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.

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.

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.

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.

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.

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.

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.

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.

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.

Intensive Care Unit Admission, Mechanical Ventilation, and Mortality Among Patients With Type 1 Diabetes Hospitalized for COVID-19 in the U.S.

OBJECTIVE: To assess whether risk of severe outcomes among patients with type 1 diabetes mellitus (T1DM) hospitalized for coronavirus disease 2019 (COVID-19) differs from that of patients without diabetes or with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: Using the Premier Healthcare Database Special COVID-19 Release records of patients discharged after COVID-19 hospitalization from U.S. hospitals from March to November 2020 (N = 269,674 after exclusion), we estimated risk differences (RD) and risk ratios (RR) of intensive care unit admission or invasive mechanical ventilation (ICU/MV) and of death among patients with T1DM compared with patients without diabetes or with T2DM. Logistic models were adjusted for age, sex, and race or ethnicity. Models adjusted for additional demographic and clinical characteristics were used to examine whether other factors account for the associations between T1DM and severe COVID-19 outcomes. RESULTS: Compared with patients without diabetes, T1DM was associated with a 21% higher absolute risk of ICU/MV (RD 0.21, 95% CI 0.19-0.24; RR 1.49, 95% CI 1.43-1.56) and a 5% higher absolute risk of mortality (RD 0.05, 95% CI 0.03-0.07; RR 1.40, 95% CI 1.24-1.57), with adjustment for age, sex, and race or ethnicity. Compared with T2DM, T1DM was associated with a 9% higher absolute risk of ICU/MV (RD 0.09, 95% CI 0.07-0.12; RR 1.17, 95% CI 1.12-1.22), but no difference in mortality (RD 0.00, 95% CI -0.02 to 0.02; RR 1.00, 95% CI 0.89-1.13). After adjustment for diabetic ketoacidosis (DKA) occurring before or at COVID-19 diagnosis, patients with T1DM no longer had increased risk of ICU/MV (RD 0.01, 95% CI -0.01 to 0.03) and had lower mortality (RD -0.03, 95% CI -0.05 to -0.01) in comparisons with patients with T2DM. CONCLUSIONS: Patients with T1DM hospitalized for COVID-19 are at higher risk for severe outcomes than those without diabetes. Higher risk of ICU/MV in patients with T1DM than in patients with T2DM was largely accounted for by the presence of DKA. These findings might further guide recommendations related to diabetes management and the prevention of COVID-19.

Trends in Total and Out-of-pocket Payments for Noninsulin Glucose-Lowering Drugs Among U.S. Adults With Large-Employer Private Health Insurance From 2005 to 2018.

OBJECTIVE: To estimate trends in total payment and patients' out-of-pocket (OOP) payments of noninsulin glucose-lowering drugs by class from 2005 to 2018. RESEARCH DESIGN AND METHODS: We analyzed data for 53 million prescriptions from adults aged >18 years with type 2 diabetes under fee-for-service plans from the 2005-2018 IBM MarketScan Commercial Databases. The total payment was measured as the amount that the pharmacy received, and the OOP payment was the sum of copay, coinsurance, and deductible paid by the beneficiaries. We applied a joinpoint regression to evaluate nonlinear trends in cost between 2005 and 2018. We further conducted a decomposition analysis to explore the drivers for total payment change. RESULTS: Total annual payments for older drug classes, including metformin, sulfonylurea, meglitinide, α-glucosidase inhibitors, and thiazolidinedione, declined during 2005-2018, ranging from -$271 (-53.8%) for metformin to -$2,406 (-92.2%) for thiazolidinedione. OOP payments for these drug classes also reduced. In the same period, the total annual payments for the newer drug classes, including dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors, increased by $2,181 (88.4%), $3,721 (77.6%), and $1,374 (37.0%), respectively. OOP payment for these newer classes remained relatively unchanged. Our study findings indicate that switching toward the newer classes for noninsulin glucose-lowering drugs was the main driver that explained the total payment increase. CONCLUSIONS: Average annual payments and OOP payment for noninsulin glucose-lowering drugs increased significantly from 2005 to 2018. The uptake of newer drug classes was the main driver.

Trends in predominant causes of death in individuals with and without diabetes in England from 2001 to 2018: an epidemiological analysis of linked primary care records.

