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Cardiology

Trends in Prevalence of Diabetes and Control of Risk Factors in Diabetes Among US Adults, 1999-2018

Educational Objective
To understand the prevalence of diabetes and associated cardiovascular risk in the US.

1 Credit CME

JAMA

Published Online: June 25, 2021

Original Investigation

Article Information and Disclosures

Li Wang, PhD¹;

Xiaoguang Li, PhD¹;

Zhaoxin Wang, PhD¹;

Michael P. Bancks, PhD²;

Mercedes R. Carnethon, PhD³;

Philip Greenland, MD³;

Ying-Qing Feng, MD⁴;

Hui Wang, MD, PhD¹;

Victor W. Zhong, PhD¹

Author Affiliations

¹School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
²Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
³Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
⁴Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China

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Key Points

Question What were the trends in prevalence of diabetes and control of risk factors in diabetes among adults in the US from 1999-2000 to 2017-2018?

Findings In this serial, cross-sectional study of nationally representative data from 28 143 participants in the National Health and Nutrition Examination Survey (NHANES), the estimated age-standardized prevalence of diabetes increased significantly, from 9.8% in 1999-2000 to 14.3% in 2017-2018. Only 21.2% of adults with diagnosed diabetes achieved all 3 risk factor control goals in 2015-2018, including individualized hemoglobin A_1c targets, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL.

Meaning Based on NHANES data from US adults, the estimated prevalence of diabetes increased significantly between 1999-2000 and 2017-2018, and only an estimated 21% of adults with diagnosed diabetes achieved all 3 risk factor control goals in 2015-2018.

Abstract

Importance Understanding population-wide trends in prevalence and control of diabetes is critical to planning public health approaches for prevention and management of the disease.

Objective To determine trends in prevalence of diabetes and control of risk factors in diabetes among US adults between 1999-2000 and 2017-2018.

Design, Setting, and Participants Ten cycles of cross-sectional National Health and Nutrition Examination Survey (NHANES) data between 1999-2000 and 2017-2018 were included. The study samples were weighted to be representative of the noninstitutionalized civilian resident US population. Adults aged 18 years or older were included, except pregnant women.

Exposures Survey cycle.

Main Outcomes and Measures Diabetes was defined by self-report of diabetes diagnosis, fasting plasma glucose level of 126 mg/dL or more, or hemoglobin A_1c (HbA_1c) level of 6.5% or more. Three risk factor control goals were individualized HbA_1c targets, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL. Prevalence of diabetes and proportion of adults with diagnosed diabetes who achieved risk factor control goals, overall and by sociodemographic variables, were estimated.

Results Among the 28 143 participants included (weighted mean age, 48.2 years; 49.3% men), the estimated age-standardized prevalence of diabetes increased significantly from 9.8% (95% CI, 8.6%-11.1%) in 1999-2000 to 14.3% (95% CI, 12.9%-15.8%) in 2017-2018 (P for trend < .001). From 1999-2002 to 2015-2018, the estimated age-standardized proportion of adults with diagnosed diabetes who achieved blood pressure less than 130/80 mm Hg (P for trend = .007) and low-density lipoprotein cholesterol level less than 100 mg/dL (P for trend < .001) increased significantly, but not individualized HbA_1c targets (P for trend = .51). In 2015-2018, 66.8% (95% CI, 63.2%-70.4%), 48.2% (95% CI, 44.6%-51.8%), and 59.7% (95% CI, 54.2%-65.2%) of adults with diagnosed diabetes achieved individualized HbA_1c targets, blood pressure less than 130/80 mm Hg, and low-density lipoprotein cholesterol level less than 100 mg/dL, respectively. Only 21.2% of these adults (95% CI, 15.5%-26.8%) achieved all 3. During the entire study period, these 3 goals were significantly less likely to be achieved among young adults aged 18 to 44 years (vs older adults ≥65 years: estimated proportion, 7.4% vs 21.7%; adjusted odds ratio, 0.32 [95% CI, 0.16-0.63]), non-Hispanic Black adults (vs non-Hispanic White adults: estimated age-standardized proportion, 12.5% vs 20.6%; adjusted odds ratio, 0.60 [95% CI, 0.40-0.90]), and Mexican American adults (vs non-Hispanic White adults: estimated age-standardized proportion, 10.9% vs 20.6%; adjusted odds ratio, 0.48 [95% CI, 0.31-0.77]).

Conclusions and Relevance Based on NHANES data from US adults, the estimated prevalence of diabetes increased significantly between 1999-2000 and 2017-2018. Only an estimated 21% of adults with diagnosed diabetes achieved all 3 risk factor control goals in 2015-2018.

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Article Information

Corresponding Authors: Victor W. Zhong, PhD, School of Public Health, Shanghai Jiao Tong University School of Medicine, 415 East No. 1 Bldg, 227 South Chongqing Rd, Shanghai 200025, China (wenze.zhong@shsmu.edu.cn); Hui Wang, MD, PhD, Shanghai Jiao Tong University School of Medicine, 227 South Chongqing Rd, Shanghai 200025, China (huiwang@shsmu.edu.cn).

Accepted for Publication: May 31, 2021.

Published Online: June 25, 2021. doi:10.1001/jama.2021.9883

Author Contributions: Dr Zhong had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: L. Wang, Li, Carnethon, Greenland, H. Wang, Zhong.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: L. Wang, Zhong.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: L. Wang, Zhong.

Administrative, technical, or material support: Li, Carnethon, H. Wang, Zhong.

Supervision: Greenland, H. Wang, Zhong.

Discussion with the lead author (and study team) on what should be the ultimate focus of the article and conclusions: Bancks.

Conflict of Interest Disclosures: Dr Bancks reported receiving grants from the National Institutes of Health (NIH) as a coinvestigator with multiple unrelated epidemiologic studies and clinical trials and receiving funding from the NIH for his work with these cohorts, outside the submitted work. Dr Greenland reported receiving grants from NIH and the American Heart Association, outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the Program for Young Eastern Scholar at Shanghai Institutions of Higher Education (QD2020027), the National Key R&D Program of China (2018YFC2000700), the National Natural Science Foundation of China (82030099, 81630086), and the Shanghai Public Health System Construction Three-Year Action Plan (GWV-10.1-XK15).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Greenland, a JAMA senior editor, was not involved in the review of or decision to publish this article.

Additional Contributions: We thank Danita D. Byrd-Clark, BBA, Social & Scientific Systems, for assisting with the SAS program development for specific analyses related to definition of diabetes and calibration of laboratory measurements across NHANES cycles. Ms Byrd-Clark did not receive financial compensation for her contribution.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.