Last data update: Nov 04, 2024. (Total: 48056 publications since 2009)
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Query Trace: Gregg EW[original query] |
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Trends in all-cause and cause-specific mortality by BMI levels in England, 2004–2019: a population-based primary care records study
Sophiea MK , Zaccardi F , Cheng YJ , Vamos EP , Holman N , Gregg EW . Lancet Reg Health Eur 2024 44 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. © 2024 The Authors |
Response to Comment on Cheng et al. Trends and Disparities in Cardiovascular Mortality Among U.S. Adults With and Without Self-Reported Diabetes, 1988-2015. Diabetes Care 2018;41:2306-2315
Cheng YJ , Imperatore G , Albright AL , Gregg EW . Diabetes Care 2019 42 (4) e63 We thank Manicardi et al. (1) for their insightful discussion of potential factors affecting our study of cardiovascular disease (CVD) mortality trends in the population with diabetes (2). Changes in diagnostic criteria and early detection of diabetes could indeed have affected the risk level and changes in rates of CVD differentially over time. We further agree that the population today is likely much different from that in the 1980s, perhaps due to the significant increases in obesity among the population with diabetes, which could influence risk as well. However, we caution that there is limited direct evidence that significant increases in detection have led to a healthier population or that the risk level at diagnosis has changed at a rate higher than the risk level of the underlying population (3). The impact of the 1997 change in diabetes definition and early detection of diabetes is also unknown but unlikely to explain the steady 12-year increase in incidence that occurred after that. Although we lack the appropriate data to quantify the impact of changing underlying risk directly, our indirect sensitivity analyses of these effects in the current report suggest that the impact of any lead-time bias on these trends was modest in comparison with the reductions that occurred (2). That said, the points raised by Manicardi et al. are important and underscore the need for more comprehensive epidemiologic data to understand the transitions underway in diabetes complications. |
Mortality trends in type 1 diabetes: a multicountry analysis of six population-based cohorts
Ruiz PLD , Chen L , Morton JI , Salim A , Carstensen B , Gregg EW , Pavkov ME , Mata-Cases M , Mauricio D , Nichols GA , Pildava S , Read SH , Wild SH , Shaw JE , Magliano DJ . Diabetologia 2022 65 (6) 964-972 AIMS/HYPOTHESIS: Mortality has declined in people with type 1 diabetes in recent decades. We examined how the pattern of decline differs by country, age and sex, and how mortality trends in type 1 diabetes relate to trends in general population mortality. METHODS: We assembled aggregate data on all-cause mortality during the period 2000-2016 in people with type 1 diabetes aged 0-79 years from Australia, Denmark, Latvia, Scotland, Spain (Catalonia) and the USA (Kaiser Permanente Northwest). Data were obtained from administrative sources, health insurance records and registries. All-cause mortality rates in people with type 1 diabetes, and standardised mortality ratios (SMRs) comparing type 1 diabetes with the non-diabetic population, were modelled using Poisson regression, with age and calendar time as quantitative variables, describing the effects using restricted cubic splines with six knots for age and calendar time. Mortality rates were standardised to the age distribution of the aggregate population with type 1 diabetes. RESULTS: All six data sources showed a decline in age- and sex-standardised all-cause mortality rates in people with type 1 diabetes from 2000 to 2016 (or a subset thereof), with annual changes in mortality rates ranging from -2.1% (95% CI -2.8%, -1.3%) to -5.8% (95% CI -6.5%, -5.1%). All-cause mortality was higher for male individuals and for older individuals, but the rate of decline in mortality was generally unaffected by sex or age. SMR was higher in female individuals than male individuals, and appeared to peak at ages 40-70 years. SMR declined over time in Denmark, Scotland and Spain, while remaining stable in the other three data sources. CONCLUSIONS/INTERPRETATION: All-cause mortality in people with type 1 diabetes has declined in recent years in most included populations, but improvements in mortality relative to the non-diabetic population are less consistent. |
Two decades of diabetes prevention efforts: A call to innovate and revitalize our approach to lifestyle change
Golovaty I , Ritchie ND , Tuomilehto J , Mohan V , Ali MK , Gregg EW , Bergman M , Moin T . Diabetes Res Clin Pract 2022 198 110195 The impact of global diabetes prevention efforts has been modest despite the promise of landmark diabetes prevention trials nearly twenty years ago. While national and regional initiatives show potential, challenges remain to adapt large-scale strategies in the real-world that fits individuals and their communities. Additionally, the sedentary lifestyle changes during the COVID-19 pandemic and guidelines that now call for earlier screening (e.g., US Preventative Task Force) will increase the pool of eligible adults worldwide. Thus, a more adaptable, person-centered approach that expands the current toolkit is urgently needed to innovate and revitalize our approach to diabetes prevention. This review identifies key priorities to optimize the population-level delivery of diabetes prevention based on a consensus-based evaluation of the current evidence among experts in global translational programs; key priorities identified include (1) participant eligibility, (2) intervention intensity, (3) delivery components, (4) behavioral economics, (5) technology, and (6) the role of pharmacotherapy. We offer a conceptual framework for a broader, person-centered approach to better address an individual's risk, readiness, barriers, and digital competency. |
