American Journal of Epidemiology
Copyright ª 2006 by the Johns Hopkins Bloomberg School of Public Health
All rights reserved; printed in U.S.A.
Vol. 164, No. 10
DOI: 10.1093/aje/kwj311
Advance Access publication October 5, 2006
Original Contribution
Prostate-specific Antigen Values in Diabetic and Nondiabetic US Men, 2001–2002
David M. Werny1, Mona Saraiya1, and Edward W. Gregg2
Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Atlanta, GA.
Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, GA.
Recent studies have shown that diabetic men have a lower risk of prostate cancer and that this association may
be related to time since diagnosis. The authors examined the association between diabetes and prostate-specific
antigen (PSA) levels, controlling for potential confounders, in a nationally representative cross-sectional survey of
the US population (National Health and Nutrition Examination Survey 2001–2002). Diabetes classification was
self-reported, and undiagnosed diabetes was determined with fasting plasma glucose measurements. Controlling
for age, men with self-reported diabetes had a 21.6% lower geometric mean PSA level than men without diabetes.
The difference increased with years since diagnosis (>10 years: 27.5% lower geometric mean PSA level). Overweight men who had had diabetes for more than 10 years had a predicted geometric mean PSA level 40.8% lower
than that of nondiabetic, normal-weight men. These results are consistent with the hypothesis that long-term
diabetes is associated with a lower risk of prostate cancer. The mechanism of this association may involve the
regulation of PSA by androgens, although the authors are unable to confirm this assertion. Better understanding of
the determinants of PSA level is needed to make the distinction between factors affecting the PSA test’s accuracy
and those altering the risk of prostate cancer.
diabetes mellitus, type 2; prostate-specific antigen; prostatic neoplasms; testosterone
Abbreviations: BMI, body mass index; IGF-1, insulin-like growth factor 1; NHANES, National Health and Nutrition Examination
Survey; PSA, prostate-specific antigen.
Recent studies have suggested an association between
type 2 diabetes mellitus and lower risk of prostate cancer
(1, 2). It has been hypothesized that men with long-term
diabetes have a lower risk of prostate cancer than nondiabetic men, and recently diagnosed men have a higher risk (3,
4). In biologic models proposed to explain this association,
researchers note the higher concentrations of insulin and
insulin-like growth factor 1 (IGF-1) in early diabetes and
the lower testosterone and IGF-1 levels and higher estrogen
concentrations in long-term diabetes (5, 6). Whether diabetes influences levels of biomarkers such as prostate-specific
antigen (PSA), which is involved in the detection of prostate
cancer, is unknown.
Factors influencing serum PSA levels in men include age,
benign prostatic hyperplasia, prostatitis, and body mass index (BMI) (7, 8). Still, we understand little about PSA, and
its relations with comorbid conditions remain unexplored
(9). Diabetes and PSA screening are prevalent among men
aged 50 years or older, and no doubt many men this age with
diabetes undergo PSA testing (10, 11). In this analysis, we
examined whether PSA concentrations varied by diabetes
status and duration of diabetes.
Correspondence to Dr. Mona Saraiya, National Center for Chronic Disease Prevention and Health Promotion, Mail Stop K-55, 4770 Buford
Highway NE, Atlanta, GA 30341 (e-mail: [email protected]).
Am J Epidemiol 2006;164:978–983
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Received for publication February 8, 2006; accepted for publication April 28, 2006.
PSA Values in Diabetic and Nondiabetic US Men
We categorized participants by measured BMI (weight
(kg)/height (m)2) as normal-weight (BMI <25), overweight
(BMI 25–<30), or obese (BMI 30) (15). Persons with
a measured systolic blood pressure of 140 mmHg or a diastolic blood pressure of 90 mmHg were considered hypertensive (16). We defined measured high density lipoprotein
cholesterol with a gender-specific 0.9-mmol/liter threshold
(17). Serum insulin concentrations were measured for the
men who had fasted. The QUICKI index of insulin sensitivity was calculated for men in the fasting subsample (1/[log
insulin (lU/ml) þ log glucose (mg/dl)]) (18). Ever having
been diagnosed with benign prostatic hyperplasia was selfreported. We categorized age by decade (40–49, 50–59, 60–
69, 70–79, and 80–85 years) in the univariate analysis but
controlled for age continuously in our multivariate models.
We categorized race/ethnicity as Mexican-American, nonHispanic White, non-Hispanic Black, or other. For all variAm J Epidemiol 2006;164:978–983
ables, responses such as ‘‘refused’’ or ‘‘don’t know’’ were
considered missing data.
