Trends and Inequalities in Diabetes-Related Complications Among U.S. Adults, 2000-2020.

OBJECTIVE: We examined national trends in diabetes-related complications (heart failure [HF], myocardial infarction [MI], stroke, end-stage renal disease [ESRD], nontraumatic lower-extremity amputation [NLEA], and hyperglycemic crisis) among U.S. adults with diagnosed diabetes during 2000-2020 by age-group, race and ethnicity, and sex. We also assessed trends in inequalities among those subgroups. RESEARCH DESIGN AND METHODS: Hospitalization rates for diabetes-related complications among adults (≥18 years) were estimated using the 2000-2020 National (Nationwide) Inpatient Sample. The incidence of diabetes-related ESRD was estimated using the United States Renal Data System. The number of U.S. adults with diagnosed diabetes was estimated from the National Health Interview Survey. Annual percent change (APC) was estimated for assessment of trends. RESULTS: After declines in the early 2000s, hospitalization rates increased for HF (2012-2020 APC 3.9%, P < 0.001), stroke (2009-2020 APC 2.8%, P < 0.001), and NLEA (2009-2020 APC 5.9%, P < 0.001), while ESRD incidence increased (2010-2020 APC 1.0%, P = 0.044). Hyperglycemic crisis increased from 2000 to 2020 (APC 2.2%, P < 0.001). MI hospitalizations declined during 2000-2008 (APC -6.0%, P < 0.001) and were flat thereafter. On average, age inequalities declined for hospitalizations for HF, MI, stroke, and ESRD incidence but increased for hyperglycemic crisis. Sex inequalities increased on average for hospitalizations for stroke and NLEA and for ESRD incidence. Racial and ethnic inequalities declined during 2012-2020 for ESRD incidence but increased for HF, stroke, and hyperglycemic crisis. CONCLUSIONS: There was a continued increase of several complications in the past decade. Age, sex, and racial and ethnic inequalities have worsened for some complications.

State-Specific Prevalence of Depression Among Adults With and Without Diabetes - United States, 2011-2019.

INTRODUCTION: In 2019 among US adults, 1 in 9 had diagnosed diabetes and 1 in 5 had diagnosed depression. Since these conditions frequently coexist, compounding their health and economic burden, we examined state-specific trends in depression prevalence among US adults with and without diagnosed diabetes. METHODS: We used data from the 2011 through 2019 Behavioral Risk Factor Surveillance System to evaluate self-reported diabetes and depression prevalence. Joinpoint regression estimated state-level trends in depression prevalence by diabetes status. RESULTS: In 2019, the overall prevalence of depression in US adults with and without diabetes was 29.2% (95% CI, 27.8%-30.6%) and 17.9% (95% CI, 17.6%-18.1%), respectively. From 2011 to 2019, the depression prevalence was relatively stable for adults with diabetes (28.6% versus 29.2%) but increased for those without diabetes from 15.5% to 17.9% (average annual percent change [APC] over the 9-year period = 1.6%, P = .015). The prevalence of depression was consistently more than 10 percentage points higher among adults with diabetes than those without diabetes. The APC showed a significant increase in some states (Illinois: 5.9%, Kansas: 3.5%) and a significant decrease in others (Arizona: -5.1%, Florida: -4.0%, Colorado: -3.4%, Washington: -0.9%). In 2019, although it varied by state, the depression prevalence among adults with diabetes was highest in states with a higher diabetes burden such as Kentucky (47.9%), West Virginia (47.0%), and Maine (41.5%). CONCLUSION: US adults with diabetes are more likely to report prevalent depression compared with adults without diabetes. These findings highlight the importance of screening and monitoring for depression as a potential complication among adults with diabetes.

Diabetes Prevalence and Incidence Inequality Trends Among U.S. Adults, 2008-2021.