BACKGROUND: The prevalence of diabetes has increased in the UK and other high-income countries alongside a substantial decline in cardiovascular mortality. Yet data are scarce on how these trends have changed the causes of death in people with diabetes who have traditionally died primarily of vascular causes. We estimated how all-cause mortality and cause-specific mortality in people with diabetes have changed over time, how the composition of the mortality burden has changed, and how this composition compared with that of the non-diabetes population. METHODS: In this epidemiological analysis of primary care records, we identified 313 907 individuals with diabetes in the Clinical Practice Research Datalink, a well described primary care database, between 2001 to 2018, and linked these data to UK Office for National Statistics mortality data. We assembled serial cross sections with longitudinal follow-up to generate a mixed prevalence and incidence study population of patients with diabetes. We used discretised Poisson regression models to estimate annual death rates for deaths from all causes and 12 specific causes for men and women with diabetes. We also identified age-matched and sex matched (1:1) individuals without diabetes from the same dataset and estimated mortality rates in this group. FINDINGS: Between Jan 1, 2001, and Oct 31, 2018, total mortality declined by 32% in men and 31% in women with diagnosed diabetes. Death rates declined from 40·7 deaths per 1000 person-years to 27·8 deaths per 1000 person-years in men and from 42·7 deaths per 1000 person-years to 29·5 deaths per 1000 person-years in women with diagnosed diabetes. We found similar declines in individuals without diabetes, hence the gap in mortality between those with and without diabetes was maintained over the study period. Cause-specific death rates declined in ten of the 12 cause groups, with exceptions in dementia and liver disease, which increased in both populations. The large decline in vascular disease death rates led to a transition from vascular causes to cancers as the leading contributor to death rates in individuals with diagnosed diabetes and to the gap in death rates between those with and without diabetes. INTERPRETATION: The decline in vascular death rates has been accompanied by a diversification of causes in individuals with diagnosed diabetes and a transition from vascular diseases to cancers as the leading contributor to diabetes-related death. Clinical and preventative approaches must reflect this trend to reduce the excess mortality risk in individuals with diabetes. FUNDING: Wellcome Trust.

Estimated number of eligible Part B beneficiaries for the medicare diabetes prevention program at the county level and by urban-rural classification.

INTRODUCTION: Diabetes imposes large health and financial burdens on Medicare beneficiaries. Type 2 diabetes can be prevented or delayed through lifestyle modification programs. In 2018, Medicare began to offer the Medicare Diabetes Prevention Program (MDPP), a lifestyle intervention, to eligible beneficiaries nationwide. The number of MDPP-eligible beneficiaries is not known, but this information is essential in efforts to expand the program and increase enrollment. This study aimed to estimate the number and spatial variation of MDPP-eligible Part B beneficiaries at the county level and by urban-rural classification. METHODS: Data from 2011-2016 National Health and Nutrition Examination Surveys and a survey-weighted logistic regression model were used to estimate proportions of prediabetes in the United States by sex, age, and race/ethnicity based on the MDPP eligibility criteria. The results from the predictive model were applied to 2015 Medicare Part B beneficiaries to estimate the number of MDPP-eligible beneficiaries. The National Center for Health Statistics' Urban-Rural Classification Scheme for Counties from 2013 were used to define urban and rural categories. RESULTS: An estimated 5.2 million (95% CI = 3.5-7.0 million) Part B beneficiaries were eligible for the MDPP. By state, estimates ranged from 13,000 (95% CI = 8,500-18,000) in Alaska to 469,000 (95% CI = 296,000-641,000) in California. There were 2,149 counties with ≤1,000 eligible beneficiaries and 11 with >25,000. Consistent with demographic patterns, urban counties had more eligible beneficiaries than rural counties. CONCLUSIONS: These estimates could be used to plan locations for new MDPPs and reach eligible Part B beneficiaries for enrollment.

Influenza vaccination coverage among adults with diabetes, United States, 2007-08 through 2017-18 seasons.

BACKGROUND: Diabetes is associated with higher risk of hospitalization, morbidity, and mortality from influenza. We assessed influenza vaccination coverage among adults aged ≥ 18 years with diabetes during the 2007-08 through 2017-18 influenza seasons and identified factors independently associated with vaccination during the 2017-18 season. METHODS: We analyzed data from the 2007-2018 National Health Interview Surveys, using Kaplan-Meier survival analysis to estimate season-specific influenza vaccination coverage. Multivariate logistic regression was conducted to examine whether diabetes was independently associated with self-reported influenza vaccination in the past 12 months and identify factors independently associated with vaccination among adults with diabetes using the 2017-18 data. RESULTS: During the 2007-08 through 2017-18 influenza seasons, influenza vaccination coverage among adults aged ≥ 18 years with diabetes ranged from 62.6% to 64.8%. In the 2017-18 influenza season, coverage was significantly higher among adults with diabetes (64.8%) compared with those without diabetes (43.9%). Having diabetes was independently associated with an increased prevalence of vaccination after controlling for other factors. Among adults with diabetes, living at or above poverty level, having more physician contacts, having usual place for health care, and being unemployed were independently associated with increased prevalence of vaccination; being 18-64 years and non-Hispanic black were independently associated with decreased prevalence of vaccination. CONCLUSIONS: Despite specific recommendations for influenza vaccination among people with diabetes, more than one-third of adults with diabetes are unvaccinated. Targeted efforts are needed to increase influenza vaccination coverage among adults with diabetes.

