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Diabetes and PrediabetesScreening and Prevalence Among Adults with

Coronary Heart Disease

Greta Kilmer, MS, Elizabeth Hughes, DrPH, Xuanping Zhang, PhD,Laurie Elam-Evans, PhD, MPH

Background: Clinical performance measures recommend that nondiabetic patients with coronary heart disease (CHD) be screened for diabetes every 3 years.

Purpose: The purpose of this study is to report the prevalence of diabetes and prediabetes amongU.S. adults aged 35 years with CHD and to determine factors associated with not receivingrecommended diabetes screenings.

Methods: The Behavioral Risk Factor Surveillance System (BRFSS) is an annual state-based tele-

phone survey of non-institutionalized U.S. adults. Information on prediabetes prevalence wascollected for 33 states in 2008; data analysis was conducted in 2009. The prevalence of diabetes andprediabetes among adults aged 35 years with CHD (n20,618) and prevalence of diabetes screen-ing among nondiabetic adults with CHD (n14,335) were assessed. Multivariate logistic regressionwas used to calculate the odds of not being screened for diabetes in the past 3 years while controllingfor other factors.

Results: Among adults with CHD, 30.7% (95% CI29.4%, 32.1%) reported being diagnosed withdiabetes and 10.0% (95% CI9.2%, 10.8%) reported prediabetes. Among nondiabetic adults withCHD, 25.4% (95% CI23.9%, 26.9%) reported not being screened for diabetes in the past 3 years.Those with no recent routine checkup and those with no health insurance had the highest odds of norecent diabetes screening.

Conclusions: The prevalence of diabetes and prediabetes is substantial among adults with CHDand likely underestimated because of suboptimal screening. One of four nondiabetic adults withCHD reported not being screened for diabetes in the past 3 years.(Am J Prev Med 2011;40(2):159–165) © 2011 American Journal of Preventive Medicine

Introduction

Adults with diabetes have a higher prevalence of coronary atherosclerosis1,2 and are more likely to die of coronary heart disease (CHD) com-

pared to adults without diabetes.3 Diabetes is a major risk

factor for myocardialinfarction and unstable angina4

andis considered a CHD risk equivalent by the NationalCholesterol Education Program.5

Clinical studies6,7 indicate a high prevalence of insulin

resistance and impaired fasting glucose among nondia-

betic patients with cardiovascular disease. However, the

prevalence of prediabetes among adults with CHD has

not yet been documented. Nationally representative esti-

mates of the prevalence of diabetes and prediabetes

among adults whohave been diagnosed with CHD can be

used to assess the impact of these comorbid conditions in

the U.S.

Clinical guidelines8 recommend diabetes screening at

3-year intervals for all adults with CHD, regardless of

other risk factors. Recommended risk reduction therapy

(e.g., angiotensin-converting enzyme [ACE] inhibitors)

and treatment goals (e.g., controlling high blood pres-

sure) for adultsdiagnosed withCHD depends on whether

or not a diabetes diagnosis has also been made.9 The

American Diabetes Association10 recommends screening

for diabetes among overweight adults with a history of

From the Behavioral Health and Criminal Justice Research Division(Kilmer), RTI International; Division of Viral Hepatitis, National Centerfor HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (Hughes), Divi-sion of Diabetes Translation, National Center for Chronic Disease Preven-tion and Health Promotion (Zhang), and Division of Behavioral Surveil-lance, Offıceof Surveillance, Epidemiology, and Laboratory Services(Elam-Evans), CDC, Atlanta, Georgia

Address correspondence to: Greta Kilmer, MS, RTI International, 2951Flowers Road, Atlanta GA 30341. E-mail: [email protected].

0749-3797/$17.00doi: 10.1016/j.amepre.2010.09.021

© 2011 American Journal of Preventive Medicine. All rights reserved. Am J Prev Med 2011;40(2)159–165 159

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cardiovascular disease and all adults aged 45 years ev-ery 3 years. Identifying disparities in diabetes screeningamong adultswithCHD could lead to improved targetingof prevention efforts and increased detection.

The purpose of the present study was to assess thepopulation-based prevalence estimates of diagnosed dia-

betes and prediabetes among U.S. adults aged

35 yearswho have been diagnosed with CHD and to report theprevalence of diabetes screening among adults withoutdiabetes by using data from the Behavioral Risk FactorSurveillance System (BRFSS). Working under the hy-pothesis that not all adults in this high-risk populationwere screened adequately for diabetes, an examinationwas made of factors associated with not receiving a dia-betes screening within the past 3 years among adults withCHD.

