Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999-2018.

Introduction: Monitoring menthol cigarette use allows for identification of potential health disparities. We examined sociodemographic and temporal differences in menthol cigarette use among US adults who smoke. Methods: We analyzed data from the 1999-2018 National Health and Nutrition Examination Survey for adults aged 20 years or older who smoke (N = 11,431) using binary logistic regression. Results: Among US adults who smoke, 28.8% used menthol cigarettes. After adjusting for age, sex, race and ethnicity, education, income-to-poverty ratio, and health status, the prevalence of menthol use among adults who smoke increased on average by 3.8% (95% CI, 2.7%-4.9%) annually. Non-Hispanic Black adults had the highest average prevalence of menthol cigarette use, 73.0% (95% CI, 70.9%-75.2%), and Mexican American adults had higher average annual increase in menthol cigarette use, 7.1% (95% CI, 4.0%-10.3%). Adults with fair or poor health status had a 4.3% annual increase in menthol cigarette use (95% CI, 2.5%-6.1%). The adjusted prevalence ratios of menthol cigarette use were 1.61 (95% CI, 1.39-1.83) for adults aged 20-29 years compared with those aged 65 years or older, 1.41 (95% CI, 1.32-1.49) for female adults compared with male adults, and 1.17 (95% CI, 1.07-1.27) for high school graduates or higher compared with those with no high school diploma. Conclusion: Non-Hispanic Black adults who smoke had the highest prevalence of menthol cigarette use among all racial and ethnic groups; the prevalence of menthol cigarette use among adults who smoke increased especially among Mexican American adults, younger adults, and adults who reported fair to poor health status.

A New Type 2 Diabetes Microsimulation Model to Estimate Long-Term Health Outcomes, Costs, and Cost-Effectiveness.

OBJECTIVES: This study aimed to develop a microsimulation model to estimate the health effects, costs, and cost-effectiveness of public health and clinical interventions for preventing/managing type 2 diabetes. METHODS: We combined newly developed equations for complications, mortality, risk factor progression, patient utility, and cost-all based on US studies-in a microsimulation model. We performed internal and external validation of the model. To demonstrate the model's utility, we predicted remaining life-years, quality-adjusted life-years (QALYs), and lifetime medical cost for a representative cohort of 10 000 US adults with type 2 diabetes. We then estimated the cost-effectiveness of reducing hemoglobin A1c from 9% to 7% among adults with type 2 diabetes, using low-cost, generic, oral medications. RESULTS: The model performed well in internal validation; the average absolute difference between simulated and observed incidence for 17 complications was < 8%. In external validation, the model was better at predicting outcomes in clinical trials than in observational studies. The cohort of US adults with type 2 diabetes was projected to have an average of 19.95 remaining life-years (from mean age 61), incur $187 729 in discounted medical costs, and accrue 8.79 discounted QALYs. The intervention to reduce hemoglobin A1c increased medical costs by $1256 and QALYs by 0.39, yielding an incremental cost-effectiveness ratio of $9103 per QALY. CONCLUSIONS: Using equations exclusively derived from US studies, this new microsimulation model achieves good prediction accuracy in US populations. The model can be used to estimate the long-term health impact, costs, and cost-effectiveness of interventions for type 2 diabetes in the United States.

Incidence and Clinical Characteristics of and Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Among Pregnant Individuals in the United States.

BACKGROUND: Data about the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among pregnant individuals are needed to inform infection-prevention guidance and counseling for this population. METHODS: We prospectively followed a cohort of pregnant individuals during August 2020-March 2021 at 3 US sites. The 3 primary outcomes were incidence rates of any SARS-CoV-2 infection, symptomatic infection, and asymptomatic infection, during pregnancy during periods of SARS-CoV-2 circulation. Participants self-collected weekly midturbinate nasal swabs for SARS-CoV-2 reverse transcription-polymerase chain reaction testing, completed weekly illness symptom questionnaires, and submitted additional swabs with coronavirus disease 2019 (COVID-19)-like symptoms. An overall SARS-CoV-2 infection incidence rate weighted by population counts of women of reproductive age in each state was calculated. RESULTS: Among 1098 pregnant individuals followed for a mean of 10 weeks, 9% (99/1098) had SARS-CoV-2 infections during the study. Population-weighted incidence rates of SARS-CoV-2 infection were 10.0 per 1000 (95% confidence interval, 5.7-14.3) person-weeks for any infection, 5.7 per 1000 (1.7-9.7) for symptomatic infections, and 3.5 per 1000 (0-7.1) for asymptomatic infections. Among 96 participants with SARS-CoV-2 infections and symptom data, the most common symptoms were nasal congestion (72%), cough (64%), headache (59%), and change in taste or smell (54%); 28% had measured or subjective fever. Median symptom duration was 10 (interquartile range, 6-16) days. CONCLUSIONS: Pregnant individuals in this study had a 1% risk of SARS-CoV-2 infection per week, underscoring the importance of COVID-19 vaccination and other prevention measures during pregnancy while SARS-CoV-2 is circulating in the community.