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.

Prevalence of Prediabetes Among Adolescents and Young Adults in the United States, 2005-2016.

Importance: Individuals with prediabetes are at increased risk of developing type 2 diabetes, chronic kidney disease, and cardiovascular disease. The incidence and prevalence of type 2 diabetes in the US adolescent population have increased in the last decade. Therefore, it is important to monitor the prevalence of prediabetes and varying levels of glucose tolerance to assess the future risk of type 2 diabetes in the youngest segment of the population. Objective: To examine the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and increased glycated hemoglobin A1c (HbA1c) levels in US adolescents (aged 12-18 years) and young adults (aged 19-34 years) without diabetes. Design, Setting, and Participants: This cross-sectional analyses of the 2005-2016 National Health and Nutrition Examination Survey assessed a population-based sample of adolescents and young adults who were not pregnant, did not have diabetes, and had measured fasting plasma glucose, 2-hour plasma glucose after a 75-g oral glucose tolerance test, and HbA1c levels. Analysis began in April 2017. Main Outcomes and Measures: Impaired fasting glucose was defined as fasting plasma glucose of 100 mg/dL to less than 126 mg/dL, IGT as 2-hour plasma glucose of 140 mg/dL to less than 200 mg/dL, and increased HbA1c level as HbA1c level between 5.7% and 6.4%. The prevalence of IFG, isolated IFG, IGT, isolated IGT, increased HbA1c level, isolated increased HbA1c level, and prediabetes (defined as having IFG, IGT, or increased HbA1c level) were estimated. Fasting insulin levels and cardiometabolic risk factors across glycemic abnormality phenotypes were also compared. Obesity was defined as having age- and sex-specific body mass index (calculated as weight in kilograms divided by height in meters squared) in the 95th percentile or higher in adolescents or 30 or higher in young adults. Results: Of 5786 individuals, 2606 (45%) were adolescents and 3180 (55%) were young adults. Of adolescents, 50.6% (95% CI, 47.6%-53.6%) were boys, and 50.6% (95% CI, 48.8%-52.4%) of young adults were men. Among adolescents, the prevalence of prediabetes was 18.0% (95% CI, 16.0%-20.1%) and among young adults was 24.0% (95% CI, 22.0%-26.1%). Impaired fasting glucose constituted the largest proportion of prediabetes, with prevalence of 11.1% (95% CI, 9.5%-13.0%) in adolescents and 15.8% (95% CI, 14.0%-17.9%) in young adults. In multivariable logistic models including age, sex, race/ethnicity, and body mass index, the predictive marginal prevalence of prediabetes was significantly higher in male than in female individuals (22.5% [95% CI, 19.5%-25.4%] vs 13.4% [95% CI, 10.8%-16.5%] in adolescents and 29.1% [95% CI, 26.4%-32.1%] vs 18.8% [95% CI, 16.5%-21.3%] in young adults). Prediabetes prevalence was significantly higher in individuals with obesity than in those with normal weight (25.7% [95% CI, 20.0%-32.4%] vs 16.4% [95% CI, 14.3%-18.7%] in adolescents and 36.9% [95% CI, 32.9%-41.1%] vs 16.6% [95% CI, 14.2%-19.4%] in young adults). Compared with persons with normal glucose tolerance, adolescents and young adults with prediabetes had significantly higher non-high-density lipoprotein cholesterol levels, systolic blood pressure, central adiposity, and lower insulin sensitivity (P < .05 for all). Conclusions and Relevance: In the United States, about 1 of 5 adolescents and 1 of 4 young adults have prediabetes. The adjusted prevalence of prediabetes is higher in male individuals and in people with obesity. Adolescents and young adults with prediabetes also present an unfavorable cardiometabolic risk profile, putting them both at increased risk of type 2 diabetes and cardiovascular diseases.

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.