Methods

Analyses were based on data from the 2008 BRFSS, a state-basedsurveillance system that utilizes a random-digit-dialing protocol to

survey a sample of non-institutionalized U.S. adults aged 18years. The data were weighted by the CDC to reflect the demo-graphics of the study population. A detailed description of BRFSSmethods has been published elsewhere.11

Each year, theCDC develops a core questionnaire that is admin-istered in all50 states, theDistrictof Columbia,and U.S. territories.Each year, various optional modules are also included at thediscre-tion of each individual state.In 2008, allstatesurveys had questions

that asked respondents about the presence of CHD and diabetes,and 33 states administered the prediabetes module. A total of 191,631 adults aged 35 years in these 33 states participated in the2008 survey. Data analysis was conducted in 2009. The age cut-off of 35 years was chosen in an attempt to limit the analysis to CHDcaused by chronic atherosclerosis, rather than rare genetic abnor-malities that may lead to heart disease in young adults.

Adults were classifıed as having CHD (n20,618) if they an-swered yes to either of the following questions:

● Have you ever been told by a doctor or other health professional that you had a heart attack, also called a myocardial infarction?

● Have you ever been told by a doctor or other health professional that you had angina or coronary heart disease?

Adults were classifıed as having diabetes if they answered yes tothe following question:

● Have you ever been told by a doctor or other health professional that you have diabetes?

Lastly, respondents who indicatedthey “had never been told by adoctor or other health professional that they had diabetes” thenwere asked the following questions:

● Have you had a test for high blood sugar or diabetes within the past 3 years? (yes, no)

● Have you ever been told by a doctor or other health professional that you have prediabetes or borderline diabetes? (yes, no)

Self-reported height and weight were used to calculate BMI,which was categorized as normal (BMI25.0); overweight

(25.0BMI30); and obese (BMI30.0).

SAS, version 9.1, and SUDAAN, version 10.0, statistical softwareprograms were used to account for the complex sample design

according to BRFSS protocol. Prevalence (%) and 95% CIs were

calculated for four mutually exclusive diabetes status groups: diag-nosed diabetes, diagnosed prediabetes, diabetes screening in the

past 3 years (no diabetes diagnosis), and no diabetes screening. Achi-square (

2) test was used to test the differences in demographic

characteristics among adults aged

35 years who had been diag-nosed with CHD by self-reported doctor-diagnosed diabetes sta-

tus. A multivariate logistic regression model was used to assess the

determinants of not being screened for diabetes within the past 3years among adults with CHD (excluding those diagnosed with

diabetes). The following variables were added to the multivariatemodel in the order given: age (35–54, 55–64, 65–74, and 75

years); gender; race/ethnicity (non-Hispanic white, non-His-panic black, Hispanic, and other race groups); education (less than

high school graduate, high school graduate, some college, collegegraduate); health insurance status; routine checkup in the past 2

years; and BMI (normal, overweight, obese). The Wald F -test wasused to assess signifıcance of ORs ( p0.05).

Results

Among adults aged 35 years who were diagnosed withCHD, 30.7% (95% CI29.4%, 32.1%) reported being di-agnosed with diabetes; 10.0% (95% CI9.2%, 10.8%) re-ported being diagnosed with prediabetes; 41.8% (95%CI40.4%, 43.2%) reported being screened for diabetes

in the past 3 years with no diagnosis of diabetes or predi-abetes; and 17.6% (95% CI16.5%, 18.7%) reported notbeing screened in the past 3 years (Table 1). Amongadults reporting a CHD diagnosis, the prevalence of di-

agnosed diabetes was signifıcantly higher for adults aged55–64 years (34.3%) and adults aged 65–74 years (36.0%)compared to those aged 75 years (28.2%, p0.001).Non-Hispanic white adults diagnosed with CHD (28.4%)were less likely to have a diabetes diagnosis compared tonon-Hispanic black adults with CHD (44.7%, p0.001).

The likelihood of a diabetes diagnosis among adultswith CHD increased with decreasing education. For exam-ple, those without a high school degree were more likely tobe diagnosed with diabetes (35.1%) compared to collegegraduates (25.7%, p0.001). Adults with CHD who did notreport having a routine checkup in the past 2 years were lesslikely to have a diabetes diagnosis (23.7%) compared tothose with a recent checkup (31.4%, p0.01). Adults of normal weight (20.0%, p0.001)andoverweightBMIstatus(26.3%, p0.001) with CHD were less likely to report adiabetes diagnosis than obese adults with CHD (43.1%).

