total prevalence of diabetes are shown in table X with their

standard errors calculated as described above. The estimates

in table 8 of prevalence of all forms of glucose intolerance were

alsoI computed with this method.

Analytic methodology

During the NHANES II physical examination, fasting, 1-

hour, and 2-hour venipunctures were performed on OGTT

subsarnple examinees. Blood was collected in evacuated specimen tubes containing 10 milligrams potassium oxrdate plus

12.5 milligrams sodium fluoride. As soon after collection as

possible, NHANES II laboratory technicians centrifuged the

tubes and separated the plasma. Samples were refrigerated

until shipped in Dry Ice to the Centers for Disease Control.

There the plasma was kept frozen until glucose determinations

were performed by the Clinical Trials Sectionj Metabolic Biochemistry Branch, Clinical Chemistry Division.
Table X. Percent and standard error of percent of adults aged 20-74 years with diabetes—sum of known diabetes estimated from the National

Health Interview Survey (1976) and unknown diabetes estimated from the Second National Health and Nutrition Examination Survey

(1 976-80)—by race, sex, and age

Age Age

Total, Total,

20-74 20-44 45-54 55-64 65-74 20-74 20-44 45-54 55-64

Race and sex years

65-74

years yaars years years years years years years years

All races!

Both sexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White

Both sexes. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black

Bothsexes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Male. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent of population

6.2 1.9 8.0 11.7 16.8

5.6 1.6 7.3 9.7 17.3

6.7 2.1 8.6 13.4 16.3

5.8 1.6 7.4 11.1 15.9

5.2 1.3 6.7 9.3 16.4

6.4 1.8 8.1 12.9 15.5

8.7 *2.3 14.3 16.5 24.2

7.6 *1.9 “1 3.3 ‘12.7 *23.1

9.5 *2.6 15.2 *1 9.0 25.1

Standard error of percent

0.36 0.32 0.83 1.05 0.91

0.42 0.40 1.31 1.07 1.50

0.44 0.39 1.17 1.71 1.00

0.38 0.31 0.93 1.25 0.91

0.37 0.28 1.28 1.05 1.47

0.53 0.40 1.27 2.10 1.05

0.95 0.71 3.13 3.85 4.15

1.75 1.01 6.48 4.10 7.54

1.41 0.95 3.85 6.06 4.71

llncludes races other than wh!te or black.

The method of analysis was a hexokinase/glucose-6-phosphatedehydrogenase procedure. Itisamicroadaptation of the

method chosen (National Glucose Reference Method) after

extensive testing showed it to be accurate, specific, and reliable,

and to have other economic and administrative virtues.g Its

precision was studied using an isotope dilution mass spectr~

metric method for providing essentially bias-free, precise serum

glucose analyses. The bias in the reference method was found

to be less than 2 percent.53

For quality control, pools were prepared from pooled human plasma. Part of the pool was diluted and another part was

concentrated to form low, norm~ and high concentration pools.

Two systems of quality control were used

● “Bench” quality control pools inserted by the analysts and

measured from two to four times in each analytical run.

NOTE A list of references follows tbe text.

● “Blind” quality control samples placed in vials and labeled

by the quality control supervisor so that they were indistinguishable from regular samples. The results of these

samples were decoded and reviewed by the quality control

supervisor.

If the average of replicate values of either “bench” or

“blind” quality control samples fell outside their respective established 95 percent confidence limits, the mn was repeated.

For the plasma glucose quality control pools used during the

survey, the coei53cientof variation (the standard deviation divided by the mean) ranged from 0.81 to 2.53 percent indicating

very tight qurdity control and high reliability of the test.s4 In the

sample data there was much greater variation by stand but

there was no trend apparent over time.

51
Appendix II

Definition of

sociodemographic terms

Age—Two ages were recorded for each exarninee Age at

last birthday prior to the time of examination and age at the

time of the census interview. The age criterion for inclusion in

the sample used in this survey was defined as age at the time of

census interview. The adjustment and weighting procedures

used to produce national estimates were based on age at the

interview. Data in the detailed tables and text of the report are

also shown by age at the time of the interview.