Lifetime risk, life expectancy, and years of life lost to type 2 diabetes in 23 high-income jurisdictions: a multinational, population-based study
Tomic D , Morton JI , Chen L , Salim A , Gregg EW , Pavkov ME , Arffman M , Balicer R , Baviera M , Boersma-van Dam E , Brinks R , Carstensen B , Chan JCN , Cheng YJ , Fosse-Edorh S , Fuentes S , Gardiner H , Gulseth HL , Gurevicius R , Ha KH , Hoyer A , Jermendy G , Kautzky-Willer A , Keskimäki I , Kim DJ , Kiss Z , Klimek P , Leventer-Roberts M , Lin CY , Lopez-Doriga Ruiz P , Luk AOY , Ma S , Mata-Cases M , Mauricio D , McGurnaghan S , Imamura T , Paul SK , Peeters A , Pildava S , Porath A , Robitaille C , Roncaglioni MC , Sugiyama T , Wang KL , Wild SH , Yekutiel N , Shaw JE , Magliano DJ . Lancet Diabetes Endocrinol 2022 10 (11) 795-803 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. |
Trends in lifetime risk and years of potential life lost from diabetes in the United States, 1997-2018
Koyama AK , Cheng YJ , Brinks R , Xie H , Gregg EW , Hoyer A , Pavkov ME , Imperatore G . PLoS One 2022 17 (5) e0268805 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. |
Potential gains in life expectancy associated with achieving treatment goals in US adults with type 2 diabetes
Kianmehr H , Zhang P , Luo J , Guo J , Pavkov ME , Bullard KM , Gregg EW , Ospina NS , Fonseca V , Shi L , Shao H . JAMA Netw Open 2022 5 (4) e227705 IMPORTANCE: Improvements in control of factors associated with diabetes risk in the US have stalled and remain suboptimal. The benefit of continually improving goal achievement has not been evaluated to date. OBJECTIVE: To quantify potential gains in life expectancy (LE) among people with type 2 diabetes (T2D) associated with lowering glycated hemoglobin (HbA1c), systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI) toward optimal levels. DESIGN, SETTING, AND PARTICIPANTS: In this decision analytical model, the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes microsimulation model was calibrated to a nationally representative sample of adults with T2D from the National Health and Nutrition Examination Survey (2015-2016) using their linked short-term mortality data from the National Death Index. The model was then used to conduct the simulation experiment on the study population over a lifetime. Data were analyzed from January to October 2021. EXPOSURE: The study population was grouped into quartiles on the basis of levels of HbA1c, SBP, LDL-C, and BMI. LE gains associated with achieving better control were estimated by moving people with T2D from the current quartile of each biomarker to the lower quartiles. MAIN OUTCOMES AND MEASURES: Life expectancy. RESULTS: Among 421 individuals, 194 (46%) were women, and the mean (SD) age was 65.6 (8.9) years. Compared with a BMI of 41.4 (mean of the fourth quartile), lower BMIs of 24.3 (first), 28.6 (second), and 33.0 (third) were associated with 3.9, 2.9, and 2.0 additional life-years, respectively, in people with T2D. Compared with an SBP of 160.4 mm Hg (fourth), lower SBP levels of 114.1 mm Hg (first), 128.2 mm Hg (second), and 139.1 mm Hg (third) were associated with 1.9, 1.5, and 1.1 years gained in LE in people with T2D, respectively. A lower LDL-C level of 59 mg/dL (first), 84.0 mg/dL (second), and 107.0 mg/dL (third) were associated with 0.9, 0.7, and 0.5 years gain in LE, compared with LDL-C of 146.2 mg/dL (fourth). Reducing HbA1c from 9.9% (fourth) to 7.7% (third) was associated with 3.4 years gain in LE. However, a further reduction to 6.8% (second) was associated with only a mean of 0.5 years gain in LE, and from 6.8% to 5.9% (first) was not associated with LE benefit. Overall, reducing HbA1c from the fourth quartile to the first is associated with an LE gain of 3.8 years. CONCLUSIONS AND RELEVANCE: These findings can be used by clinicians to motivate patients in achieving the recommended treatment goals and to help prioritize interventions and programs to improve diabetes care in the US. |
Trends in all-cause mortality among people with diagnosed diabetes in high-income settings: a multicountry analysis of aggregate data
Magliano DJ , Chen L , Carstensen B , Gregg EW , Pavkov ME , Salim A , Andes LJ , Balicer R , Baviera M , Chan JCN , Cheng YJ , Gardiner H , Gulseth HL , Gurevicius R , Ha KH , Jermendy G , Kim DJ , Kiss Z , Leventer-Roberts M , Lin CY , Luk AOY , Ma S , Mata-Cases M , Mauricio D , Nichols GA , Pildava S , Porath A , Read SH , Robitaille C , Roncaglioni MC , Lopez-Doriga Ruiz P , Wang KL , Wild SH , Yekutiel N , Shaw JE . Lancet Diabetes Endocrinol 2022 10 (2) 112-119 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. |
Time to start addressing (and not just describing) the social determinants of diabetes: results from the NEXT-D 2.0 network
Siegel KR , Gregg EW , Duru OK , Shi L , Mangione CM , Thornton PL , Clauser S , Ali MK . BMJ Open Diabetes Res Care 2021 9 Social determinants of health (SDOH) are not new. For example, observational data over 40 years have shown consistent—and often heart-wrenching—differences in diabetes outcomes across populations, where populations at socioeconomic disadvantage, in terms of lower education and income levels, experience less access to care and preventive services,1 lower rates of diagnosis, poorer health behaviors and control,2 worse cardiometabolic outcomes,3 and shorter life expectancy as compared with more advantaged populations of higher socioeconomic status.4 These findings suggest that diabetes is not a purely biological issue; its onset and progression are heavily influenced by the broader social context. In particular, type 2 diabetes is in large part the result of choices that people are unable to make based on the health-promoting resources and opportunities available and accessible to them.5 In in the USA, social and economic stressors and related disparities are patterned by geography and race/ethnicity.6 Type 2 diabetes, therefore, is as much an issue of where you live, as it is an issue of how you live. |