Cigarette Smoking Among US Adults With Selected Chronic Diseases Associated With Smoking, 2010-2019.

INTRODUCTION: People who smoke cigarettes are at greater risk of developing chronic diseases and related complications. Our study provides recent estimates and trends in cigarette smoking among people with respiratory and cardiovascular diseases, cancers, and diabetes. METHODS: Using data from the 2019 National Health Interview Survey, we calculated the prevalence of current and former cigarette smoking among adults aged 18 to 44 years, 45 to 64 years, and 65 years or older with chronic diseases. Those diseases were cancers associated with smoking, chronic obstructive pulmonary disease, diabetes, coronary heart disease, and/or stroke (N = 3,741). Using data from the 2010-2019 National Health Interview Surveys, we assessed trends in current cigarette smoking by chronic disease by using the National Cancer Institute's Joinpoint Regression Program. RESULTS: In 2019, current cigarette smoking prevalence among adults with chronic diseases associated with smoking ranged from 6.0% among adults aged 65 or older with diabetes to 51.9% among adults aged 18 to 44 years with 2 or more chronic diseases. During 2010 through 2019, a significant decrease occurred in current cigarette smoking among adults aged 45 to 64 years with diabetes. CONCLUSION: Overall, smoking prevalence remains high and relatively unchanged among people with chronic diseases associated with smoking, even as the overall prevalence of cigarette smoking in the US continues to decrease. The lack of progress in smoking cessation among adults with chronic diseases associated with smoking suggests that access, promotion, and integration of cessation treatment across the continuum of health care (ie, oncology, pulmonology, and cardiology settings) may be important in the success of smoking cessation in this population.

Efficacy of lifestyle intervention in adults with impaired glucose tolerance with and without impaired fasting plasma glucose: A post hoc analysis of Da Qing Diabetes Prevention Outcome Study.

AIMS: The extent that pre-diabetic fasting plasma glucose (FPG) levels influence the effectiveness of lifestyle interventions in preventing type 2 diabetes (T2DM) is uncertain. We aimed to determine if the outcome of lifestyle intervention in people with impaired glucose tolerance (IGT) differs in those with normal or impaired FPG levels. MATERIALS AND METHODS: Data were used from the Da Qing Diabetes Prevention Outcome Study, which was a 30-year follow-up of a 6-year randomized trial of lifestyle intervention in 576 people with IGT. We then conducted a post-hoc analysis to compare the efficacy of intervention to reduce the incidence of T2DM and its complications in those with baseline FPG <100 mg/dL and FPG ≥100 mg/dL. RESULTS: Lifestyle intervention reduced the cumulative incidence of T2DM by 37%-46% in those with baseline FPG <100 mg/dL and by 47%-51% in those with FPG ≥100 mg/dL. The FPG <100 mg/dL group had a lower cumulative incidence of diabetes and 6.41 years median delay in its onset compared with 2.21 years delay in the FPG ≥100 mg/dL group. In those with FPG <100 mg/dL intervention was associated with at least as great a reduction in cardiovascular disease and all-cause mortality as in the FPG ≥100 mg/dL group. CONCLUSIONS: Lifestyle intervention reduced the incidence of T2DM in people with IGT regardless of baseline FPG levels, and in those with FPG <100 mg/dL led to a substantial delay in its onset. All persons with IGT, with normal or impaired FPG levels, may benefit from lifestyle intervention to delay its onset and mitigate the incidence of T2DM.

Trends in cancer mortality among people with vs without diabetes in the USA, 1988-2015.

AIMS/HYPOTHESIS: Cancer-related death is higher among people with vs without diabetes. However, it is not known if this excess risk has changed over time or what types of cancer may be driving these changes. METHODS: To estimate rates of site-specific cancer mortality in adults with vs without self-reported diagnosed diabetes, we used data from adults aged ≥18 years at the time of the interview who participated in the 1985-2012 National Health Interview Survey. Participants' data were linked to the National Death Index by the National Center for Health Statistics to determine vital status and cause of death through to the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2015) were estimated using discrete Poisson regression models adjusted for age, sex and race/ethnicity with p for linear trend reported (ptrend). Site-specific cancer mortality rates were stratified by diabetes status and period, and total cancer mortality rates were additionally stratified by sex, race/ethnicity, education and BMI status. RESULTS: Among adults with diabetes, age-adjusted cancer mortality rates (per 10,000 person-years) declined 25.5% from 39.1 (95% CI 30.1, 50.8) in 1988-1994 to 29.7 (26.6, 33.1) in 2010-2015, ptrend < 0.001. Among adults without diabetes, rates declined 25.2% from 30.9 (28.6, 33.4) in 1988-1994 to 23.2 (22.1, 24.2) in 2010-2015, ptrend < 0.01. Adults with diabetes remained approximately 30% more likely to die from cancer than people without diabetes, and this excess risk did not improve over time. In adults with diabetes, cancer mortality rates did not decline in some population subgroups (including black people, people with lower levels of education and obese people), and the excess risk increased for obese adults with vs without diabetes. Declines in total cancer mortality rates in adults with diabetes appear to be driven by large relative declines in cancers of the pancreas (55%) and breast (65%), while for lung cancer, declines are modest (7%). CONCLUSIONS/INTERPRETATION: Declines in cancer mortality rates were observed in adults with and without diabetes. However, adults with diabetes continue to be more likely to die from cancer than people without diabetes. This study highlights the continued need for greater cancer risk-factor mitigation, especially in adults with diabetes.