Race— For each individual, race (as observed by the interviewer) was recorded as “white,” “black,” or “other.” CMher

includes Japanese, Chinese, American Indian, Korean, Eskimo, and all races other than white and black Persons of

Mexican descent were included with “white” unless definitely

known to be American Indian or of another race. Black persons

and persons of mixed black and other parentage were recorded

as black. When a person of mixed racial background was uncertain about his or her race, the race of the father was recorded

Sex—For each individual, sex was recorded as observed

by the interviewer or examiner.

Family income group—The respondent was given a card

listing categories and was instructed to select the one that rep

resented his or her total combined family income for the past

12 months. Respondents were asked to include income from all

sources such as wages, salaries, social security or retirement

benefits, help from relatives, rent horn property, and so forth

Place of residence— The place of residence of a member of

the civilian noninstitutionalized population is classified as inside a standard metropolitan statistical area (SMSA) or outside an SMSA.

Standard metropolitan statistical areas— The definitions

and titles of SMSA’s are established by the U.S. OffIce of

Management and Budget with the advice of the Federal Committee on Standard Metropolitan Statistical Areas.

The deftition of an individual SMSA involves two considlerationx First, a city (or cities) of at least 50,000 inhabitants

that constitutes a central city and identifies the county in

which it is located as a central countfi second, economic and

social relationships with contiguous counties (except in New

Er@md) that are metropolitan in character so that the periphery

of the specific metropolitan area may be determined. SMSA’S

am not limited by State boundaries. In New England SMSA’S

consist of towns and cities, rather than counties.

Geographic region— The United States was divided into

four broad geographic regions of approximately equal population. The regions, which deviate somewhat from the groups

used by the U.S. Bureau of the Census, are as follows:

Region States included

Northeast. . . Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York,

New Jersey, snd Pennsylvania

Midwest. . . . Ohio, Michigan, Indiana, Illinois, Wisconsin,

Minnesota, Iowa, and Missouri

South . . . . . . Delaware, Maryland, Virginia, West Virginia,

Kentucky, Arkansas, Tennessee, Noflh ‘Carolina, South Carolina, Georgia, Florida, AIsbama, Mississippi, Louisiana, and District of

Columbia

West . ...<.. Washington, Oregon, Idaho, Montana, Wyoming, Colorado, Utah, Nevsda, California,

Arizona, New Mexico, Texss, Oklahoma, Kansaa, Nebraska, South Dakota, North Dakota,

Alaska, and Hawaii

52
Appendix III

Medical history questionnaire

items related to diabetes

DIABETES

?60. Do you hove diabetes or sugar diabetes? @lmy=

2 ;:] NO (27)

b. Did o doctor tell you that you hod it?

@ 1 D y=

!

z ~] NO

Z7a. How many living brothers and sisters do you have?

,

Do not count adopted, step or half brothers and sisters. @ —

Living

o n None (27c)

I

b. How mony of these brothers and sisters have

diabetes or sugar diabetes?

10

Diabetics

o ~ None

;

c. How mony of your brothers and sisters are

——-—.

not living?

k9

Not living

o I_J None (27e) I

d. How mony of these brothers and sisters had

diobetes or sugar diabetes?

I@ —

Diabetics

!

o D None

—.

e. Including those living ond deceosed, how mony of 1

your brothers ond sisters were born before you?

!@ —

Number

I o ~ None

,.. -—. ——

f. Is your mother still living?

‘O 1 ~] Yes ---- 1

2~No

— —— [ — . .

g. Does (did) she have diabetes or sugar diabetes?

!

~@ I n’fes

I 2mNo

.— -

h. Is your father still living?