There were fewer differences among subgroups whencomparing the prevalence of diagnosed prediabetesamong adults with CHD. Among adults reporting a CHDdiagnosis, the prevalence of diagnosed prediabetes wassignifıcantly higher for adults aged 55–64 years (11.6%)and adults aged 65–74 years (10.3%) compared to those

aged 75 years (8.0%, p0.01 and p0.05, respectively;

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Table 1). Non-Hispanic white adults with CHD in thispopulation were more likely to be diagnosed with predi-abetes (10.3%) compared to non-Hispanic black adults(7.4%, p0.05). Adults of normal weight (8.0%, p0.001)and overweight BMI status (9.3%, p0.01) with CHDwere less likely to report a prediabetes diagnosis thanobese adults with CHD (12.2%).

Among adults diagnosed with CHD, adults aged55–64 years (13.3%, p0.001) and those aged 65–74years (14.2%, p0.001) differed signifıcantly in the like-

lihood of not being screened for diabetes compared to

those aged75 years (20.5%; Table 1). A higher percent-ageof womenwith CHD were not screened (19.0%) com-pared to men with CHD (16.6%, p0.05). Non-Hispanicwhite adults (17.9%, p0.001) and Hispanic adults(17.8%, p0.05) with CHD had higher rates of no recentscreening compared to non-Hispanic black adults withCHD (9.6%). Those without a high school degree in thispopulation with CHD were more likely to report noscreening in the past 3 years (19.8%) compared to collegegraduates (16.0%, p0.05). A signifıcantly higher per-

centage of adults without health insurance in this popu-

Table 1. Diabetes status and screening rates among adults aged 35 years with CHD, 33 states, 2008 BRFSSa

Characteristics

Unweighted

sample size

Weighted prevalence (95% CI)

Diagnosed diabetes

(n 6283)

Diagnosed prediabetes

(n 2032)

Screened in past 3 years,

not diagnosed (n 8605)

Not screened in past

3 years (n 3698)

Total 20,618 30.7 (29.4, 32.1) 10.0 (9.2, 10.8) 41.8 (40.4, 43.2) 17.6 (16.5, 18.7)

Age (years)

35–54 2,745 24.3 (21.0, 28.0) 10.6 (8.6, 13.1) 43.1 (39.1, 47.2) 22.0 (18.8, 25.5)

55–64 4,798 34.3*** (31.6, 37.1) 11.6** (9.9, 13.6) 40.8 (38.0, 43.6) 13.3*** (11.6, 15.1)

65–74 5,947 36.0*** (33.6, 38.5) 10.3* (8.9, 11.9) 39.6* (37.2, 42.0) 14.2*** (12.5, 15.9)

75 (ref) 7,128 28.2 (26.0, 30.6) 8.0 (6.9, 9.4) 43.3 (41.0, 45.6) 20.5 (18.6, 22.4)

Gender

Male (ref) 10,278 30.7 (28.8, 32.7) 9.6 (8.6, 10.8) 43.1 (41.1, 45.1) 16.6 (15.2, 18.1)

Female 10,340 30.6 (28.9, 32.5) 10.5 (9.2, 11.9) 39.9* (38.0, 41.8) 19.0* (17.5, 20.7)

Race

Non-Hispanic black (ref) 1,034 44.7 (38.9, 50.6) 7.4 (5.2, 10.5) 38.3 (33.1, 43.9) 9.6 (7.1, 12.7)

Non-Hispanic white 17,436 28.4*** (27.1, 29.7) 10.3* (9.5, 11.2) 43.4 (42.0, 44.8) 17.9*** (16.9, 19.0)

Hispanic 915 36.0 (29.2, 43.5) 8.0 (4.9, 12.7) 38.2 (31.1, 45.9) 17.8* (12.8, 24.3)

Education

Some high school or less 3,649 35.1*** (31.5, 38.8) 9.8 (7.8, 12.2) 35.3*** (31.5, 39.3) 19.8* (17.0, 23.0)

High school graduate 7,187 31.1** (28.9, 33.3) 9.8 (8.5, 11.2) 41.1*** (38.8, 43.4) 18.1 (16.3, 20.0)