Trends in leading causes of hospitalisation of adults with diabetes in England from 2003 to 2018: an epidemiological analysis of linked primary care records
Pearson-Stuttard J , Cheng YJ , Bennett J , Vamos EP , Zhou B , Valabhji J , Cross AJ , Ezzati M , Gregg EW . Lancet Diabetes Endocrinol 2021 10 (1) 46-57 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. |
Lifetime risk of developing diabetes and years of life lost among those with diabetes in Brazil
Bracco PA , Gregg EW , Rolka DB , Schmidt MI , Barreto SM , Lotufo PA , Bensenor I , Duncan BB . J Glob Health 2021 11 04041 BACKGROUND: Given the paucity of studies for low- or middle-income countries, we aim to provide the first ever estimations of lifetime risk of diabetes, years of life spent and lost among those with diabetes for Brazilians. Estimates of Brazil´s diabetes burden consist essentially of reports of diabetes prevalence from national surveys and mortality data. However, these additional metrics are at times more meaningful ways to characterize this burden. METHODS: We joined data on incidence of physician-diagnosed diabetes from the Brazilian risk factor surveillance system, all-cause mortality from national statistics, and diabetes mortality rate ratios from ELSA-Brasil, an ongoing cohort study. To calculate lifetime risk of developing diabetes, we applied an illness-death state model. To calculate years of life lost for those with diabetes and years lived with the disease, we additionally calculated the mortality rates for those with diabetes. RESULTS: A 35-year-old white adult had a 23.4% (95% CI = 22.5%-25.5%) lifetime risk of developing diabetes by age 80 while a same-aged black/brown adult had a 30.8% risk (95% confidence interval (CI) = 29.6%-33.2%). Men diagnosed with diabetes at age 35 would live 32.9 (95% CI = 32.4-33.2) years with diabetes and lose 5.5 (95% CI = 5.1-6.1) years of life. Similarly-aged women would live 38.8 (95% CI = 38.3-38.9) years with diabetes and lose 2.1 (95% CI = 1.9-2.6) years of life. CONCLUSIONS: Assuming maintenance of current rates, one-quarter of young Brazilians will develop diabetes over their lifetimes, with this number reaching almost one-third among young, black/brown women. Those developing diabetes will suffer a decrease in life expectancy and will generate a considerable cost in terms of medical care. |
Trends in total and out-of-pocket payments for insulin among privately insured U.S. adults with diabetes from 2005 to 2018
Laxy M , Zhang P , Benoit SR , Imperatore G , Cheng YJ , Gregg EW , Yang S , Shao H . Diabetes Care 2021 More than 30 million people in the U.S. have diabetes, and approximately 7.4 million (30% of those with diabetes) regularly use one or more insulin formulations. For those who rely on it, i.e., all patients with type 1 diabetes and many patients with type 2 diabetes, insulin is a lifesaving medication. Between 2007 and 2016, the average annual total Medicare Part D payment on insulin per person increased by 358%, which resulted in an 81% increase for the out-of-pocket (OOP) payment (1). The consequences of unaffordability for insulin can be severe and costly. High OOP payments may force individuals to choose between purchasing their medication and paying for other necessities. To date, there are limited data on how total insulin payment and the corresponding OOP payment changed in the commercially insured population within the same period. The objective of this study is to delineate total and patients’ OOP payment trends for insulin among privately insured U.S. adults. |
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
Gong Q , Zhang P , Wang J , Gregg EW , Cheng YJ , Li G , Bennett PH . Diabetes Obes Metab 2021 23 (10) 2385-2394 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. METHODS: Using data from the Da Qing Diabetes Prevention Outcome Study, a 30-year follow-up of a six-year randomized trial of lifestyle intervention in 576 people with IGT, we 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 (CVD) 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. This article is protected by copyright. All rights reserved. |
Differences in U.S. Rural-Urban Trends in Diabetes ABCS, 1999-2018
Mercado CI , McKeever Bullard K , Gregg EW , Ali MK , Saydah SH , Imperatore G . Diabetes Care 2021 44 (8) 1766-1773 OBJECTIVE: To examine changes in and the relationships between diabetes management and rural and urban residence. RESEARCH DESIGN AND METHODS: Using National Health and Nutrition Examination Survey (1999-2018) data from 6,372 adults aged ≥18 years with self-reported diagnosed diabetes, we examined poor ABCS: A1C >9% (>75 mmol/mol), Blood pressure (BP) ≥140/90 mmHg, Cholesterol (non-HDL) ≥160 mg/dL (≥4.1 mmol/L), and current Smoking. We compared odds of urban versus rural residents (census tract population size ≥2,500 considered urban, otherwise rural) having poor ABCS across time (1999-2006, 2007-2012, and 2013-2018), overall and by sociodemographic and clinical characteristics. RESULTS: During 1999-2018, the proportion of U.S. adults with diabetes residing in rural areas ranged between 15% and 19.5%. In 1999-2006, there were no statistically significant rural-urban differences in poor ABCS. However, from 1999-2006 to 2013-2018, there were greater improvements for urban adults with diabetes than for rural for BP ≥140/90 mmHg (relative odds ratio [OR] 0.8, 95% CI 0.6-0.9) and non-HDL ≥160 mg/dL (≥4.1 mmol/L) (relative OR 0.45, 0.4-0.5). These differences remained statistically significant after adjustment for race/ethnicity, education, poverty levels, and clinical characteristics. Yet, over the 1999-2018 time period, minority race/ethnicity, lower education attainment, poverty, and lack of health insurance coverage were factors associated with poorer A, B, C, or S in urban adults compared with their rural counterparts. CONCLUSIONS: Over two decades, rural U.S. adults with diabetes have had less improvement in BP and cholesterol control. In addition, rural-urban differences exist across sociodemographic groups, suggesting that efforts to narrow this divide may need to address both socioeconomic and clinical aspects of care. |
