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Introduction: Diabetes and hyperglycemia are risk factors for critical COVID-19 outcomes; however, the impact of pre-diabetes and previously unidentified cases of diabetes remains undefined. Here, we profiled hospitalized patients with undiagnosed type 2 diabetes and pre-diabetes to evaluate its impact on adverse COVID-19 outcomes. We also explored the role of de novo and intrahospital hyperglycemia in mediating critical COVID-19 outcomes., Research Design and Methods: Prospective cohort of 317 hospitalized COVID-19 cases from a Mexico City reference center. Type 2 diabetes was defined as previous diagnosis or treatment with diabetes medication, undiagnosed diabetes and pre-diabetes using glycosylated hemoglobin (HbA1c) American Diabetes Association (ADA) criteria and de novo or intrahospital hyperglycemia as fasting plasma glucose (FPG) ≥140 mg/dL. Logistic and Cox proportional regression models were used to model risk for COVID-19 outcomes., Results: Overall, 159 cases (50.2%) had type 2 diabetes and 125 had pre-diabetes (39.4%), while 31.4% of patients with type 2 diabetes were previously undiagnosed. Among 20.0% of pre-diabetes cases and 6.1% of normal-range HbA1c had de novo hyperglycemia. FPG was the better predictor for critical COVID-19 compared with HbA1c. Undiagnosed type 2 diabetes (OR: 5.76, 95% CI 1.46 to 27.11) and pre-diabetes (OR: 4.15, 95% CI 1.29 to 16.75) conferred increased risk of severe COVID-19. De novo/intrahospital hyperglycemia predicted critical COVID-19 outcomes independent of diabetes status., Conclusions: Undiagnosed type 2 diabetes, pre-diabetes and de novo hyperglycemia are risk factors for critical COVID-19. HbA1c must be measured early to adequately assess individual risk considering the large rates of undiagnosed type 2 diabetes in Mexico., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Prior studies examining diabetes prevalence in India have found that nearly 50% of the diabetes population remains undiagnosed; however, the specific populations at risk are unclear., Research Design and Methods: First, we estimated the prevalence of undiagnosed diabetes in India for 750 924 persons between the ages of 15 years and 50 years who participated in the National Family Health Survey (NFHS-4)/Demographic Health Survey (2015-2016), a cross-sectional survey of all 29 states and 7 union territories of India. We defined 'undiagnosed diabetes' as individuals who did not know about their diabetes status but had high random (≥200 mg/dL) or fasting (≥126 mg/dL) blood glucose levels. Second, using Poisson regression, we associated 10 different factors, including the role of healthcare access, and undiagnosed diabetes. Third, we examined the association of undiagnosed diabetes with other potential comorbid conditions., Results: The crude prevalence of diabetes for women and men aged 15-50 years was 2.9%, 95% CI 2.9% to 3.1%, with self-reported diabetes prevalence at 1.7%, 95% CI 1.6 to 1.8. The overall prevalence of undiagnosed diabetes for 15-50 year olds was at 1.2%, 95% CI 1.2% to 1.3%. Forty-two per cent, 95% CI 40.7% to 43.4% of the individuals with high glucose levels were unaware of their diabetes status. Approximately 45%, 95% CI 42.9% to 46.4% of undiagnosed diabetes population had access to healthcare. Men, younger individuals, and those with lower levels of education were most at risk of being undiagnosed. Geographically, the Southern states in India had a significantly higher prevalence of undiagnosed diabetes despite having nearly universal access to healthcare. Risk factors combined with random glucose could predict undiagnosed diabetes (area under the curve of 97.8%, 95% CI 97.7% to 97.8%), Nagelkerke R 2 of 66%)., Conclusion: Close to half (42%) of the people with diabetes in India are not aware of their disease status, and a large subset of these people are at risk of poor detection, despite having health insurance and/or having access to healthcare. Younger age groups and men are the most vulnerable., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)