Statistical analyses
PSA values were natural-log-transformed to improve normality. Log PSA was used as the dependent variable for the
bivariate and linear regression analyses. In all analyses, we
used SUDAAN, version 9.0 (Research Triangle Institute,
Research Triangle Park, North Carolina), to account for the
complex sampling design. All p values (from t tests) were
two-sided. We analyzed log-transformed PSA values, and
accordingly we present geometric means in table 1. We controlled for age when presenting results because of the known
association between PSA and age. Variables for the categories of years since diagnosis of diabetes were coded as separate terms in the multivariate analyses. In constructing the
multiple linear regression model (table 2), we first assessed
variables using a series of models containing only the variable in question, the diabetes terms, including time since
diagnosis, and an interaction term for the interaction between the two. Variables that were themselves significant
predictors in the presence of the diabetes terms were included in the multiple linear regression model, as were any
confounders that altered the predicted effect of the diabetes
terms by more than 10 percent (19). Interactions between
the diabetes terms and BMI, high density lipoprotein cholesterol, race/ethnicity, blood pressure, age, and benign
prostatic hyperplasia were nonsignificant. The race/ethnicity terms were included in the model because of previous
reports that showed variation in PSA levels by race/ethnicity (20).
Geometric mean PSA levels increased with age (40–49
years: 0.75 ng/ml; 50–59 years: 0.93 ng/ml; 60–69 years:
1.11 ng/ml; 70–79 years: 1.76 ng/ml; 80–85 years: 2.15 ng/
ml). Results are shown in table 1 after controlling for age
(median age, 51 years). Both the overweight and obese
BMI groups showed lower predicted geometric mean PSA
levels than the comparison group (BMI <25) (table 1). No
significant differences in predicted geometric mean PSA levels were seen by race/ethnicity, blood pressure, high density
lipoprotein cholesterol, or past diagnosis of benign prostatic
hyperplasia. The predicted geometric mean PSA value was
lower in the diabetic group than in the nondiabetic group (p <
0.001) and was lowest in men who had been diagnosed with
diabetes more than 10 years previously. The trend for decreased PSA by diabetes status (beginning with nondiabetic
men and ending with men diagnosed more than 10 years
previously) was statistically significant (p ¼ 0.001). Diabetic
men taking medication to control blood glucose levels had
lower PSA levels than nondiabetic men, but in a comparison
with diabetic men not taking medication, the p value was not
statistically significant (p ¼ 0.073).
We examined the association between PSA and diabetes
covariates in a fasting subsample of our study population,
adjusting for age as in table 1. There was no association
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The 2001–2002 National Health and Nutrition Examination Survey (NHANES) was weighted to provide a nationally
representative sample of the noninstitutionalized, civilian
US population (12). In 2001–2002, participation rates for
the NHANES interview and medical examination were 83.9
percent and 79.7 percent, respectively. An institutional review board approved the survey. Participants provided informed consent for PSA testing.
PSA assays were conducted on serum samples taken from
all men aged 40 years who did not meet any of the PSA
testing exclusion criteria, including current prostatitis or diagnosis of prostate cancer (n ¼ 1,308) (13). PSA was measured using the Hybritech assay (Hybritech, Inc., San Diego,
California) in the Beckman immunoassay system (Beckman
Instruments, Inc., Fullerton, California).
Sample adults were asked, ‘‘Have you ever been told by
a doctor or health professional that you have diabetes or sugar
diabetes?’’ Men answering affirmatively (n ¼ 173) were classified as having diabetes. We calculated time since diagnosis
(in years) by subtracting age at diagnosis from current age,
producing categories of 0–5, 6–10, and >10 years (3). Men
who reported being diabetic were also asked whether they
were currently taking ‘‘diabetic pills to lower blood sugar.’’
A subset of our 1,308 participants were instructed to fast
before the medical examination (n ¼ 605). In NHANES,
separate weights are assigned to ensure that this fasting sample is nationally representative. Among participants not selfclassified as diabetic, we designated a fasting plasma glucose
level of 126 mg/dl as undiagnosed diabetes, and we created
separate groups for persons with fasting plasma glucose levels of <100 mg/dl, 100–110 mg/dl, and 111–125 mg/dl. Selfclassified diabetic men were categorized by years since
diagnosis, as noted above. Fasting has not been shown to
affect PSA levels (14), and there was no statistically significant difference between PSA values in the fasting and nonfasting groups (p ¼ 0.415).