Trends in the incidence of diagnosed diabetes: a multicountry analysis of aggregate data from 22 million diagnoses in high-income and middle-income settings
Magliano DJ , Chen L , Islam RM , Carstensen B , Gregg EW , Pavkov ME , Andes LJ , Balicer R , Baviera M , Boersma-van Dam E , Booth GL , Chan JCN , Chua YX , Fosse-Edorh S , Fuentes S , Gulseth HL , Gurevicius R , Ha KH , Hird TR , Jermendy G , Khalangot MD , Kim DJ , Kiss Z , Kravchenko VI , Leventer-Roberts M , Lin CY , Luk AOY , Mata-Cases M , Mauricio D , Nichols GA , Nielen MM , Pang D , Paul SK , Pelletier C , Pildava S , Porath A , Read SH , Roncaglioni MC , Lopez-Doriga Ruiz P , Shestakova M , Vikulova O , Wang KL , Wild SH , Yekutiel N , Shaw JE . Lancet Diabetes Endocrinol 2021 9 (4) 203-211 BACKGROUND: Diabetes prevalence is increasing in most places in the world, but prevalence is affected by both risk of developing diabetes and survival of those with diabetes. Diabetes incidence is a better metric to understand the trends in population risk of diabetes. Using a multicountry analysis, we aimed to ascertain whether the incidence of clinically diagnosed diabetes has changed over time. METHODS: In this multicountry data analysis, we assembled aggregated data describing trends in diagnosed total or type 2 diabetes incidence from 24 population-based data sources in 21 countries or jurisdictions. Data were from administrative sources, health insurance records, registries, and a health survey. We modelled incidence rates with Poisson regression, using age and calendar time (1995-2018) as variables, describing the effects with restricted cubic splines with six knots for age and calendar time. FINDINGS: Our data included about 22 million diabetes diagnoses from 5 billion person-years of follow-up. Data were from 19 high-income and two middle-income countries or jurisdictions. 23 data sources had data from 2010 onwards, among which 19 had a downward or stable trend, with an annual estimated change in incidence ranging from -1·1% to -10·8%. Among the four data sources with an increasing trend from 2010 onwards, the annual estimated change ranged from 0·9% to 5·6%. The findings were robust to sensitivity analyses excluding data sources in which the data quality was lower and were consistent in analyses stratified by different diabetes definitions. INTERPRETATION: The incidence of diagnosed diabetes is stabilising or declining in many high-income countries. The reasons for the declines in the incidence of diagnosed diabetes warrant further investigation with appropriate data sources. FUNDING: US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program. |
Associations of progression to diabetes and regression to normal glucose tolerance with development of cardiovascular and microvascular disease among people with impaired glucose tolerance: a secondary analysis of the 30year Da Qing Diabetes Prevention Outcome Study
Chen Y , Zhang P , Wang J , Gong Q , An Y , Qian X , Zhang B , Li H , Gregg EW , Bennett PH , Li G . Diabetologia 2021 64 (6) 1279-1287 AIMS/HYPOTHESIS: We aimed to determine associations of regression to normal glucose tolerance (NGT), maintaining impaired glucose tolerance (IGT) or progression to diabetes with subsequent risks of CVD and microvascular disease among Chinese adults with IGT. METHODS: We conducted an observational study among 540 participants in the Da Qing Diabetes Prevention Study, a 6 year lifestyle intervention trial in people with IGT, defined by 1985 WHO criteria as fasting plasma glucose <7.8 mmol/l and 2 h post-load plasma glucose ≥7.8 and <11.1 mmol/l. At the end of the trial, the groups that had regressed to NGT, remained with IGT or progressed to diabetes were identified. Participants were then followed for 24 years after completion of the trial, during which we compared the incidence and hazard ratios for CVD and microvascular disease in each group and estimated the differences in their median time to onset from parametric Weibull distribution models. RESULTS: At the end of the 6 year trial, 252 (46.7%) participants had developed diabetes, 114 (21.1%) had remained with IGT and 174 (32.2%) had regressed to NGT. Compared with those who developed diabetes during the trial, the median time to onset of diabetes was delayed by 14.86 years (95% CI 12.49, 17.25) in the NGT and 9.87 years (95% CI 8.12, 11.68) in the IGT groups. After completion of the trial, among those with diabetes, IGT and NGT, the 24 year cumulative incidence of CVD was 64.5%, 48.5% and 45.1%, respectively, and 36.8%, 21.7% and 16.5% for microvascular diseases. Compared with participants who had progressed to diabetes during the trial, those who regressed to NGT had a 37% (HR 0.63; 95% CI 0.47, 0.85) reduction in CVD incidence and a median delay of 7.45 years (95% CI 1.91, 12.99) in onset, and those who remained with IGT had a 34% (HR 0.66; 95% CI 0.47, 0.91) lower CVD incidence with a median delay in onset of 5.69 years (95% CI 1.0, 10.38). Participants with NGT had a 66% (HR 0.34; 95% CI 0.20, 0.56) lower incidence of microvascular diseases and a median delay in the onset of 18.66 years (95% CI 6.08, 31.24), and those remaining with IGT had a 52% (HR 0.48; 95% CI 0.29, 0.81) lower incidence with a median delay of 12.56 years (95% CI 2.49, 22.63). CONCLUSIONS/INTERPRETATION: People with IGT who reverted to NGT or remained with IGT at the end of the 6 year trial subsequently had significantly lower incidences of CVD and microvascular disease than those who had developed diabetes. |
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
