Race-ethnicity as an effect modifier of the association between HbAlc and mortality in U.S. adults without diagnosed diabetes

Objective: HbAlc is increasingly appreciated as a risk factor for all-cause and cardiovascular disease (CVD) mortality in the non-diabetic population. In this study, we investigated the association between HbAlc and mortality with a particular focus on the impact of race-ethnicity. Design: Cohort study. Methods:We analyzed the association between HbAlc and all-cause and CVD mortality in 12 698 non-diabetic adults 20 years or older from the Third National Health and Nutrition Examination Survey using separate models for people of different race-ethnicity. Results: In our stratified analyses, higher non-diabetic HbAlc levels were associated with all-cause and CVD mortality in non-Hispanic whites only. In this group, compared with HbAlc values of 5.0- < 5.35%, the multivariable-adjusted estimated hazard ratios (est. HR) with 95% confidence interval (CI) for allcause mortality were 1.21 (0.92, 1.58), 1.22 (1.03, 1.45), 1.29 (1.14, 1.47), and 1.4 (1.02, 1.87) for HbAlc levels of < 5.0, 5.35- < 5.7, 5.7- < 6.5, and 6.5% or greater respectively. The association did not reach significance in Mexican-Americans (est. HR (95% CI): 1.77 (1.08, 2.91), 0.81 (0.56, 1.19), 1.16 (0.86, 1.57), and 1.4 (0.83, 2.36)). No association was observed in non-Hispanic blacks: 1.13 (0.91, 1.39), 0.81 (0.61, 1.08), 0.84 (0.69, 1.03), and 0.94 (0.67, 1.33). Resultswere similar for CVDmortality. Conclusions: Our data suggest limitations of HbAlc as a risk factor for all-cause and cardiovascular mortality across race-ethnic populations.