Some college 5,198 31.4** (28.8, 34.1) 10.1 (8.5, 11.9) 41.4** (38.8, 44.1) 17.2 (15.2, 19.3)

College graduate (ref) 4,520 25.7 (23.2, 28.5) 10.4 (8.8, 12.2) 47.9 (45.0, 50.9) 16.0 (13.9, 18.3)

Health insurance status

Yes (ref) 19,324 30.9 (29.6, 32.4) 9.9 (9.1, 10.7) 42.3 (40.9, 43.8) 16.9 (15.8, 18.0)

No 1,262 26.9 (21.9, 32.6) 11.5 (8.0, 16.3) 35.4* (29.6, 41.6) 26.3** (20.7, 32.7)

Checkup in past 2 years

Yes (ref) 18,757 31.4 (30.0, 32.8) 9.9 (9.1, 10.8) 42.8 (41.4, 44.3) 15.9 (14.9, 17.0)

No 1,602 23.7** (19.2, 28.8) 11.0 (7.7, 15.4) 31.5*** (26.8, 36.6) 34.0*** (29.0, 39.3)

BMI

Normal 5,489 20.0*** (17.4, 22.9) 8.0*** (6.6, 9.5) 47.5*** (44.7, 50.4) 24.5*** (22.2, 27.0)

Overweight 7,669 26.3*** (24.2, 28.4) 9.3** (8.1, 10.7) 45.7*** (43.3, 48.1) 18.7*** (17.0, 20.6)

Obese (ref) 6,835 43.1 (40.7, 45.4) 12.2 (10.7, 13.8) 33.5 (31.3, 35.8) 11.3 (9.7, 13.1)

aIncludes 33 states: Alabama, Alaska, Arizona, California, Colorado, Connecticut, Delaware, Iowa, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Missouri,

Montana, Nebraska, New Hampshire, New Mexico, New York, North Carolina, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Dakota, Tennessee, Texas,

Utah, Vermont, Virginia, West Virginia, Wisconsin, and Wyoming

*p 0.05,**p 0.01,***p 0.001

BRFSS, Behavioral Risk Factor Surveillance System; CHD, coronary heart disease

Kilmer et al / Am J Prev Med 2011;40(2):159–165 161

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lation with CHD were not screened (26.3%) compared tothose with health insurance (16.9%, p0.01). A higherpercentage of adults who reported no routine checkupwithin the past 2 years in this population with CHD werenot screened (34.0%) compared to those with a recentcheckup (15.9%, p0.001). Overweight (18.7%, p0.001)

and normal-weight (24.5%, p0.001) adults with CHD

were more likely to report no recent screening comparedto obese adults (11.3%).

After excluding those with diagnosed diabetes(n14,335), 25.4% (95% CI23.9%, 26.9%) of adultswith CHD reported no diabetes screening in the past 3years (Table 2). In the multivariate model, the odds of no

diabetes screening among adults diagnosed with CHD

Table 2. Prevalence and adjusted oddsa of not receiving a diabetes screening in the past 3 years among adults

aged 35 years with CHD,b 33 states, 2008 BRFSS

Characteristics

Unweighted

sample size

Weighted prevalence of no

diabetes screening in the

past 3 years (95% CI)

Adjusted odds of no diabetes

screening in past 3 years

Weighted and adjusted OR (95% CI)

Total 14,335 25.4 (23.9, 26.9) —Age (years)

35–54 2,032 29.0 (25.0, 33.4) 1.36 (1.27, 1.46)

55–64 3,232 20.2 (17.8, 22.9) 0.90 (0.83, 0.97)

65–74 3,891 22.1 (19.7, 24.7) 0.79 (0.73, 0.86)

75 5,180 28.5 (26.1, 31.0) 1.0 (ref)

Gender

Male 7,195 23.9 (22.0, 26.0) 1.0 (ref)

Female 7,140 27.4 (25.3, 29.7) 1.13 (1.08, 1.19)

Race

Non-Hispanic black 585 17.3 (13.0, 22.6) 1.0 (ref)

Non-Hispanic white 12,414 25.1 (23.7, 26.5) 1.22 (1.10, 1.36)

Hispanic 562 27.9 (20.2, 37.1) 0.83 (0.71, 0.96)

Education

Some high school or less 2,346 30.5 (26.3, 35.1) 1.22 (1.11, 1.35)