Pearson-Stuttard J , Bennett J , Cheng YJ , Vamos EP , Cross AJ , Ezzati M , Gregg EW . Lancet Diabetes Endocrinol 2021 9 (3) 165-173 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. |
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
Shao H , Laxy M , Benoit SR , Cheng YJ , Gregg EW , Zhang P . Diabetes Care 2021 44 (4) 925-934 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, have declined during 2005-2018, ranging from -$271 (-53.8%) (USD) 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, have 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 have increased significantly from 2005 to 2018. The uptake of newer drug classes was the main driver. |
The Lancet Commission on diabetes: using data to transform diabetes care and patient lives
Chan JCN , Lim LL , Wareham NJ , Shaw JE , Orchard TJ , Zhang P , Lau ESH , Eliasson B , Kong APS , Ezzati M , Aguilar-Salinas CA , McGill M , Levitt NS , Ning G , So WY , Adams J , Bracco P , Forouhi NG , Gregory GA , Guo J , Hua X , Klatman EL , Magliano DJ , Ng BP , Ogilvie D , Panter J , Pavkov M , Shao H , Unwin N , White M , Wou C , Ma RCW , Schmidt MI , Ramachandran A , Seino Y , Bennett PH , Oldenburg B , Gagliardino JJ , Luk AOY , Clarke PM , Ogle GD , Davies MJ , Holman RR , Gregg EW . Lancet 2020 396 (10267) 2019-2082 2020 will go down in history as the year when the global community was awakened to the fragility of human health and the interdependence of the ecosystem, economy, and humanity. Amid the COVID-19 pandemic, the vulnerability of people with diabetes during a public health emergency became evident by their at least 2 times increased risk of severe disease or death, especially in individuals with poorly controlled diabetes, comorbidities, or both. The disease burden caused by COVID-19, exacerbated by chronic conditions like diabetes, has inflicted a heavy toll on health-care systems and the global economy. | | In this Lancet Commission on diabetes, which embodies 4 years of extensive work on data curation, synthesis, and modelling, we urge policy makers, payers, and planners to collectively change the ecosystem, build capacity, and improve the clinical practice environment. Such actions will enable practitioners to systematically collect data during routine practice and to use these data effectively to diagnose early, stratify risks, define needs, improve care, evaluate solutions, and drive changes at patient, system, and policy levels to prevent and control diabetes and other non-communicable diseases. Emerging evidence regarding the possible damaging effects of severe acute respiratory syndrome coronavirus 2 on pancreatic islets implies the potential worsening of the COVID-19 pandemic and the diabetes epidemic, adding to the urgency of these collective actions. | | Prevention, early detection, prompt diagnosis, and continuing care with regular monitoring and ongoing evaluation are key elements in reducing the growing burden of diabetes. Given the silent and progressive nature of diabetes, it is epidemiological analyses that have provided a framework for identifying populations and subgroups at risk of diabetes and its complications. Although the total prevalence of diabetes reflects disease burden, incidence rates might reflect the effects of interventions among determinant factors that include, but are not limited to, political, socioeconomical, and technological changes within a population, area, or both. | | In 2019, 463 million people had diabetes worldwide, with 80% from low-income and middle-income countries. Over 70% of global deaths are due to non-communicable diseases, including diabetes, cardiovascular disease, cancer, and respiratory disease. On average, diabetes reduces life expectancy in people aged 40–60 years by 4–10 years and independently increases the risk of death from cardiovascular disease, renal disease, and cancer by 1·3–3·0 times. Diabetes is among the leading causes of non-traumatic lower extremity amputation and blindness, especially in people of working age. The co-occurrence of these morbidities severely impairs quality of life, reduces productivity, and causes major suffering. |
Cost-effectiveness of the new 2018 American College of Physicians Glycemic Control Guidance Statements Among US Adults With Type 2 Diabetes
Shao H , Laxy M , Gregg EW , Albright A , Zhang P . Value Health 2020 24 (2) 227-235 Objectives: This study aims to estimate the national impact and cost-effectiveness of the 2018 American College of Physicians (ACP) guidance statements compared to the status quo. Methods: Survey data from the 2011-2016 National Health and Nutrition Examination were used to generate a national representative sample of individuals with diagnosed type 2 diabetes in the United States. Individuals with A1c <6.5% on antidiabetic medications are recommended to deintensify their A1c level to 7.0% to 8.0% (group 1); individuals with A1c 6.5% to 8.0% and a life expectancy of <10 years are recommended to deintensify their A1c level >8.0% (group 2); and individuals with A1c >8.0% and a life expectancy of >10 years are recommended to intensify their A1c level to 7.0% to 8.0% (group 3). We used a Markov-based simulation model to evaluate the lifetime cost-effectiveness of following the ACP recommended A1c level. Results: 14.41 million (58.1%) persons with diagnosed type 2 diabetes would be affected by the new guidance statements. Treatment deintensification would lead to a saving of $363 600 per quality-adjusted life-year (QALY) lost for group 1 and a saving of $118 300 per QALY lost for group 2. Intensifying treatment for group 3 would lead to an additional cost of $44 600 per QALY gain. Nationally, the implementation of the guidance would add 3.2 million life-years and 1.1 million QALYs and reduce healthcare costs by $47.7 billion compared to the status quo. Conclusions: Implementing the new ACP guidance statements would affect a large number of persons with type 2 diabetes nationally. The new guidance is cost-effective. |