Trends in cause-specific mortality among adults with and without diagnosed diabetes in the USA: an epidemiological analysis of linked national survey and vital statistics data.

BACKGROUND: Large reductions in diabetes complications have altered diabetes-related morbidity in the USA. It is unclear whether similar trends have occurred in causes of death. METHODS: Using data from the National Health Interview Survey Linked Mortality files from 1985 to 2015, we estimated age-specific death rates and proportional mortality from all causes, vascular causes, cancers, and non-vascular, non-cancer causes among US adults by diabetes status. FINDINGS: From 1988-94, to 2010-15, all-cause death rates declined by 20% every 10 years among US adults with diabetes (from 23·1 [95% CI 20·1-26·0] to 15·2 [14·6-15·8] per 1000 person-years), while death from vascular causes decreased 32% every 10 years (from 11·0 [9·2-12·2] to 5·2 [4·8-5·6] per 1000 person-years), deaths from cancers decreased 16% every 10 years (from 4·4 [3·2-5·5] to 3·0 [2·8-3·3] per 1000 person-years), and the rate of non-vascular, non-cancer deaths declined by 8% every 10 years (from 7·7 [6·3-9·2] to 7·1 [6·6-7·5]). Death rates also declined significantly among people without diagnosed diabetes for all four major mortality categories. However, the declines in death rates were significantly greater among people with diabetes for all-causes (pinteraction<0·0001), vascular causes (pinteraction=0·0214), and non-vascular, non-cancer causes (pinteration<0·0001), as differences in all-cause and vascular disease death between people with and without diabetes were reduced by about a half. Among people with diabetes, all-cause mortality rates declined most in men and adults aged 65-74 years of age, and there was no decline in death rates among adults aged 20-44 years. The different magnitude of changes in cause-specific mortality led to large changes in the proportional mortality. The proportion of total deaths among adults with diabetes from vascular causes declined from 47·8% (95% CI 38·9-58·8) in 1988-94 to 34·1% (31·4-37·1) in 2010-15; this decline was offset by large increases in the proportion of deaths from non-vascular, non-cancer causes, from 33·5% (26·7-42·1) to 46·5% (43·3-50·0). The proportion of deaths caused by cancer was relatively stable over time, ranging from 16% to 20%. INTERPRETATION: Declining rates of vascular disease mortality are leading to a diversification of forms of diabetes-related mortality with implications for clinical management, prevention, and disease monitoring. FUNDING: None.

Prevalence of Diabetes by Race and Ethnicity in the United States, 2011-2016.

