Associations between trends in race/ethnicity, aging, and body mass index with diabetes prevalence in the United States: a series of cross-sectional studies.

BACKGROUND: The increase in the prevalence of diabetes over the past few decades has coincided with an increase in certain risk factors for diabetes, such as a changing race/ethnicity distribution, an aging population, and a rising obesity prevalence. OBJECTIVE: To determine the extent to which the increase in diabetes prevalence is explained by changing distributions of race/ethnicity, age, and obesity prevalence in U.S. adults. DESIGN: Cross-sectional, using data from 5 NHANES (National Health and Nutrition Examination Surveys): NHANES II (1976-1980), NHANES III (1988-1994), and the continuous NHANES 1999-2002, 2003-2006, and 2007-2010. SETTING: Nationally representative samples of the U.S. noninstitutionalized civilian population. PATIENTS: 23 932 participants aged 20 to 74 years. MEASUREMENTS: Diabetes was defined as a self-reported diagnosis or fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or more. RESULTS: Between 1976 to 1980 and 2007 to 2010, diabetes prevalence increased from 4.7% to 11.2% in men and from 5.7% to 8.7% in women (P for trends for both groups < 0.001). After adjustment for age, race/ethnicity, and body mass index, diabetes prevalence increased in men (6.2% to 9.6%; P for trend < 0.001) but not women (7.6% to 7.5%; P for trend = 0.69). Body mass index was the greatest contributor among the 3 covariates to the change in prevalence estimates after adjustment. LIMITATION: Some possible risk factors, such as physical activity, waist circumference, and mortality, could not be studied because data on these variables were not collected in all surveys. CONCLUSION: The increase in the prevalence of diabetes was greater in men than in women in the U.S. population between 1976 to 1980 and 2007 to 2010. After changes in age, race/ethnicity, and body mass index were controlled for, the increase in diabetes prevalence over time was approximately halved in men and diabetes prevalence was no longer increased in women. PRIMARY FUNDING SOURCE: Centers for Disease Control and Prevention and National Institutes of Diabetes and Digestive and Kidney Diseases.

Opioid prescription and diabetes among Medicare beneficiaries.

AIMS: To determine the prevalence of opioid prescriptions among U.S. Medicare beneficiaries by diabetes status, and predictors of opioid prescription among those with diabetes. METHODS: This retrospective study used claims data from the Centers for Medicare and Medicaid Services among beneficiaries age ≥ 65 years who were continuously enrolled in Part A, Part B, and Part D Medicare between 2017 and 2019 (N = 709,374). Logistic regression was used to determine the odds of opioid prescription among those with vs without diabetes; and, among those with diabetes, significant predictors of opioid prescription. RESULTS: Overall, the prevalence of any opioid prescription was 30.8 % among persons with diabetes and 24.2 % in those without diabetes (p < 0.001); chronic use was 8.0 % and 7.4 %, respectively (p < 0.001). Those with diabetes had a 45 % higher odds of having an opioid prescription compared to those without diabetes after adjusting for sociodemographic characteristics (OR = 1.45, 1.44-1.47). After adjustment for comorbidities/complications, the association reversed (OR = 0.83, 0.82-0.84). Persons with diabetes who had hypertension, obesity, CVD, neuropathy, amputation, liver disease, COPD, cancer, osteoporosis, depression, or alcohol/drug abuse had a 20 %-140 % higher odds of opioid prescription compared to those without these conditions. CONCLUSIONS: Comorbidities and complications accounted for the higher odds of opioid prescriptions among those with diabetes.

Comparison of several survey-based algorithms to ascertain type 1 diabetes among US adults with self-reported diabetes.