Within-trial cost-effectiveness of a structured lifestyle intervention in adults with overweight/obesity and type 2 diabetes: Results from the Action for Health in Diabetes (Look AHEAD) Study
Zhang P , Atkinson KM , Bray G , Chen H , Clark JM , Coday M , Dutton GR , Egan C , Espeland MA , Evans M , Foreyt JP , Greenway FL , Gregg EW , Hazuda HP , Hill JO , Horton ES , Hubbard VS , Huckfeldt PJ , Jackson SD , Jakicic JM , Jeffery RW , Johnson KC , Kahn SE , Killean T , Knowler WC , Korytkowski M , Lewis CE , Maruthur NM , Michaels S , Montez MG , Nathan DM , Patricio J , Peters A , Pi-Sunyer X , Pownall H , Redmon B , Rushing JT , Steinburg H , Wadden TA , Wing RR , Wyatt H , Yanovski SZ . Diabetes Care 2020 44 (1) 67-74 OBJECTIVE: To assess the cost-effectiveness (CE) of an intensive lifestyle intervention (ILI) compared with standard diabetes support and education (DSE) in adults with overweight/obesity and type 2 diabetes, as implemented in the Action for Health in Diabetes study. RESEARCH DESIGN AND METHODS: Data were from 4,827 participants during their first 9 years of the study participation from 2001 to 2012. Information on Health Utilities Index Mark 2 (HUI-2) and HUI-3, Short-Form 6D (SF-6D), and Feeling Thermometer (FT), cost of delivering the interventions, and health expenditures was collected during the study. CE was measured by incremental CE ratios (ICERs) in costs per quality-adjusted life year (QALY). Future costs and QALYs were discounted at 3% annually. Costs were in 2012 U.S. dollars. RESULTS: Over the 9 years studied, the mean cumulative intervention costs and mean cumulative health care expenditures were $11,275 and $64,453 per person for ILI and $887 and $68,174 for DSE. Thus, ILI cost $6,666 more per person than DSE. Additional QALYs gained by ILI were not statistically significant measured by the HUIs and were 0.07 and 0.15, respectively, measured by SF-6D and FT. The ICERs ranged from no health benefit with a higher cost based on HUIs to $96,458/QALY and $43,169/QALY, respectively, based on SF-6D and FT. CONCLUSIONS: Whether ILI was cost-effective over the 9-year period is unclear because different health utility measures led to different conclusions. |
The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR): Unique 1.4 M patient Electronic Health Record cohort.
Fishbein HA , Birch RJ , Mathew SM , Sawyer HL , Pulver G , Poling J , Kaelber D , Mardon R , Johnson MC , Pace W , Umbel KD , Zhang X , Siegel KR , Imperatore G , Shrestha S , Proia K , Cheng Y , McKeever Bullard K , Gregg EW , Rolka D , Pavkov ME . Healthc (Amst) 2020 8 (4) 100458 BACKGROUND: The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR) study uses a novel Electronic Health Record (EHR) data approach as a tool to assess the epidemiology of known and new risk factors for type 2 diabetes mellitus (T2DM) and study how prevention interventions affect progression to and onset of T2DM. We created an electronic cohort of 1.4 million patients having had at least 4 encounters with a healthcare organization for at least 24-months; were aged ≥18 years in 2010; and had no diabetes (i.e., T1DM or T2DM) at cohort entry or in the 12 months following entry. EHR data came from patients at nine healthcare organizations across the U.S. between January 1, 2010-December 31, 2016. RESULTS: Approximately 5.9% of the LEADR cohort (82,922 patients) developed T2DM, providing opportunities to explore longitudinal clinical care, medication use, risk factor trajectories, and diagnoses for these patients, compared with patients similarly matched prior to disease onset. CONCLUSIONS: LEADR represents one of the largest EHR databases to have repurposed EHR data to examine patients' T2DM risk. This paper is first in a series demonstrating this novel approach to studying T2DM. IMPLICATIONS: Chronic conditions that often take years to develop can be studied efficiently using EHR data in a retrospective design. LEVEL OF EVIDENCE: While much is already known about T2DM risk, this EHR's cohort's 160 M data points for 1.4 M people over six years, provides opportunities to investigate new unique risk factors and evaluate research hypotheses where results could modify public health practice for preventing T2DM. |
Cost-effectiveness of interventions to manage diabetes: Has the evidence changed since 2008
Siegel KR , Ali MK , Zhou X , Ng BP , Jawanda S , Proia K , Zhang X , Gregg EW , Albright AL , Zhang P . Diabetes Care 2020 43 (7) 1557-1592 OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS Weconducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: Cost-saving (more health benefit at a lower cost), very cost-effective (£$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not costeffective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ‡30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared withnostatin therapy for individualswithT2Dandhistoryof cardiovascular disease,4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ‡50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources. |
National- and state-level trends in nontraumatic lower-extremity amputation among U.S. Medicare beneficiaries with diabetes, 2000-2017
Harding JL , Andes LJ , Rolka DB , Imperatore G , Gregg EW , Li Y , Albright A . Diabetes Care 2020 43 (10) 2453-2459 OBJECTIVE: Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. RESEARCH DESIGN AND METHODS: To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. RESULTS: NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, P < 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P < 0.01). Trends were similar across most age, sex, and race/ethnic groups, but absolute rates were highest in the oldest age-groups, blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates. CONCLUSIONS: This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (<65 years) in the general population. Preventive foot care has been shown to reduce rates of NLEA among adults with diabetes, and the findings of the study suggest that those with diabetes-across the age spectrum-could benefit from increased attention to this strategy. |