Importance: The prevalence of diabetes among Hispanic and Asian American subpopulations in the United States is unknown. Objective: To estimate racial/ethnic differences in the prevalence of diabetes among US adults 20 years or older by major race/ethnicity groups and selected Hispanic and non-Hispanic Asian subpopulations. Design, Setting, and Participants: National Health and Nutrition Examination Surveys, 2011-2016, cross-sectional samples representing the noninstitutionalized, civilian, US population. The sample included adults 20 years or older who had self-reported diagnosed diabetes during the interview or measurements of hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), and 2-hour plasma glucose (2hPG). Exposures: Race/ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic and Hispanic subgroups (Mexican, Puerto Rican, Cuban/Dominican, Central American, and South American), non-Hispanic Asian and non-Hispanic Asian subgroups (East, South, and Southeast Asian), and non-Hispanic other. Main Outcomes and Measures: Diagnosed diabetes was based on self-reported prior diagnosis. Undiagnosed diabetes was defined as HbA1c 6.5% or greater, FPG 126 mg/dL or greater, or 2hPG 200 mg/dL or greater in participants without diagnosed diabetes. Total diabetes was defined as diagnosed or undiagnosed diabetes. Results: The study sample included 7575 US adults (mean age, 47.5 years; 52% women; 2866 [65%] non-Hispanic white, 1636 [11%] non-Hispanic black, 1952 [15%] Hispanic, 909 [6%] non-Hispanic Asian, and 212 [3%] non-Hispanic other). A total of 2266 individuals had diagnosed diabetes; 377 had undiagnosed diabetes. Weighted age- and sex-adjusted prevalence of total diabetes was 12.1% (95% CI, 11.0%-13.4%) for non-Hispanic white, 20.4% (95% CI, 18.8%-22.1%) for non-Hispanic black, 22.1% (95% CI, 19.6%-24.7%) for Hispanic, and 19.1% (95% CI, 16.0%-22.1%) for non-Hispanic Asian adults (overall P < .001). Among Hispanic adults, the prevalence of total diabetes was 24.6% (95% CI, 21.6%-27.6%) for Mexican, 21.7% (95% CI, 14.6%-28.8%) for Puerto Rican, 20.5% (95% CI, 13.7%-27.3%) for Cuban/Dominican, 19.3% (95% CI, 12.4%-26.1%) for Central American, and 12.3% (95% CI, 8.5%-16.2%) for South American subgroups (overall P < .001). Among non-Hispanic Asian adults, the prevalence of total diabetes was 14.0% (95% CI, 9.5%-18.4%) for East Asian, 23.3% (95% CI, 15.6%-30.9%) for South Asian, and 22.4% (95% CI, 15.9%-28.9%) for Southeast Asian subgroups (overall P = .02). The prevalence of undiagnosed diabetes was 3.9% (95% CI, 3.0%-4.8%) for non-Hispanic white, 5.2% (95% CI, 3.9%-6.4%) for non-Hispanic black, 7.5% (95% CI, 5.9%-9.1%) for Hispanic, and 7.5% (95% CI, 4.9%-10.0%) for non-Hispanic Asian adults (overall P < .001). Conclusions and Relevance: In this nationally representative survey of US adults from 2011 to 2016, the prevalence of diabetes and undiagnosed diabetes varied by race/ethnicity and among subgroups identified within the Hispanic and non-Hispanic Asian populations.

Projection of the future diabetes burden in the United States through 2060.

BACKGROUND: In the United States, diabetes has increased rapidly, exceeding prior predictions. Projections of the future diabetes burden need to reflect changes in incidence, mortality, and demographics. We applied the most recent data available to develop an updated projection through 2060. METHODS: A dynamic Markov model was used to project prevalence of diagnosed diabetes among US adults by age, sex, and race (white, black, other). Incidence and current prevalence were from the National Health Interview Survey (NHIS) 1985-2014. Relative mortality was from NHIS 2000-2011 follow-up data linked to the National Death Index. Future population estimates including birth, death, and migration were from the 2014 Census projection. RESULTS: The projected number and percent of adults with diagnosed diabetes would increase from 22.3 million (9.1%) in 2014 to 39.7 million (13.9%) in 2030, and to 60.6 million (17.9%) in 2060. The number of people with diabetes aged 65 years or older would increase from 9.2 million in 2014 to 21.0 million in 2030, and to 35.2 million in 2060. The percent prevalence would increase in all race-sex groups, with black women and men continuing to have the highest diabetes percent prevalence, and black women and women of other race having the largest relative increases. CONCLUSIONS: By 2060, the number of US adults with diagnosed diabetes is projected to nearly triple, and the percent prevalence double. Our estimates are essential to predict health services needs and plan public health programs aimed to reduce the future burden of diabetes.

Using multi-year national survey cohorts for period estimates: an application of weighted discrete Poisson regression for assessing annual national mortality in US adults with and without diabetes, 2000-2006.

BACKGROUND: Monitoring national mortality among persons with a disease is important to guide and evaluate progress in disease control and prevention. However, a method to estimate nationally representative annual mortality among persons with and without diabetes in the United States does not currently exist. The aim of this study is to demonstrate use of weighted discrete Poisson regression on national survey mortality follow-up data to estimate annual mortality rates among adults with diabetes. METHODS: To estimate mortality among US adults with diabetes, we applied a weighted discrete time-to-event Poisson regression approach with post-stratification adjustment to national survey data. Adult participants aged 18 or older with and without diabetes in the National Health Interview Survey 1997-2004 were followed up through 2006 for mortality status. We estimated mortality among all US adults, and by self-reported diabetes status at baseline. The time-varying covariates used were age and calendar year. Mortality among all US adults was validated using direct estimates from the National Vital Statistics System (NVSS). RESULTS: Using our approach, annual all-cause mortality among all US adults ranged from 8.8 deaths per 1,000 person-years (95% confidence interval [CI]: 8.0, 9.6) in year 2000 to 7.9 (95% CI: 7.6, 8.3) in year 2006. By comparison, the NVSS estimates ranged from 8.6 to 7.9 (correlation = 0.94). All-cause mortality among persons with diabetes decreased from 35.7 (95% CI: 28.4, 42.9) in 2000 to 31.8 (95% CI: 28.5, 35.1) in 2006. After adjusting for age, sex, and race/ethnicity, persons with diabetes had 2.1 (95% CI: 2.01, 2.26) times the risk of death of those without diabetes. CONCLUSION: Period-specific national mortality can be estimated for people with and without a chronic condition using national surveys with mortality follow-up and a discrete time-to-event Poisson regression approach with post-stratification adjustment.