980 Werny et al.
TABLE 1. Predicted geometric mean prostate-specific antigen values for men aged 51 years, by
demographic and clinical characteristics, National Health and Nutrition Examination Survey 2001–2002*
geometric mean
% change in
geometric mean
0 (reference)
95% confidence interval
for change in predicted
geometric mean
p valuey
Body mass indexz (total n ¼ 1,239)§
<25 (n ¼ 296)
25–<30 (n ¼ 559)
28.0, 6.2
30 (n ¼ 375)
28.4, 2.3
0 (reference)
Race/ethnicity (total n ¼ 1,308)
Non-Hispanic White (n ¼ 767)
Non-Hispanic Black (n ¼ 225)
6.8, 28.6
Mexican-American (n ¼ 235)
7.6, 28.8
Other (n ¼ 81)
25.9, 23.9
21.9, 4.0
16.1, 10.3
High blood pressure (total n ¼ 1,300){
0 (reference)
High density lipoprotein cholesterol
level (total n ¼ 1,308)
0.9 mmol/liter (n ¼ 1,103)
<0.9 mmol/liter (n ¼ 205)
0 (reference)
30.5, 11.5
41.7, 9.9
Diabetes status (total n ¼ 1,308)
Diabetic (n ¼ 173)#
Duration of diabetes
>10 years (n ¼ 63)
6–10 years (n ¼ 31)
40.8, 6.2
0–5 years (n ¼ 77)
32.7, 2.0
41.7, 14.4
22.6, 36.1
Use of diabetes medication
Currently taking medication
(n ¼ 123)
Not taking medication (n ¼ 49)
Nondiabetic (n ¼ 1,135)
0 (reference)
* Results are from a multiple linear regression model weighted analysis with the complex sample design taken
into account.
y Two-sided t test for the difference in mean log-transformed prostate-specific antigen value compared with the
reference group.
z Weight (kg)/height (m)2.
§ Data on height and/or weight were missing for 69 participants.
{ Persons with a measured systolic pressure 140 mmHg or a diastolic pressure 90 mmHg were considered
hypertensive. Eight participants had missing values for either measure.
# Two diabetic participants did not report their age at diagnosis; one diabetic participant did not report on
medication use.
between PSA and fasting insulin levels (p ¼ 0.182; data not
shown), as well as no change in predicted geometric mean
PSA by category of fasting plasma glucose among the nondiabetic men (p ¼ 0.800; data not shown). Additionally,
there was no association between the QUICKI index of insulin sensitivity and PSA (p ¼ 0.122; data not shown). The
predicted geometric mean PSA for self-reporting diabetic
men was lower than that of self-reporting nondiabetic men
(n ¼ 540) (0.62 ng/ml vs. 0.88 ng/ml; p ¼ 0.012). There was
no statistically significant difference between self-reporting
diabetic men (n ¼ 65) and men with undiagnosed diabetes
(n ¼ 45) (0.57 ng/ml vs. 0.77 ng/ml; p ¼ 0.146). When we
compared the group of diagnosed and undiagnosed diabetic
men (n ¼ 109) with those self-reporting nondiabetic men
who had a fasting plasma glucose level less than 100 mg/dl
(n ¼ 250), there was no statistically significant difference
(0.70 ng/ml vs. 0.86 ng/ml; p ¼ 0.120). In contrast to the
results in the larger sample, the lowest predicted geometric
mean PSA level in the fasting subsample was for persons
diagnosed with diabetes within the previous 5 years (n ¼ 28)
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Yes (n ¼ 359)
No (n ¼ 941)
PSA Values in Diabetic and Nondiabetic US Men
TABLE 2. Predictors of prostate-specific antigen (PSA) concentration obtained using
multivariate linear regression, National Health and Nutrition Examination Survey
Age (per year)
% change in
geometric mean
95% confidence interval
for change in predicted
geometric mean
þ2.2, 3.2
p valuey
Body mass index (BMI)z
0 (reference)
27.6, 6.7
26.9, 1.6
8.1, 28.4
Non-Hispanic White
0 (reference)
Non-Hispanic Black
7.0, 32.2
29.2, 25.5
Diabetes status
Any duration
31.2, 7.5
Duration >10 years
43.6, 11.4
Duration 6–10 years
43.5, 1.1
Duration 0–5 years
32.0, 8.9
Not diabetic
0 (reference)
* Final model: log PSA ¼ B0 þ B1 3 age þ B2–3 3 BMI1–2 þ B4–6 3 race1–3 þ B7–9 3
diabetes1–3; R2 ¼ 0.13; n ¼ 1,237. Results were obtained from a weighted analysis with the
complex sample design taken into account.
y Two-sided t test for the probability that the predicted percent change in the geometric mean
differs from 0.
z Weight (kg)/height (m)2.