A systematic review of trends in all-cause mortality among people with diabetes
Chen L , Islam RM , Wang J , Hird TR , Pavkov ME , Gregg EW , Salim A , Tabesh M , Koye DN , Harding JL , Sacre JW , Barr ELM , Magliano DJ , Shaw JE . Diabetologia 2020 63 (9) 1718-1735 AIMS/HYPOTHESIS: We examined all-cause mortality trends in people with diabetes and compared them with trends among people without diabetes. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for observational studies published from 1980 to 2019 reporting all-cause mortality rates across >/=2 time periods in people with diabetes. Mortality trends were examined by ethnicity, age and sex within comparable calendar periods. RESULTS: Of 30,295 abstracts screened, 35 studies were included, providing data on 69 separate ethnic-specific or sex-specific populations with diabetes since 1970. Overall, 43% (3/7), 53% (10/19) and 74% (32/43) of the populations studied had decreasing trends in all-cause mortality rates in people with diabetes in 1970-1989, 1990-1999 and 2000-2016, respectively. In 1990-1999 and 2000-2016, mortality rates declined in 75% (9/12) and 78% (28/36) of predominantly Europid populations, and in 14% (1/7) and 57% (4/7) of non-Europid populations, respectively. In 2000-2016, mortality rates declined in 33% (4/12), 65% (11/17), 88% (7/8) and 76% (16/21) of populations aged <40, 40-54, 55-69 and >/=70 years, respectively. Among the 33 populations with separate mortality data for those with and without diabetes, 60% (6/10) of the populations with diabetes in 1990-1999 and 58% (11/19) in 2000-2016 had an annual reduction in mortality rates that was similar to or greater than in those without diabetes. CONCLUSIONS/INTERPRETATION: All-cause mortality has declined in the majority of predominantly Europid populations with diabetes since 2000, and the magnitude of annual mortality reduction matched or exceeded that observed in people without diabetes in nearly 60% of populations. Patterns of diabetes mortality remain uncertain in younger age groups and non-Europid populations. REGISTRATION: PROSPERO registration ID CRD42019095974. Graphical abstract. |
Implementing lifestyle change interventions to prevent type 2 diabetes in US Medicaid programs: Cost effectiveness, and cost, health, and health equity impact
Laxy M , Zhang P , Ng BP , Shao H , Ali MK , Albright A , Gregg EW . Appl Health Econ Health Policy 2020 18 (5) 713-726 BACKGROUND: Lifestyle change interventions (LCI) for prevention of type 2 diabetes are covered by Medicare, but rarely by US Medicaid programs that constitute the largest public payer system in the USA. We estimate the long-term health and economic implications of implementing LCIs in state Medicaid programs. METHODS: We compared LCIs modeled after the intervention of the Diabetes Prevention Program versus routine care advice using a decision analytic simulation model and best available data from representative surveys, cohort studies, Medicaid claims data, and the published literature. Target population were non-disability-based adult Medicaid beneficiaries aged 19-64 years at high risk for type 2 diabetes (BMI >/=25 kg/m(2) and HbA1c >/= 5.7% or fasting plasma glucose >/= 110 mg/dl) from eight study states (Alabama, California, Connecticut, Florida, Iowa, Illinois, New York, Oklahoma) that represent around 50% of the US Medicaid population. Incremental cost-effectiveness ratios (ICERs) measured in cost per quality-adjusted life years (QALYs) gained, and population cost and health impact were modeled from a healthcare system perspective and a narrow Medicaid perspective. RESULTS: In the eight selected study states, 1.9 million or 18% of non-disability-based adult Medicaid beneficiaries would belong to the eligible high-risk target population - 66% of them Hispanics or non-Hispanic black. In the base-case analysis, the aggregated 5- and 10-year ICERs are US$226 k/QALY and US$34 k/QALY; over 25 years, the intervention dominates routine care. The 5-, 10-, and 25-year probabilities that the ICERs are below US$50 k (US$100 k)/QALY are 6% (15%), 59% (82%) and 96% (100%). From a healthcare system perspective, initial program investments of US$800 per person would be offset after 13 years and translate to US$548 of savings after 25 years. With a 20% LCI uptake in eligible beneficiaries, this would translate to upfront costs of US$300 million, prevent 260 thousand years of diabetes and save US$205 million over a 25-year time horizon. Cost savings from a narrow Medicaid perspective would be much smaller. Minorities and low-income groups would over-proportionally benefit from LCIs in Medicaid, but the impact on population health and health equity would be marginal. CONCLUSIONS: In the long-term, investments in LCIs for Medicaid beneficiaries are likely to improve health and to decrease healthcare expenditures. However, population health and health equity impact would be low and healthcare expenditure savings from a narrow Medicaid perspective would be much smaller than from a healthcare system perspective. |
Filling the public health science gaps for diabetes with natural experiments