Population-based geographic access to endocrinologists in the United States, 2012.

BACKGROUND: Increases in population and life expectancy of Americans may result in shortages of endocrinologists by 2020. This study aims to assess variations in geographic accessibility to endocrinologists in the US, by age group at state and county levels, and by urban/rural status, and distance. METHODS: We used the 2012 National Provider Identifier Registry to obtain office locations of all adult and pediatric endocrinologists in the US. The population with geographic access to an endocrinologist within a series of 6 distance radii, centered on endocrinologist practice locations, was estimated using the US Census 2010 block-level population. We assumed that persons living within the same circular buffer zone of an endocrinologist location have the same geographic accessibility to that endocrinologist. The geographic accessibility (the percentage of the population with geographic access to at least one endocrinologist) and the population-to-endocrinologist ratio for each geographic area were estimated. RESULTS: By using 20 miles as the distance radius, geographic accessibility to at least one pediatric/adult endocrinologist for age groups 0-17, 18-64, and ≥ 65 years was 64.1%, 85.4%, and 82.1%. The overall population-to-endocrinologist ratio within 20 miles was 39,492:1 for children, 29,887:1 for adults aged 18-64 years, and 6,194:1 for adults aged ≥ 65 years. These ratios varied considerably by state, county, urban/rural status, and distance. CONCLUSIONS: This study demonstrates that there are geographic variations of accessibility to endocrinologists in the US. The areas with poorer geographic accessibility warrant further study of the effect of these variations on disease prevention, detection, and management of endocrine diseases in the US population. Our findings of geographic access to endocrinologists also may provide valuable information for medical education and health resources allocation.

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.

Prevalence and incidence trends for diagnosed diabetes among adults aged 20 to 79 years, United States, 1980-2012.

IMPORTANCE: Although the prevalence and incidence of diabetes have increased in the United States in recent decades, no studies have systematically examined long-term, national trends in the prevalence and incidence of diagnosed diabetes. OBJECTIVE: To examine long-term trends in the prevalence and incidence of diagnosed diabetes to determine whether there have been periods of acceleration or deceleration in rates. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 1980-2012 data for 664,969 adults aged 20 to 79 years from the National Health Interview Survey (NHIS) to estimate incidence and prevalence rates for the overall civilian, noninstitutionalized, US population and by demographic subgroups (age group, sex, race/ethnicity, and educational level). MAIN OUTCOMES AND MEASURES: The annual percentage change (APC) in rates of the prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined). RESULTS: The APC for age-adjusted prevalence and incidence of diagnosed diabetes did not change significantly during the 1980s (for prevalence, 0.2% [95% CI, -0.9% to 1.4%], P = .69; for incidence, -0.1% [95% CI, -2.5% to 2.4%], P = .93), but each increased sharply during 1990-2008 (for prevalence, 4.5% [95% CI, 4.1% to 4.9%], P < .001; for incidence, 4.7% [95% CI, 3.8% to 5.6%], P < .001) before leveling off with no significant change during 2008-2012 (for prevalence, 0.6% [95% CI, -1.9% to 3.0%], P = .64; for incidence, -5.4% [95% CI, -11.3% to 0.9%], P = .09). The prevalence per 100 persons was 3.5 (95% CI, 3.2 to 3.9) in 1990, 7.9 (95% CI, 7.4 to 8.3) in 2008, and 8.3 (95% CI, 7.9 to 8.7) in 2012. The incidence per 1000 persons was 3.2 (95% CI, 2.2 to 4.1) in 1990, 8.8 (95% CI, 7.4 to 10.3) in 2008, and 7.1 (95% CI, 6.1 to 8.2) in 2012. Trends in many demographic subpopulations were similar to these overall trends. However, incidence rates among non-Hispanic black and Hispanic adults continued to increase (for interaction, P = .03 for non-Hispanic black adults and P = .01 for Hispanic adults) at rates significantly greater than for non-Hispanic white adults. In addition, the rate of increase in prevalence was higher for adults who had a high school education or less compared with those who had more than a high school education (for interaction, P = .006 for

Trends in all-cause and cause-specific mortality by BMI levels in England, 2004-2019: a population-based primary care records study.