INTRODUCTION: Defining type of diabetes using survey data is challenging, although important, for determining national estimates of diabetes. The purpose of this study was to compare the percentage and characteristics of US adults classified as having type 1 diabetes as defined by several algorithms. RESEARCH DESIGN AND METHODS: This study included 6331 respondents aged ≥18 years who reported a physician diagnosis of diabetes in the 2016-2017 National Health Interview Survey. Seven algorithms classified type 1 diabetes using various combinations of self-reported diabetes type, age of diagnosis, current and continuous insulin use, and use of oral hypoglycemics. RESULTS: The percentage of type 1 diabetes among those with diabetes ranged from 3.4% for those defined by age of diagnosis <30 years and continuous insulin use (algorithm 2) to 10.2% for those defined only by continuous insulin use (algorithm 1) and 10.4% for those defined as self-report of type 1 (supplementary algorithm 6). Among those defined by age of diagnosis <30 years and continuous insulin use (algorithm 2), by self-reported type 1 diabetes and continuous insulin use (algorithm 4), and by self-reported type 1 diabetes and current insulin use (algorithm 5), mean body mass index (BMI) (28.6, 27.4, and 28.5 kg/m2, respectively) and percentage using oral hypoglycemics (16.1%, 11.1%, and 19.0%, respectively) were lower than for all other algorithms assessed. Among those defined by continuous insulin use alone (algorithm 1), the estimates for mean age and age of diagnosis (54.3 and 30.9 years, respectively) and BMI (30.9 kg/m2) were higher than for other algorithms. CONCLUSIONS: Estimates of type 1 diabetes using commonly used algorithms in survey data result in varying degrees of prevalence, characteristic distributions, and potential misclassification.

Diabetes based on 2-h plasma glucose among those classified as having prediabetes based on fasting plasma glucose or A1c.

OBJECTIVE: Determine the prevalence of diabetes using 2-h plasma glucose among people who otherwise would be categorized as having prediabetes based on A1c and fasting glucose, and to determine whether those people were more likely to have cardiometabolic risk factors. METHODS: Among 3644 adults with prediabetes based on A1c and fasting glucose in the 2005-2014 National Health and Nutrition Examination Survey, a cross-sectional survey of the US general population, we estimated the percentage who would be categorized as having diabetes based on having a 2-h plasma glucose ⩾200 mg/dL. We calculated odds ratios of cardiometabolic risk factors associated with having 2-h plasma glucose ⩾200 mg/dL. RESULTS: A total of 6.9% would be categorized as having diabetes based on 2-h plasma glucose. The adjusted odds ratios (95% confidence interval) associated with having 2-h plasma glucose ⩾200 mg/dL were significant for total hypertension (2.06, 1.35-3.14), high triglycerides (1.64, 1.10-2.44), low high-density lipoprotein cholesterol (1.55, 1.01-2.39), albuminuria (2.05, 1.33-3.14) and elevated alanine aminotransferase (1.78, 1.09-2.91), but not for other cardiometabolic risk factors. CONCLUSION: A total of 6.9% of people categorized as having prediabetes based on A1c and fasting glucose would be categorized as having diabetes based on 2-h plasma glucose. They were more likely to have hypertension, high triglycerides, low high-density lipoprotein cholesterol, albuminuria and elevated alanine aminotransferase.

Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999-2002.

OBJECTIVE: The purpose of this study was to examine the prevalences of diagnosed and undiagnosed diabetes, and impaired fasting glucose (IFG) in U.S. adults during 1999-2002, and compare prevalences to those in 1988-1994. RESEARCH DESIGN AND METHODS: The National Health and Nutrition Examination Survey (NHANES) contains a probability sample of adults aged > or =20 years. In the NHANES 1999-2002, 4,761 adults were classified on glycemic status using standard criteria, based on an interview for diagnosed diabetes and fasting plasma glucose measured in a subsample. RESULTS: The crude prevalence of total diabetes in 1999-2002 was 9.3% (19.3 million, 2002 U.S. population), consisting of 6.5% diagnosed and 2.8% undiagnosed. An additional 26.0% had IFG, totaling 35.3% (73.3 million) with either diabetes or IFG. The prevalence of total diabetes rose with age, reaching 21.6% for those aged > or =65 years. The prevalence of diagnosed diabetes was twice as high in non-Hispanic blacks and Mexican Americans compared with non-Hispanic whites (both P < 0.00001), whereas the prevalence of undiagnosed diabetes was similar by race/ethnicity, adjusted for age and sex. The prevalence of diagnosed diabetes was similar by sex, but prevalences of undiagnosed diabetes and IFG were significantly higher in men. The crude prevalence of diagnosed diabetes rose significantly from 5.1% in 1988-1994 to 6.5% in 1999-2002, but the crude prevalences were stable for undiagnosed diabetes (from 2.7 to 2.8%) and IFG (from 24.7 to 26.0%). Results were similar after adjustment for age and sex. CONCLUSIONS: Although the prevalence of diagnosed diabetes has increased significantly over the last decade, the prevalences of undiagnosed diabetes and IFG have remained relatively stable. Minority groups remain disproportionately affected.