Gregg EW , Duru OK , Shi L , Mangione CM , Siegel KR , Ramsay A , Thornton PL , Clauser S , Ali MK . Med Care 2020 58 Suppl 6 Suppl 1 S1-s3 Two decades ago, a wave of effectiveness trials demonstrating the enormous potential to reduce both diabetes and its complications gave a new stimulus to implementation research intended to find the best ways to translate, implement, and evaluate prevention through mediums of public health action.1–3 This burgeoning research portfolio largely used approaches that were limited by the available data infrastructures and study designs of the day. For example, translating primary prevention of diabetes employed pragmatic, randomized implementation studies, using the proof of concept of prevention but modifying the target population, context, dosage, or delivery mode.4 Similarly, translation studies to improve care for diabetes focused on trials or observations of the health care delivery unit and how changes in team composition and workflows, information sharing, communication, or decision support could improve real-world delivery of care.5,6 These efforts contributed to long-term reductions in diabetes complications in the United States and laid the groundwork for broader efforts to scale up primary prevention.7,8 Despite these successes, though, the impact of the diabetes epidemic is persistent and unpredictable.9 National surveillance data of diabetes complications and the cascades of care have shown that the diffusion of effective interventions is often patchwork and selective, and there has been no narrowing of the socioeconomic disparities that have characterized the diabetes epidemic.10–12 Further, there is new evidence of an increasing divide along age and socioeconomic lines.13 |
A nationwide analysis of the excess death attributable to diabetes in Brazil
Bracco PA , Gregg EW , Rolka DB , Schmidt MI , Barreto SM , Lotufo PA , Bensenor I , Chor D , Duncan BB . J Glob Health 2020 10 (1) 010401 Background: Data on mortality burden and excess deaths attributable to diabetes are sparse and frequently unreliable, particularly in low and middle-income countries. Estimates in Brazil to date have relied on death certificate data, which do not consider the multicausal nature of deaths. Our aim was to combine cohort data with national prevalence and mortality statistics to estimate the absolute number of deaths that could have been prevented if the mortality rates of people with diabetes were the same as for those without. In addition, we aimed to estimate the increase in burden when considering undiagnosed diabetes. Methods: We estimated self-reported diabetes prevalence from the National Health Survey (PNS) and overall mortality from the national mortality information system (SIM). We estimated the diabetes mortality rate ratio (rates of those with vs without diabetes) from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), an ongoing cohort study. Joining estimates from these three sources, we calculated for the population the absolute number and the fraction of deaths attributable to diabetes. We repeated our analyses considering both self-reported and unknown diabetes, the latter estimated based on single point-in-time glycemic determinations in ELSA-Brasil. Finally, we compared results with diabetes-related mortality information from death certificates. Results: In 2013, 65 581 deaths, 9.1% of all deaths between the ages of 35-80, were attributable to known diabetes. If cases of unknown diabetes were considered, this figure would rise to 14.3%. In contrast, based on death certificates only, 5.3% of all death had diabetes as the underlying cause and 10.4% as any mentioned cause. Conclusions: In this first report of diabetes mortality burden in Brazil using cohort data to estimate diabetes mortality rate ratios and the prevalence of unknown diabetes, we showed marked underestimation of the current burden, especially when unknown cases of diabetes are also considered. |
Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006-2017
Bullock A , Sheff K , Hora I , Burrows NR , Benoit SR , Saydah SH , Hardin CL , Gregg EW . BMJ Open Diabetes Res Care 2020 8 (1) INTRODUCTION: The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population. RESEARCH DESIGN AND METHODS: Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region. RESULTS: After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years. CONCLUSIONS: Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people. |
Weight change 2 years after termination of the intensive lifestyle intervention in the Look AHEAD Study
Chao AM , Wadden TA , Berkowitz RI , Blackburn G , Bolin P , Clark JM , Coday M , Curtis JM , Delahanty LM , Dutton GR , Evans M , Ewing LJ , Foreyt JP , Gay LJ , Gregg EW , Hazuda HP , Hill JO , Horton ES , Houston DK , Jakicic JM , Jeffery RW , Johnson KC , Kahn SE , Knowler WC , Kure A , Michalski KL , Montez MG , Neiberg RH , Patricio J , Peters A , Pi-Sunyer X , Pownall H , Reboussin D , Redmon B , Rejeski WJ , Steinburg H , Walker M , Williamson DA , Wing RR , Wyatt H , Yanovski SZ , Zhang P . Obesity (Silver Spring) 2020 28 (5) 893-901 OBJECTIVE: This study evaluated weight changes after cessation of the 10-year intensive lifestyle intervention (ILI) in the Look AHEAD (Action for Health in Diabetes) study. It was hypothesized that ILI participants would be more likely to gain weight during the 2-year observational period following termination of weight-loss-maintenance counseling than would participants in the diabetes support and education (DSE) control group. METHODS: Look AHEAD was a randomized controlled trial that compared the effects of ILI and DSE on cardiovascular morbidity and mortality in participants with overweight/obesity and type 2 diabetes. Look AHEAD was converted to an observational study in September 2012. RESULTS: Two years after the end of the intervention (EOI), ILI and DSE participants lost a mean (SE) of 1.2 (0.2) kg and 1.8 (0.2) kg, respectively (P = 0.003). In addition, 31% of ILI and 23.9% of DSE participants gained >/= 2% (P < 0.001) of EOI weight, whereas 36.3% and 45.9% of the respective groups lost >/= 2% of EOI weight (P = 0.001). Two years after the EOI, ILI participants reported greater use of weight-control behaviors than DSE participants. CONCLUSIONS: Both groups lost weight during the 2-year follow-up period, but more ILI than DSE participants gained >/= 2% of EOI weight. Further understanding is needed of factors that affected long-term weight change in both groups. |
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