Background: In the UK, obesity rates are rising concurrently with declining mortality rates. Yet, there is limited research on the shifts of mortality trends and the impact of obesity-related mortality. In this study, we examine mortality trends and the cause-specific proportional composition of deaths by body mass index. Methods: We used primary healthcare records from the Clinical Practice Research Datalink between 2004 and 2019, linked to national death registration data. There were 880,683 individuals with at least one BMI measurement and a 5-year survival period. We used discrete Poisson regression and joinpoint analysis to estimate the all-cause and cause-specific mortality rate and significance of the trends. Findings: Between January 1, 2004, and December 31, 2019, all-cause mortality rates declined in the obese category by 3% on average per year (from 23.3 to 14.6 deaths per 1000 person years) in males and 2% on average per year (from 12.5 to 9.4 deaths per 1000 person years) in females. Cardiovascular disease mortality declined 7% on average per year (from 12.4 to 4.4 deaths per 1000 person years) in males and 4% on average per year (from 5.5 to 3.0 deaths per 1000 person years) in females in the obese category. Increases in mortality rates from neurological conditions occurred in all BMI categories in males and females. By the end of the study, cancers became the primary contributor of death in males in all BMI categories and females in the overweight category. Interpretation: There have been significant declines in all-cause and cardiovascular disease mortality in males and females, leading to a diversification of mortality, with cancers contributing to the highest proportion of deaths and increases in causes such as neurological and respiratory conditions. Further screening, prevention, and treatment implementation for a broader set of diseases is necessary for continued mortality improvements. Funding: Imperial College London, Science Foundation Ireland.

Type 1 Diabetes Genetic Risk in 109,954 Veterans With Adult-Onset Diabetes: The Million Veteran Program (MVP).

OBJECTIVE: To characterize high type 1 diabetes (T1D) genetic risk in a population where type 2 diabetes (T2D) predominates. RESEARCH DESIGN AND METHODS: Characteristics typically associated with T1D were assessed in 109,594 Million Veteran Program participants with adult-onset diabetes, 2011-2021, who had T1D genetic risk scores (GRS) defined as low (0 to <45%), medium (45 to <90%), high (90 to <95%), or highest (≥95%). RESULTS: T1D characteristics increased progressively with higher genetic risk (P < 0.001 for trend). A GRS ≥90% was more common with diabetes diagnoses before age 40 years, but 95% of those participants were diagnosed at age ≥40 years, and their characteristics resembled those of individuals with T2D in mean age (64.3 years) and BMI (32.3 kg/m2). Compared with the low-risk group, the highest-risk group was more likely to have diabetic ketoacidosis (low GRS 0.9% vs. highest GRS 3.7%), hypoglycemia prompting emergency visits (3.7% vs. 5.8%), outpatient plasma glucose <50 mg/dL (7.5% vs. 13.4%), a shorter median time to start insulin (3.5 vs. 1.4 years), use of a T1D diagnostic code (16.3% vs. 28.1%), low C-peptide levels if tested (1.8% vs. 32.4%), and glutamic acid decarboxylase antibodies (6.9% vs. 45.2%), all P < 0.001. CONCLUSIONS: Characteristics associated with T1D were increased with higher genetic risk, and especially with the top 10% of risk. However, the age and BMI of those participants resemble those of people with T2D, and a substantial proportion did not have diagnostic testing or use of T1D diagnostic codes. T1D genetic screening could be used to aid identification of adult-onset T1D in settings in which T2D predominates.

Trends and Demographic Differences in the Incidence and Mean Age of Starting to Smoke Cigarettes Regularly, National Health Interview Survey, 1997-2018.

OBJECTIVES: Surveillance of cigarette smoking behavior provides evidence for evaluating the impact of current tobacco control measures. We examined temporal changes and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly in the United States. METHODS: We conducted retrospective birth-cohort and cross-sectional analyses using self-reported data from the 1997-2018 National Health Interview Survey to evaluate trends and demographic differences in the incidence and mean age of starting to smoke cigarettes regularly among participants aged 18-84 years. We estimated the incidence and mean age of starting to smoke cigarettes regularly by using Poisson and linear regression. RESULTS: Among adults born during 1950-1999, the incidence of starting to smoke cigarettes regularly before age 35 years decreased by 18.8% (95% CI, 17.0%-20.7%) per 10 years, with a peak incidence at age about age 18 years. Male, non-Hispanic White, and US-born people had a higher incidence of starting to smoke cigarettes regularly than female, other racial and ethnic, and non-US-born people, respectively (P < .001 for all). From 1997 to 2018, the mean age of starting to smoke cigarettes regularly decreased by 0.4% (95% CI, 0.2%-0.6%) per 10 years among adults who ever smoked. CONCLUSION: The incidence of starting to smoke cigarettes regularly decreased dramatically at all ages during the study period, which suggests a positive impact of current tobacco control measures. For evaluating trends in starting to smoke cigarettes regularly, incidence can be a more sensitive indicator of temporal change than mean age. Differences in smoking incidence by demographic subgroup suggest that additional opportunities exist to further reduce the incidence of starting to smoke cigarettes regularly.

Trends in leading causes of hospitalisation of adults with diabetes in England from 2003 to 2018: an epidemiological analysis of linked primary care records.