High school graduate 4,956 26.2 (23.7, 28.8) 1.14 (1.08, 1.21)

Some college 3,632 25.0 (22.3, 27.9) 0.99 (0.93, 1.05)

College graduate 3,363 21.5 (18.8, 24.5) 1.0 (ref)

Health insurance status

Yes 13,391 24.5 (23.0, 26.0) 1.0 (ref)

No 921 35.9 (28.7, 43.9) 1.55 (1.42, 1.70)

Checkup in past 2 years

Yes 12,924 23.2 (21.7, 24.7) 1.0 (ref)

No 1,238 44.5 (38.4, 50.7) 4.19 (3.92, 4.48)

BMI

Normal 4,550 30.7 (28.0, 33.5) 1.86 (1.75, 1.99)

Overweight 5,608 25.4 (23.2, 27.8) 1.37 (1.29, 1.46)

Obese 3,785 19.8 (17.1, 22.8) 1.0 (ref)aAdjusted for age, gender, race, education, health insurance status, checkup in past 2 years, and BMI.bExcludes adults diagnosed with diabetes.

BRFSS, Behavioral Risk Factor Surveillance System; CHD, coronary heart disease


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multiple biological mechanisms contribute to the in-crease in various cardiovascular conditions, includingCHD, among those with diabetes. Both diabetes andCHD share common underlying risk factors (e.g., obe-sity); however, the relationship between these two dis-eases is complex. Metabolic factorsassociated with diabe-

tes, such as insulin resistance and hyperinsulinemia, canlead to increased risk for conventional CHD risk factors,such as hypertension. Reduced recognition of cardiacsymptoms in those with diabetes may contribute to theincrease in adverse outcomes following myocardial in-farction in these patients. In addition, life expectancy isseverely diminished in patients with CHD once end-stagerenal diseasehas developed as a consequence of diabetes.4

Limitations

Several limitations need to be considered when interpret-ing the results of the current study. BRFSS data excludehouseholds without a land-line telephone, and survey response rates vary by state. The current analysis focusedon data from 33 states; therefore,caremustbe taken whengeneralizing results to states where diabetes screeningand prediabetes datawere not collected. BRFSS was basedon self-report, and it is likely that prevalence of diseasefrom self-report will be underestimated. Diabetes screen-ing rates are underestimated because some patients may not recall being tested or were not aware of being tested,especially if the test was completed as a part of routine labwork. Lack of screening leads to an underestimation of

the prevalence of diabetes and prediabetes, which is evi-dent when self-reported data (such as BRFSS) are com-pared to data collected through direct measurement(such as the National Health and Nutrition ExaminationSurvey).12 Recall bias may explain the difference inscreening rates by education level because adults with alower level of education may be less likely to rememberwhether they were screened. CHD and diabetes are alsomeasured by self-report of a diagnosis by a health profes-sional; therefore, both of these chronic conditions may beunder-reported. Because this is a cross-sectional study, anumber of adults with CHD may have been diagnosedrecently and not yet been tested for diabetes.

There is a need in the medical community to empha-size the importance of screening for diabetes amongadults with CHD. Clinical guidelines from the AmericanCollege of Cardiology/American Heart Association weremost recently updated in 2003, and the American Diabe-tes Association recommendations do not specifıcally tar-get these individuals.8,10 A recent recommendation fromthe U.S. Preventive Services Task Force for diabetesscreening in adults with sustained blood pressure greaterthan 135/80 mmHg may cause confusion among health

professionals. This recommendation was meant for pri-

mary prevention in the general population and does notapply to adults diagnosed with CHD.23 Recently, whenthe USDHHS organized a discussion about the objectivesof Healthy People 2020, the American Association of Diabetes Educators urged Healthy People 2020 to con-sider the inclusion of two additional objectives related to

early detection of diabetes/prediabetes, especially amongpopulations at high risk.24

Conclusion

Adults with CHD should be screened for diabetes accord-ing to clinical guidelines in order to promote appropriatetreatment goals. Barriers to conducting this importantscreening in clinical settings should be studied further.

The BRFSS provides datato monitor trends among adultsin the general population who have been diagnosed withCHD. As this population grows in the U.S., further stud-

ies regarding comorbid health conditions and behavioralrisk factors can benefıt the clinical management of thiscomplex disease.

The fındings and conclusions in this report are those of the

authors and do not necessarily represent the offıcial position of

the CDC.

No fınancial disclosures were reported by the authors of this

paper.

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