~@ 1 C] Yes –

I

2DN0

, —,..——

i. Does (did) he have diobetes or sugar diabetes? @j l~Yes

I

2 (_] No

!8. Hove YoU EVER been told by a doctor that YOU hove -

Yes No

Borderline diabetes? . . . . . . . . . . . . . . . . . . . . . . . . .

(@In 2 CJ

Prediobetes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . @ln 2 [:1

Potential diobetcs? . . . . . . . . . . . . . . . . . . . . . . . . . . @Kl 2[:J

Iotes

;@

:0

)F?M HE S.32 (1.23.76)

53
CHECK ITEM F

i~280 31 \’” No” ln26a and all of 28 (Check lfem G)

2“ :j All other (i’9)

I

/90. About how old were you when the doctor first told YOU

thot you had (diabetes/. . .)?

[o -—

Years old

——— — —.. —.. — —

b. Were youa potient in o hospital otthetime a doctor

first told you that you had it?

--— —.—.—— —— .—...— —-

C. Were you in the hospital at that time because you had

~~~—-

-..

symptoms of (diabetes/. . .)? 1= ~,-.

I -:No

10. (Not counting that first time) Have you ever been

—

hospitalized because of your (diabetes/. . .)?

@jI 1 :J Yes

I

2 ~] No

.— I

ha. Have you EVER taken insulin infections?

@ 1 ❑ ‘es

Z~ NO (33)

1

-—————–-–-———–~—

b. Have yau been taking insulin iniectians for mast of

the past 12 months?

;@ 1 ~ Yes

I

2~No

.—

c. Are you NOW taking insulin infections? ‘@1 n ‘fes

2~No

d. How many years (ha;e you been takirsgldid you

take) them?

!@) —

Years

o ~ Less than I year

I

k. Do you know what an insulin reaction is?

!@ 1 ~ Yes

-__L ‘m ‘0 ’33)

b. Have you EVER had an insulin reaction?

@jj 1 ~ Yes

I 2 ~ No (33)

------+

c. Haw many insulin reoctions have yau had

during the past 3CI days?

~@l

—----Number

o ~ None

I

d. (Including these reactions) Abaut how many have

1

yau had during the past 12 months?

:@3 —

Number

o D None

I

3a. Have you EVER taken diabetes pills?

~(jz 1 n Yes

20 No (34)

-

b. Have yau taken them most of the past 12 manths?

~@ 1 ❑ ‘fes

I 2DN0

c. Are you NOW taking diabetes pills?

:0

; 295 1 ❑ ‘fes

2 a No (33e) 1

e. Haw many ears (have you been taking/did you

J

take) them.

i’a —Years

I o i_’J Less than I year

ORM HE S-32 11-23.761

54
14a. Have you EVER been given a WRITTEN diet for

your (diabetes/ . . .)?

~@ 1 -“; YS.S

I

r Z L~ No (35)

I

b. Was this diet ordered by a doctor?

~@ 1 ayes

[

I

2 ~] No

I

c. ~You NOW follow this diet?

~@ 1 ~Yes

1 2,3 No

1

d. How many years (have you been/were you) an

,

a diet for your (diabetes/ . . .)?

;@ — ‘fears

I o ~ Less than [ year

I

5. Da you carry or wear an thing which identifies ~

you as a (diabetic/ . . .r?.

@ 1 n ye’

I

I

2~No

6. When did you last see or talk to o doctor

about your (diabetes/ . . .)?

;@ — Days

~@ —Weeks

l@—

Months

!@ — Years

7a. During the past 12 months did your (diabetes/ . . .) ~

cause you to cut dawn on the things you ,@ 1 Iqyes

usually da? I z ~ No (Check Item G)

1

b. During the past 12 months, about how manY daYs did I

you cut down on your activity for all or most

;@ _ Days

of the day?

I o L~j None (Check [tern G)

c. During the past 12 months, about how many

days did this condition keep you from work or

~@ _ Days

schaol, not counting work oraund the house?

o ~~_] None t

d. During the past 12 months, about how many

days did your condition limit the kind or amount

;@ _ Days

of work around the house you could da?

o ~ None I

I

e. During the past 12 months, about how many

days has this condition kept you in bed all or i@ — Days

most of the day?

( o In None

CHECK ITEM G

Iotes

H

~C!RM HE S-32 11.23.761

55
Vital and Health Statistics

series descriptions

SERIES 1.

SERIES 2.

SERIES 3.

SERIES 4.

SERIES 5.

SERIES 10.

SERIES 11.

SERIES 12.

SERIES 13.

Programs and Collection Procedures—Reports describing

the general programs of the National Center for Health

Statistics and its offices and divisions and the data collection methods used. They also include definitions and

other material necessary for understanding the data.

Data Evaluation and Mathods Research—Studies of new

statistical methodology including experimental tests of

new suwey methods, studies of vital statistics collection