BACKGROUND: Diabetes leads to a wide range of established vascular and metabolic complications that has resulted in the implementation of diverse prevention programmes across high-income countries. Diabetes has also been associated with an increased risk of a broader set of conditions including cancers, liver disease, and common infections. We aimed to examine the trends in a broad set of cause-specific hospitalisations in individuals with diabetes in England from 2003 to 2018. METHODS: In this epidemiological analysis, we identified 309 874 individuals 18 years or older with diabetes (type 1 or 2) in England from the Clinical Practice Research Datalink linked to Hospital Episode Statistics inpatient data from 2003 to 2018. We generated a mixed prevalent and incident diabetes study population through serial cross sections and follow-up over time. We used a discretised Poisson regression model to estimate annual cause-specific hospitalisation rates in men and women with diabetes across 17 cause groupings. We generated a 1:1 age-matched and sex-matched population of individuals without diabetes to compare cause-specific hospitalisation rates in those with and without diabetes. FINDINGS: Hospitalisation rates were higher for all causes in persons with diabetes than in those without diabetes throughout the study period. Diabetes itself and ischaemic heart disease were the leading causes of excess (defined as absolute difference in the rate in the populations with and without diabetes) hospitalisation in 2003. By 2018, non-infectious and non-cancerous respiratory conditions, non-diabetes-related cancers, and ischaemic heart disease were the most common causes of excess hospitalisation across men and women. Hospitalisation rates of people with diabetes declined and causes of hospitalisation changed. Almost all traditional diabetes complication groups (vascular diseases, amputations, and diabetes) decreased, while conditions non-specific to diabetes (cancers, infections, non-infectious and non-cancerous respiratory conditions) increased. These differing trends represented a change in the cause of hospitalisation, such that the traditional diabetes complications accounted for more than 50% of hospitalisation in 2003, but only approximately 30% in 2018. In contrast, the proportion of hospitalisations due to respiratory infections between the same time period increased from 3% to 10% in men and from 4% to 12% in women. INTERPRETATIONS: Changes in the composition of excess risk and hospitalisation burden in those with diabetes means that preventative and clinical measures should evolve to reflect the diverse set of causes that are driving persistent excess hospitalisation in those with diabetes. FUNDING: Wellcome Trust.

Trends in lifetime risk and years of potential life lost from diabetes in the United States, 1997-2018.

BACKGROUND: Both incidence and mortality of diagnosed diabetes have decreased over the past decade. However, the impact of these changes on key metrics of diabetes burden-lifetime risk (LR), years of potential life lost (YPLL), and years spent with diabetes-is unknown. METHODS: We used data from 653,811 adults aged ≥18 years from the National Health Interview Survey, a cross-sectional sample of the civilian non-institutionalized population in the United States. LR, YPLL, and years spent with diabetes were estimated from age 18 to 84 by survey period (1997-1999, 2000-2004, 2005-2009, 2010-2014, 2015-2018). The age-specific incidence of diagnosed diabetes and mortality were estimated using Poisson regression. A multistate difference equation accounting for competing risks was used to model each metric. RESULTS: LR and years spent with diabetes initially increased then decreased over the most recent time periods. LR for adults at age 20 increased from 31.7% (95% CI: 31.2-32.1%) in 1997-1999 to 40.7% (40.2-41.1%) in 2005-2009, then decreased to 32.8% (32.4-33.2%) in 2015-2018. Both LR and years spent with diabetes were markedly higher among adults of non-Hispanic Black, Hispanic, and other races compared to non-Hispanic Whites. YPLL significantly decreased over the study period, with the estimated YPLL due to diabetes for an adult aged 20 decreasing from 8.9 (8.7-9.1) in 1997-1999 to 6.2 (6.1-6.4) in 2015-2018 (p = 0.02). CONCLUSION: In the United States, diabetes burden is declining, but disparities by race/ethnicity remain. LR remains high with approximately one-third of adults estimated to develop diabetes during their lifetime.

Trends in all-cause mortality among people with diagnosed diabetes in high-income settings: a multicountry analysis of aggregate data.