INTRODUCTION: This study examined national trends in age, sex, racial and ethnic, and socioeconomic inequalities for diagnosed diabetes prevalence and incidence among U.S. adults from 2008 to 2021. METHODS: Adults (aged ≥18 years) were from the National Health Interview Survey (2008-2021). The annual between-group variance (BGV) for sex, race, and ethnicity; and the slope index of inequality (SII) for age, education, and poverty-to-income ratio along with the average annual percentage change (AAPC) were estimated in 2023 to assess trends in inequalities over time in diabetes prevalence and incidence. For BGV and SII, a value of 0 represents no inequality, whereas a value further from 0 represents greater inequality. RESULTS: On average over time, poverty-to-income ratio inequalities in diabetes prevalence worsened (SII= -8.24 in 2008 and -9.80 in 2021; AAPC for SII= -1.90%, p=0.003), whereas inequalities in incidence for age (SII=17.60 in 2008 and 8.85 in 2021; AAPC for SII= -6.47%, p<0.001), sex (BGV=0.09 in 2008, 2.05 in 2009, 1.24 in 2010, and 0.27 in 2021; AAPC for BGV= -12.34%, p=0.002), racial and ethnic (BGV=4.80 in 2008 and 2.17 in 2021; AAPC for BGV= -10.59%, p=0.010), and education (SII= -9.89 in 2008 and -2.20 in 2021; AAPC for SII=8.27%, p=0.001) groups improved. CONCLUSIONS: From 2008 to 2021, age, sex, racial and ethnic, and education inequalities in the incidence of diagnosed diabetes improved but persisted. Income-related diabetes prevalence inequalities worsened over time. To close these gaps, future research could focus on identifying the factors driving these trends, including the contribution of morbidity and mortality.

Trends in inpatient admissions and emergency department visits for heart failure in adults with versus without diabetes in the USA, 2006-2017.

INTRODUCTION: Heart failure (HF) is a major contributor to cardiovascular morbidity and mortality in people with diabetes. In this study, we estimated trends in the incidence of HF inpatient admissions and emergency department (ED) visits by diabetes status. RESEARCH DESIGN AND METHODS: Population-based age-standardized HF rates in adults with and without diabetes were estimated from the 2006-2017 National Inpatient Sample, Nationwide ED Sample and year-matched National Health Interview Survey, and stratified by age and sex. Trends were assessed using Joinpoint. RESULTS: HF inpatient admissions did not change in adults with diabetes between 2006 and 2013 (from 53.9 to 50.4 per 1000 persons; annual percent change (APC): -0.3 (95% CI -2.5 to 1.9) but increased from 50.4 to 62.3 between 2013 and 2017 (APC: 4.8 (95% CI 0.3 to 9.6)). In adults without diabetes, inpatient admissions initially declined (from 14.8 in 2006 to 12.9 in 2014; APC -2.3 (95% CI -3.2 to -1.2)) and then plateaued. Patterns were similar in men and women, but relative increases were greatest in young adults with diabetes. HF-related ED visits increased overall, in men and women, and in all age groups, but increases were greater in adults with (vs without) diabetes. CONCLUSIONS: Causes of increased HF rates in hospital settings are unknown, and more detailed data are needed to investigate the aetiology and determine prevention strategies, particularly among adults with diabetes and especially young adults with diabetes.

Sustained Lower Incidence of Diabetes-Related End-Stage Kidney Disease Among American Indians and Alaska Natives, Blacks, and Hispanics in the U.S., 2000-2016.