(0.56 ng/ml; in comparison with nondiabetic men with a
fasting plasma glucose level less than 100 mg/dl, p ¼
In the multiple linear regression model, neither BMI nor
race/ethnicity confounded the association between the diabetes terms and PSA (table 2). We used the model to examine the joint associations of BMI and diabetes with PSA.
The predicted geometric mean PSA for all 51-year-old nondiabetic men with a BMI less than 25 was 1.03 ng/ml—
significantly higher than the value for their same-age peers
with diabetes of more than 10 years’ duration who had a
BMI greater than or equal to 25 (0.61 ng/ml, a 40.8 percent
reduction; p ¼ 0.001).
Diabetes and an overweight BMI are independently associated with lower geometric mean PSA levels. Together they
are associated with as much as a 40.8 percent lower predicted geometric mean PSA level relative to nondiabetic,
normal-weight men. Diabetic men have lower androgen levels than nondiabetic men, and this may partially explain
their lower PSA levels (6). Our finding of a significant downward trend of PSA (from no diabetes to diabetes of more
Am J Epidemiol 2006;164:978–983
than 10 years’ duration) is consistent with a possible association between progressing diabetes and decreasing testosterone concentrations, which may lower the risk of prostate
cancer (21). Despite the existence of functional androgenresponsive elements upstream of the PSA gene promoter,
previous investigations have not shown an association between serum testosterone and PSA levels (22). However,
PSA may be associated with testosterone in men with subnormal levels of the sex hormone (23), as is the case with
diabetic men. Diabetes might also alter PSA values through
impaired kidney function (24) or as a consequence of diabetes medication use. Metformin, a hypoglycemic agent,
has been shown to decrease testosterone levels in nondiabetic men but not in diabetic men (25, 26). In our study,
diabetic men taking medication appeared to have lower PSA
levels than diabetic men not taking medication, but our
small sample size limited our statistical power to detect a
difference. This association can be examined more appropriately with additional data.
In diabetes, IGF-1 levels increase during hyperinsulinemia
and decrease as insulin production drops (27). Previous studies have found a peak in prostate cancer risk during early
diabetes, and a recent study (28) found a modest positive
association between serum PSA and serum IGF-1 that was
proposed to be due to IGF-1-induced benign prostatic
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982 Werny et al.
The analysis was repeated with these men categorized as
diabetic; no substantial changes were noted.
Some investigators have recommended age- and racespecific thresholds for prostate cancer detection based on
population-level differences (20). While this study was unable to demonstrate that modified PSA thresholds for diabetic men would result in greater accuracy, future studies
should investigate whether diabetes status, duration of diabetes, and obesity should be considered when interpreting
a PSA test result. Better understanding of the determinants
of PSA levels is needed to make the distinction between
factors affecting the test’s accuracy and those altering the
risk of prostate cancer.
This research was performed while David Werny was
a fellow in the Centers for Disease Control and Prevention
Research Participation Program, administered by the Oak
Ridge Institute for Science and Education under contract
DE-AC05-00OR22750 between the US Department of
Energy and Oak Ridge Associated Universities.
Mr. Werny thanks Dr. Kevin Sullivan for his guidance.
Conflict of interest: none declared.
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hyperplasia in older men (3, 4). We did not observe a positive
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PSA levels among diabetic men.
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participants with undiagnosed cancer was unknown, and
thus we do not know whether differences in PSA were due
to undiagnosed prostate cancer in the diabetic and nondiabetic groups. Furthermore, without clinical data, we cannot
be sure that these differences in PSA result in missed biopsy
opportunities, nor can we recommend alternate biopsy
thresholds for diabetic men. A third limitation is that selfreported measures of diabetes status have been shown to be
highly specific but only 66 percent sensitive (31). We addressed this concern by analyzing the fasting subsample,
although there may have been additional diabetic men in
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results. In another potential source of misclassification, participants were given the option to report having ‘‘borderline’’
diabetes. We categorized these men as nondiabetic (n ¼ 29).
PSA Values in Diabetic and Nondiabetic US Men
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