BACKGROUND: Population-level trends in mortality among people with diabetes are inadequately described. We aimed to examine the magnitude and trends in excess all-cause mortality in people with diabetes. METHODS: In this retrospective, multicountry analysis, we collected aggregate data from 19 data sources in 16 high-income countries or jurisdictions (in six data sources in Asia, eight in Europe, one from Australia, and four from North America) for the period from Jan 1, 1995, to Dec 31, 2016, (or a subset of this period) on all-cause mortality in people with diagnosed total or type 2 diabetes. We collected data from administrative sources, health insurance records, registries, and a health survey. We estimated excess mortality using the standardised mortality ratio (SMR). FINDINGS: In our dataset, there were approximately 21 million deaths during 0·5 billion person-years of follow-up among people with diagnosed diabetes. 17 of 19 data sources showed decreases in the age-standardised and sex-standardised mortality in people with diabetes, among which the annual percentage change in mortality ranged from -0·5% (95% CI -0·7 to -0·3) in Hungary to -4·2% (-4·3 to -4·1) in Hong Kong. The largest decreases in mortality were observed in east and southeast Asia, with a change of -4·2% (95% CI -4·3 to -4·1) in Hong Kong, -4·0% (-4·8 to -3·2) in South Korea, -3·5% (-4·0 to -3·0) in Taiwan, and -3·6% (-4·2 to -2·9) in Singapore. The annual estimated change in SMR between people with and without diabetes ranged from -3·0% (95% CI -3·0 to -2·9; US Medicare) to 1·6% (1·4 to 1·7; Lombardy, Italy). Among the 17 data sources with decreasing mortality among people with diabetes, we found a significant SMR increase in five data sources, no significant SMR change in four data sources, and a significant SMR decrease in eight data sources. INTERPRETATION: All-cause mortality in diabetes has decreased in most of the high-income countries we assessed. In eight of 19 data sources analysed, mortality decreased more rapidly in people with diabetes than in those without diabetes. Further longevity gains will require continued improvement in prevention and management of diabetes. FUNDING: US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program.

Lifetime risk, life expectancy, and years of life lost to type 2 diabetes in 23 high-income jurisdictions: a multinational, population-based study.

BACKGROUND: Diabetes is a major public health issue. Because lifetime risk, life expectancy, and years of life lost are meaningful metrics for clinical decision making, we aimed to estimate these measures for type 2 diabetes in the high-income setting. METHODS: For this multinational, population-based study, we sourced data from 24 databases for 23 jurisdictions (either whole countries or regions of a country): Australia; Austria; Canada; Denmark; Finland; France; Germany; Hong Kong; Hungary; Israel; Italy; Japan; Latvia; Lithuania; the Netherlands; Norway; Scotland; Singapore; South Korea; Spain; Taiwan; the UK; and the USA. Our main outcomes were lifetime risk of type 2 diabetes, life expectancy in people with and without type 2 diabetes, and years of life lost to type 2 diabetes. We modelled the incidence and mortality of type 2 diabetes in people with and without type 2 diabetes in sex-stratified, age-adjusted, and calendar year-adjusted Poisson models for each jurisdiction. Using incidence and mortality, we constructed life tables for people of both sexes aged 20-100 years for each jurisdiction and at two timepoints 5 years apart in the period 2005-19 where possible. Life expectancy from a given age was computed as the area under the survival curves and lifetime lost was calculated as the difference between the expected lifetime of people with versus without type 2 diabetes at a given age. Lifetime risk was calculated as the proportion of each cohort who developed type 2 diabetes between the ages of 20 years and 100 years. We estimated 95% CIs using parametric bootstrapping. FINDINGS: Across all study cohorts from the 23 jurisdictions (total person-years 1 577 234 194), there were 5 119 585 incident cases of type 2 diabetes, 4 007 064 deaths in those with type 2 diabetes, and 11 854 043 deaths in those without type 2 diabetes. The lifetime risk of type 2 diabetes ranged from 16·3% (95% CI 15·6-17·0) for Scottish women to 59·6% (58·5-60·8) for Singaporean men. Lifetime risk declined with time in 11 of the 15 jurisdictions for which two timepoints were studied. Among people with type 2 diabetes, the highest life expectancies were found for both sexes in Japan in 2017-18, where life expectancy at age 20 years was 59·2 years (95% CI 59·2-59·3) for men and 64·1 years (64·0-64·2) for women. The lowest life expectancy at age 20 years with type 2 diabetes was observed in 2013-14 in Lithuania (43·7 years [42·7-44·6]) for men and in 2010-11 in Latvia (54·2 years [53·4-54·9]) for women. Life expectancy in people with type 2 diabetes increased with time for both sexes in all jurisdictions, except for Spain and Scotland. The life expectancy gap between those with and without type 2 diabetes declined substantially in Latvia from 2010-11 to 2015-16 and in the USA from 2009-10 to 2014-15. Years of life lost to type 2 diabetes ranged from 2·5 years (Latvia; 2015-16) to 12·9 years (Israel Clalit Health Services; 2015-16) for 20-year-old men and from 3·1 years (Finland; 2011-12) to 11·2 years (Israel Clalit Health Services; 2010-11 and 2015-16) for 20-year-old women. With time, the expected number of years of life lost to type 2 diabetes decreased in some jurisdictions and increased in others. The greatest decrease in years of life lost to type 2 diabetes occurred in the USA between 2009-10 and 2014-15 for 20-year-old men (a decrease of 2·7 years). INTERPRETATION: Despite declining lifetime risk and improvements in life expectancy for those with type 2 diabetes in many high-income jurisdictions, the burden of type 2 diabetes remains substantial. Public health strategies might benefit from tailored approaches to continue to improve health outcomes for people with diabetes. FUNDING: US Centers for Disease Control and Prevention and Diabetes Australia.