OBJECTIVE: Diabetes-related end-stage kidney disease (ESKD-D) disproportionately affects U.S. racial/ethnic minority populations compared with whites. However, from 1996 to 2013, ESKD-D incidence among American Indians and Alaska Natives (AIANs) and blacks declined. We assessed recent ESKD-D incidence data to determine whether trends by race/ethnicity have changed since 2013. RESEARCH DESIGN AND METHODS: United States Renal Data System data from 2000 to 2016 were used to determine the number of whites, blacks, AIANs, Asians, and Hispanics aged ≥18 years with newly treated ESKD-D (with diabetes listed as primary cause). Using census population estimates as denominators, annual ESKD-D incidence rates were calculated and age adjusted to the 2000 U.S. standard population. Joinpoint regression was used to analyze trends and estimate an average annual percent change (AAPC) in incidence rates. RESULTS: For adults overall, from 2000 to 2016, age-adjusted ESKD-D incidence rates decreased by 53% for AIANs (66.7-31.2 per 100,000, AAPC -4.5%, P < 0.001), by 33% for Hispanics (50.0-33.3, -2.1%, P < 0.001), and by 20% for blacks (56.2-44.7, -1.6%, P < 0.001). However, during the study period, age-adjusted ESKD-D incidence rates did not change significantly for Asians and increased by 10% for whites (15.4-17.0, 0.6%, P = 0.01). In 2016, ESKD-D incidence rates in AIANs, Hispanics, and blacks were ∼2.0-2.5 times higher than whites. CONCLUSIONS: ESKD-D incidence declined for AIANs, Hispanics, and blacks and increased for whites. Continued efforts might be considered to reverse the trend in whites and sustain and lower ESKD-D incidence in the other populations.

Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017.

INTRODUCTION: The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population. RESEARCH DESIGN AND METHODS: Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region. RESULTS: After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years. CONCLUSIONS: Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

Trends in Emergency Department Visits and Inpatient Admissions for Hyperglycemic Crises in Adults With Diabetes in the U.S., 2006-2015.

OBJECTIVE: To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings. RESEARCH DESIGN AND METHODS: We analyzed data from 1 January 2006 through 30 September 2015 from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED visits and inpatient admissions with DKA and HHS. We used corresponding year cross-sectional survey data from the National Health Interview Survey to estimate the number of adults ≥18 years with diagnosed diabetes to calculate population-based rates for DKA and HHS in both ED and inpatient settings. Linear trends from 2009 to 2015 were assessed using Joinpoint software. RESULTS: In 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age-groups and in both men and women. CONCLUSIONS: Causes of increased rates of hyperglycemic events are unknown. More detailed data are needed to investigate the etiology and determine prevention strategies.

New directions in incidence and prevalence of diagnosed diabetes in the USA.

Objective: To determine whether diabetes prevalence and incidence has remained flat or changed direction during the past 5 years. Research design and methods: We calculated annual prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined) for civilian, non-institutionalized adults aged 18-79 years using annual, nationally representative cross-sectional survey data from the National Health Interview Survey from 1980 to 2017. Trends in rates by age group, sex, race/ethnicity, and education were calculated using annual percentage change (APC). Results: Overall, the prevalence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.4%) from 1990 to 2009 to a peak of 8.2 per 100 adults (95% CI 7.8 to 8.6), and then plateaued through 2017. The incidence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.8%) from 1990 to 2007 to 7.8 per 1000 adults (95% CI 6.7 to 9.0), and then decreased significantly (APC -3.1%) to 6.0 (95% CI 4.9 to 7.3) in 2017. The decrease in incidence appears to be driven by non-Hispanic whites with an APC of -5.1% (p=0.002) after 2008. Conclusions: After an almost 20-year increase in the national prevalence and incidence of diagnosed diabetes, an 8-year period of stable prevalence and a decrease in incidence has occurred. Causes of the plateauing and decrease are unclear but the overall burden of diabetes remains high and deserves continued monitoring and intervention.

Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population.

OBJECTIVE: To determine whether declining trends in lower-extremity amputations have continued into the current decade. RESEARCH DESIGN AND METHODS: We calculated hospitalization rates for nontraumatic lower-extremity amputation (NLEA) for the years 2000-2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes. RESULTS: Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women. CONCLUSIONS: After a two-decade decline in lower-extremity amputations, the U.S. may now be experiencing a reversal in the progress, particularly in young and middle-aged adults.

Trajectory of Excess Medical Expenditures 10 Years Before and After Diabetes Diagnosis Among U.S. Adults Aged 25-64 Years, 2001-2013.