methods, new analytical techniques, objective evaluations

of reliability of collected data, and contributions to

statistical theory. Studies also include comparison of

U.S. methodology with those of other countries.

Analytical and Epidemiological Studies—Reports presenting analytical or interpretive studies based on vital

and health statistics, carrying the analysis further than

the expository types of reports in the other series.

Documants and Committee Raports-Final reports of

major committees concerned with vital and health statistics and documents such as recommended model vital

registration laws and revised birth and death certificates.

Comparative International Vital and Health Statistic

Reports-Analytical and descriptive reports comparing

U.S. vital and health statistics with those of other countries.

Data From tha National Health Interview Survay-Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other

health-related topics, all based on data collected in the

continuing national household interview suwey.

Data From the National Health Examination Survey and

the National Health and Nutrition Examination Survey—

Data from direct examination, testing, and measurement

of national samples of the civilian noninstitutional ized

population provide the basis for (1) estimates of the

medically defined prevalence of specific diseases in the

United States and the distributions of the population

with respect to physical, physiological, and psychological characteristics and (2) analysis of relationships

among the various measurements without reference to

an explicit finite universe of persons.

Data From the Institutionafiied Population Surveys-Discontinued in 1975. Repo~ from these surveys are included in Series 13.

Data on Health Resources Utilization—Statistics on the

utilization of health manpower and facilities providing

long-term care; ambulato~ care, hospital care, and family

planning services.

SERIES 14.

SERIES 15.

SERIES 20.

SERIES 21.

SERIES 22.

SERIES 23.

For answers

Data on Health Resources: Manpower and Facilities—

Statistics on the numbers, geographic distribution, and

characteristics of health resources including physicians,

dentists, nurses, other health occupations, hospitals,

nursing homes, and outpatient facilities.

Data From Spatial Surveys-Statistics on health and

health-related topics collected in special surveys that

are not a part of the continuing data systems of the

National Center for Health Statistics.

Data on Mortality-Various statistics on mortality other

than as included in regular annual or monthly reports.

Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses;

and statistics on characteristics of deaths not available

from the vital records based on sample surveys of those

records.

Data on Netali~, Marriage, and Divorce-Various statistics on natality, marriage, and divorce other than as

included in regular annual or monthly reports. Special

analyses by demographic variables; geographic and time

series analyses; studies of fertility; and statistics on

characteristics of births not available from the vital

records based on sample surveys of those records.

Data From the National Mortality and Natalii Surveys—

Discontinued in 1975. Reports from these sample surveya

based on vital records are included in Series 20 and 21,

respectively.

Data From the National Survey of Family GrowthStatistics on fertility, family formation and dissolution,

family planning, and related maternal and infant health

topics derived from a periodic survey of a nationwide

probability sample of women 15-44 years of age.

to questions about this report or for a list of titles of

reports published in these series, contact

Scientific and Technical Information Branch

National Center for Health Statistics

Public Health Service

Hyattsville, Md. 20782

301-436-8500
U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Public Health Service

National Center for Health Statistics

3700 East-West Highway

Hyattsville, Maryland 20782

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