Hemoglobin A1c, fasting plasma glucose, and 2-hour plasma glucose distributions in U.S. population subgroups: NHANES 2005-2010.

PURPOSE: Although mean concentrations of hemoglobin A1c (A1C), fasting plasma glucose, and 2-hour plasma glucose differ by demographics, it is unclear what other characteristics of the distributions may differ, such as the amount of asymmetry of the distribution (skewness) and shift left or right compared with another distribution (shift). METHODS: Using kernel density estimation, we created smoothed plots of the distributions of fasting plasma glucose (N = 7250), 2-hour plasma glucose (N = 5851), and A1C (N = 16,209) by age, race-ethnicity, and sex in the 2005-2010 National Health and Nutrition Examination Survey, a nationally representative sample of U.S. adults including people with and without diabetes. We tested differences in distributions using cumulative logistic regression. RESULTS: The distributions were generally unimodal and right-skewed. All distributions were shifted higher and more right-skewed for older age groups (P < .001 for each marker). Compared with non-Hispanic whites, the distribution of fasting plasma glucose was shifted higher for Mexican-Americans (P = .01), whereas the distribution of A1C was shifted higher for non-Hispanic blacks (P < .001). The distribution of fasting plasma glucose was shifted higher for men (P < .001) and the distribution of 2-hour plasma glucose was shifted higher for women (P = .01). CONCLUSIONS: We provide a graphic reference for comparing these distributions and diabetes cut-points by demographic factors.

The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010.

OBJECTIVE: To determine the prevalence of people with diabetes who meet hemoglobin A1c (A1C), blood pressure (BP), and LDL cholesterol (ABC) recommendations and their current statin use, factors associated with goal achievement, and changes in the proportion achieving goals between 1988 and 2010. RESEARCH DESIGN AND METHODS: Data were cross-sectional from the National Health and Nutrition Examination Surveys (NHANES) from 1988-1994, 1999-2002, 2003-2006, and 2007-2010. Participants were 4,926 adults aged ≥ 20 years who self-reported a previous diagnosis of diabetes and completed the household interview and physical examination (n = 1,558 for valid LDL levels). Main outcome measures were A1C, BP, and LDL cholesterol, in accordance with the American Diabetes Association recommendations, and current use of statins. RESULTS: In 2007-2010, 52.5% of people with diabetes achieved A1C <7.0% (<53 mmol/mol), 51.1% achieved BP <130/80 mmHg, 56.2% achieved LDL <100 mg/dL, and 18.8% achieved all three ABCs. These levels of control were significant improvements from 1988 to 1994 (all P < 0.05). Statin use significantly increased between 1988-1994 (4.2%) and 2007-2010 (51.4%, P < 0.01). Compared with non-Hispanic whites, Mexican Americans were less likely to meet A1C and LDL goals (P < 0.03), and non-Hispanic blacks were less likely to meet BP and LDL goals (P < 0.02). Compared with non-Hispanic blacks, Mexican Americans were less likely to meet A1C goals (P < 0.01). Younger individuals were less likely to meet A1C and LDL goals. CONCLUSIONS: Despite significant improvement during the past decade, achieving the ABC goals remains suboptimal among adults with diabetes, particularly in some minority groups. Substantial opportunity exists to further improve diabetes control and, thus, to reduce diabetes-related morbidity and mortality.

Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. population in 1988-2006.