OBJECTIVE: We assessed the excess medical expenditures for adults newly diagnosed with diabetes, for up to 10 years before and after diabetes diagnosis. RESEARCH DESIGN AND METHODS: Using the 2001-2013 MarketScan data, we identified people with newly diagnosed diabetes among adults aged 25-64 years (diabetes cohort) and matched them with people who did not have diagnosed diabetes (control cohort) using 1:1 propensity score matching. We followed these two cohorts up to ±10 years from the index date, with annual matched cohort sizes ranging from 3,922 to 39,726 individuals. We estimated the yearly and cumulative excess medical expenditures of the diabetes cohorts before and after the diagnosis of diabetes. RESULTS: The per capita annual total excess medical expenditure for the diabetes cohort was higher for the entire 10 years prior to their index date, ranging between $1,043 in year -10 and $4,492 in year -1. Excess expenditure spiked in year 1 ($8,109), declined in year 2, and then increased steadily, ranging from $4,261 to $6,162 in years 2-10. The cumulative excess expenditure for the diabetes cohort during the entire 20 years of follow-up was $69,177 ($18,732 before and $50,445 after diagnosis). CONCLUSIONS: People diagnosed with diabetes had higher medical expenditures compared with their counterparts, not only after diagnosis but also up to 10 years prior to diagnosis. Managing risk factors for type 2 diabetes and cardiovascular disease before diagnosis, and for diabetes-related complications after diagnosis, could alleviate medical expenditure in people with diabetes.

Factors Contributing to Increases in Diabetes-Related Preventable Hospitalization Costs Among U.S. Adults During 2001-2014.

OBJECTIVE: To examine changes in diabetes-related preventable hospitalization costs and to determine the contribution of each underlying factor to these changes. RESEARCH DESIGN AND METHODS: We used data from the 2001-2014 U.S. National (Nationwide) Inpatient Sample (NIS) for adults (≥18 years old) to estimate the trends in hospitalization costs (2014 USD) in total and by condition (short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputation). Using regression and growth models, we estimated the relative contribution of following underlying factors: total number of hospitalizations, rate of hospitalization, the number of people with diabetes, mean cost per admission, length of stay, and cost per day. RESULTS: During 2001-2014, the estimated total cost of diabetes-related preventable hospitalizations increased annually by 1.6% (92.9 million USD; P < 0.001). Of this 1.6% increase, 75% (1.2%) was due to the increase in the number of hospitalizations, which is a result of a 3.8% increase in diabetes population and a 2.6% decrease in the hospitalization rate, and 25% (0.4%) was due to the increase in cost per admission, for a net result of a 1.6% increase in cost per day and a 1.3% decline in mean length of stay. By component, the cost of short-term complications, lower-extremity amputations, and long-term complications increased annually by 4.2, 1.9, and 1.5%, respectively, while the cost of uncontrolled diabetes declined annually by 2.6%. CONCLUSIONS: The total cost of diabetes-related preventable hospitalizations had been increasing during 2001-2014, mainly resulting from increases in number of people with diabetes and cost per hospitalization day. The underlying factors identified in our study could lead to efforts that may lower future hospitalization costs.

Incidence of End-Stage Renal Disease Attributed to Diabetes Among Persons with Diagnosed Diabetes - United States and Puerto Rico, 2000-2014.

During 2014, 120,000 persons in the United States and Puerto Rico began treatment for end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) (1). Among these persons, 44% (approximately 53,000 persons) had diabetes listed as the primary cause of ESRD (ESRD-D) (1). Although the number of persons initiating ESRD-D treatment each year has increased since 1980 (1,2), the ESRD-D incidence rate among persons with diagnosed diabetes has declined since the mid-1990s (2,3). To determine whether ESRD-D incidence has continued to decline in the United States overall and in each state, the District of Columbia (DC), and Puerto Rico, CDC analyzed 2000-2014 data from the U.S. Renal Data System and the Behavioral Risk Factor Surveillance System. During that period, the age-standardized ESRD-D incidence among persons with diagnosed diabetes declined from 260.2 to 173.9 per 100,000 diabetic population (33%), and declined significantly in most states, DC, and Puerto Rico. No state experienced an increase in ESRD-D incidence rates. Continued awareness of risk factors for kidney failure and interventions to improve diabetes care might sustain and improve these trends.

Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives - United States, 1996-2013.

BACKGROUND: American Indians and Alaska Natives (AI/AN) have the highest diabetes prevalence among any racial/ethnic group in the United States. Among AI/AN, diabetes accounts for 69% of new cases of end-stage renal disease (ESRD), defined as kidney failure treated with dialysis or transplantation. During 1982-1996, diabetes-related ESRD (ESRD-D) in AI/AN increased substantially and disproportionately compared with other racial/ethnic groups. METHODS: Data from the U.S. Renal Data System, the Indian Health Service (IHS), the National Health Interview Survey, and the U.S. Census were used to calculate ESRD-D incidence rates by race/ethnicity among U.S. adults aged ≥18 years during 1996-2013 and in the diabetic population during 2006-2013. Rates were age-adjusted based on the 2000 U.S. standard population. IHS clinical data from the Diabetes Cares and Outcomes Audit were analyzed for diabetes management measures in AI/AN. RESULTS: Among AI/AN adults, age-adjusted ESRD-D rates per 100,000 population decreased 54%, from 57.3 in 1996 to 26.5 in 2013. Although rates for adults in other racial/ethnic groups also decreased during this period, AI/AN had the steepest decline. Among AI/AN with diabetes, ESRD-D incidence decreased during 2006-2013 and, by 2013, was the same as that for whites. Measures related to the assessment and treatment of ESRD-D risk factors also showed more improvement during this period in AI/AN than in the general population. CONCLUSION AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Despite well-documented health and socioeconomic disparities among AI/AN, ESRD-D incidence rates among this population have decreased substantially since 1996. This decline followed implementation by the IHS of public health and population management approaches to diabetes accompanied by improvements in clinical care beginning in the mid-1980s. These approaches might be a useful model for diabetes management in other health care systems, especially those serving populations at high risk.

Trends in incidence of end-stage renal disease among persons with diagnosed diabetes--Puerto Rico, 1996-2010.

During 2010, approximately 6,091 persons aged ≥18 years in Puerto Rico were living with end-stage renal disease (ESRD) (i.e., kidney failure that requires regular dialysis or kidney transplantation for survival). This included 1,462 persons who began treatment for ESRD in 2010. Diabetes is the leading cause of ESRD in Puerto Rico, accounting for 66% of new cases in adults, followed by hypertension, which accounts for 15% of the cases. Although the number of adults initiating ESRD treatment (i.e., dialysis or kidney transplantation) in Puerto Rico each year who have diabetes listed as a primary cause (ESRD-D) has increased since 1996, ESRD-D incidence among adults with diagnosed diabetes has not shown a consistent trend. To assess recent trends in ESRD-D incidence among adults aged ≥18 years in Puerto Rico with diagnosed diabetes and to further examine trends by age group and sex, CDC analyzed 1996-2010 data from the U.S. Renal Data System (USRDS) and the Behavioral Risk Factor Surveillance System (BRFSS). After increasing in the late 1990s, ESRD-D incidence decreased during the 2000s among adult men and among persons aged 18-44 years with diagnosed diabetes in Puerto Rico. Throughout the period, ESRD-D incidence among adult women and among persons aged 45-64 and ≥75 years with diagnosed diabetes did not show a consistent trend, and ESRD-D incidence among persons aged 65-74 years with diagnosed diabetes increased. Increased awareness of the risk factors for kidney disease and implementation of effective interventions to prevent or delay kidney disease among persons with diagnosed diabetes might decrease ESRD incidence in Puerto Rico, particularly among women and older persons.