American College of Endocrinology Pre-Diabetes Consensus Conference: Part One
- Zachary T. Bloomgarden, MD, is a practicing endocrinologist in New York, New York, and is affiliated with the Division of Endocrinology, Mount Sinai School of Medicine, New York, New York
The American College of Endocrinology held a Consensus Conference in Washington, DC, on 21–22 July 2008 on the topic of pre-diabetes, organized around a series of interrelated questions. This is the first of a three-part series summarizing presentations at the conference.
What should be the criteria for diagnosis of nondiabetes, pre-diabetes, and diabetes?
Michael Stern (San Antonio, TX) opened the conference by discussing approaches to identifying pre-diabetes, noting that, of course, there is always pre-diabetes before diabetes and that, of course, diabetes is associated with a number of complications such that pre-diabetes cannot be considered a benign condition (as it is clearly associated, for example, with increased cardiovascular risk). Pre-diabetes is, however, an asymptomatic condition not associated with functional impairment, Stern argued, suggesting that if a state is associated with future morbidity and mortality, one should not use the paradigm of treating illness in devising approaches to manage the condition. Citing the adage “prediction is very difficult, especially about the future,” variously attributed to Niels Bohr and Yogi Bera, he pointed out that predictions applying to a group differ somewhat from those applying to individuals. He reviewed a well-recognized approach to assessing the performance of continuous risk factors, the receiver operating characteristic (ROC) curve of sensitivity vs. false-positive rate, with the area under the curve (AUC) a measure of the reliability of the test, ranging from 0.5 for a test no better than a flip of a coin to 1.0 for a completely reliable test (1). Relative risk ratios that are considered important are associated with a very modest AUCROC, with an odds ratio of 1.5 only associated with an AUCROC of 0.56 and relative risk ratios of 9–10 required for AUCROC >0.8. It should be noted, however, that the analysis to which Stern referred simply noted the complexity of relative risk in establishing disease likelihood in an …