OBJECTIVE We examined prevalences of previously diagnosed diabetes and undiagnosed diabetes and high risk for diabetes using recently suggested A1C criteria in the U.S. during 2003-2006. We compared these prevalences to those in earlier surveys and those using glucose criteria. RESEARCH DESIGN AND METHODS In 2003-2006, the National Health and Nutrition Examination Survey included a probability sample of 14,611 individuals aged > or =12 years. Participants were classified on glycemic status by interview for diagnosed diabetes and by A1C, fasting, and 2-h glucose challenge values measured in subsamples. RESULTS Using A1C criteria, the crude prevalence of total diabetes in adults aged > or =20 years was 9.6% (20.4 million), of which 19.0% was undiagnosed (7.8% diagnosed, 1.8% undiagnosed using A1C > or =6.5%). Another 3.5% of adults (7.4 million) were at high risk for diabetes (A1C 6.0 to <6.5%). Prevalences were disproportionately high in the elderly. Age-/sex-standardized prevalence was more than two times higher in non-Hispanic blacks and Mexican Americans versus non-Hispanic whites for diagnosed, undiagnosed, and total diabetes (P < 0.003); standardized prevalence at high risk for diabetes was more than two times higher in non-Hispanic blacks versus non-Hispanic whites and Mexican Americans (P < 0.00001). Since 1988-1994, diagnosed diabetes generally increased, while the percent of diabetes that was undiagnosed and the percent at high risk of diabetes generally decreased. Using A1C criteria, prevalences of undiagnosed diabetes and high risk of diabetes were one-third that and one-tenth that, respectively, using glucose criteria. CONCLUSIONS Although A1C detects much lower prevalences than glucose criteria, hyperglycemic conditions remain high in the U.S., and elderly and minority groups are disproportionately affected.

Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006.

OBJECTIVE: We examined the prevalences of diagnosed diabetes, and undiagnosed diabetes and pre-diabetes using fasting and 2-h oral glucose tolerance test values, in the U.S. during 2005-2006. We then compared the prevalences of these conditions with those in 1988-1994. RESEARCH DESIGN AND METHODS: In 2005-2006, the National Health and Nutrition Examination Survey included a probability sample of 7,267 people aged > or =12 years. Participants were classified according to glycemic status by interview for diagnosed diabetes and by fasting and 2-h glucoses measured in subsamples. RESULTS: In 2005-2006, the crude prevalence of total diabetes in people aged > or =20 years was 12.9%, of which approximately 40% was undiagnosed. In people aged > or =20 years, the crude prevalence of impaired fasting glucose was 25.7% and of impaired glucose tolerance was 13.8%, with almost 30% having either. Over 40% of individuals had diabetes or pre-diabetes. Almost one-third of the elderly had diabetes, and three-quarters had diabetes or pre-diabetes. Compared with non-Hispanic whites, age- and sex-standardized prevalence of diagnosed diabetes was approximately twice as high in non-Hispanic blacks (P < 0.0001) and Mexican Americans (P = 0.0001), whereas undiagnosed diabetes was not higher. Crude prevalence of diagnosed diabetes in people aged > or =20 years rose from 5.1% in 1988-1994 to 7.7% in 2005-2006 (P = 0.0001); this was significant after accounting for differences in age and sex, particularly in non-Hispanic blacks. Prevalences of undiagnosed diabetes and pre-diabetes were generally stable, although the proportion of total diabetes that was undiagnosed decreased in Mexican Americans. CONCLUSIONS: Over 40% of people aged > or =20 years have hyperglycemic conditions, and prevalence is higher in minorities. Diagnosed diabetes has increased over time, but other conditions have been relatively stable.

Mitigating case mix factors by choice of glycemic control performance measure threshold.

OBJECTIVE: Performance measures are tools for assessing quality of care but may be influenced by patient factors. We investigated how currently endorsed performance measures for glycemic control in diabetes may be influenced by case mix composition. We assessed differences in A1C performance measure threshold attainment by case mix factors for A1C >9% and examined how lowering the threshold to A1C >8% or >7% changed these differences. RESEARCH DESIGN AND METHODS: Using data from the 1999-2002 National Health and Nutrition Examination Survey for 843 adults self-reporting diabetes, we computed the mean difference in A1C threshold attainment of >9, >8, and >7% by various case mix factors. The mean difference is the average percentage point difference in threshold attainment for population groups compared with that for the overall population. RESULTS: Diabetes medication was the only factor for which the difference in threshold attainment increased at lower thresholds, with mean differences of 5.7 percentage points at A1C >9% (reference), 10.1 percentage points at A1C >8% (P < 0.05), and 14.1 percentage points at A1C >7% (P < 0.001). CONCLUSIONS: As 87% of U.S. adults have A1C <9%, a performance measure threshold of >9% will not drive major improvements in glycemic control. Lower thresholds do not exacerbate differences in threshold attainment for most factors. Reporting by diabetes medication use may compensate for heterogeneous case mix when a performance measure threshold of A1C >8% or lower is used.