Improvements in risk factor control among persons with diabetes in the United States: Evidence and implications for remaining life expectancy
Introduction
Good control of hemoglobin A1c (A1c), blood pressure, and lipid levels have all been well established as crucial to the reduction of risk for complications of diabetes [1], [2]. Accordingly, public health programs promote the ABCs (A1c, blood pressure, cholesterol) as a key component of clinical and public health interventions for diabetes in the United States [3]. Therefore, tracking national trends in A1c, blood pressure, and cholesterol is a priority.
Previous analyses have demonstrated reductions in blood pressure and cholesterol levels in persons with diabetes in the United States during the past 30 years [4]. Until recently, there was little evidence from nationally representative data that glycemic control had improved. Studies using National Health and Nutrition Examination Survey (NHANES) data found that A1c did not improve significantly between 1988–1994 and 1999–2002 [5], [6], [7]. Moreover, one study found no change in blood pressure levels between 1988–1994 and 1998–2002 [5].
Two studies using more recent NHANES data showed that A1c levels improved by about 0.5 percentage points between 1999–2000 and 2003–2004 [8], [9]. However, these studies did not examine whether blood pressure and cholesterol levels also changed during the period among persons with diabetes. Furthermore, no study has estimated the potential population-level impact of these changes on long-term health outcomes, including life expectancy and diabetes-related complications.
Here, we examine whether A1c, blood pressure, and cholesterol values changed for persons with diagnosed diabetes between NHANES III (1988–1994) and the latest NHANES wave (2005–2006). We then use a diabetes progression model to project the impact of risk factor changes on life expectancy and diabetes-related complications for U.S. adults newly diagnosed with diabetes.
Section snippets
Changes in risk factor control
We analyzed data from NHANES to assess temporal changes in selected risk factors. NHANES is a nationally representative, population-based survey designed to collect information on the health and nutrition of U.S. civilians. Participants respond to a household interview, and most complete clinical examinations. Additional details on the surveys are available elsewhere [10].
We estimated changes in hemoglobin A1c (measuring glycemic control), systolic (SBP) and diastolic (DBP) blood pressure
Results
Table 1 shows the (unweighted) number of observations used in the A1c, blood pressure, and cholesterol regressions by NHANES wave. Table 2 presents the explanatory variables for the baseline (NHANES III) and final (2005–2006) waves for the A1c regression. Fig. 1 shows unadjusted changes in A1c, blood pressure, and cholesterol across NHANES waves beginning with NHANES III. Table 3 shows 2005–2006 risk factor control relative to baseline after adjusting for other explanatory variables in the
Discussion
Our analysis indicates that risk factor control improved for persons with diabetes during the period between NHANES III (1988–1994) and NHANES 2005–2006. For A1c, most of the improvement occurred after 2000 or 2002. The source of the recent improvement in glycemic control is unclear. Possible sources include strengthened clinical guidelines, improved diabetes disease management programs, improved delivery of diabetes care services in the health system, enhanced public health education, and the
Conflict of interest
We declare that we have no conflict of interest.
Acknowledgments
This research was supported by funding (Contract # 200-2002-00776) from CDC, which supported the study's design and implementation. The findings and conclusions in this article are solely those of the authors and do not necessarily reflect the official position of CDC. Steven Couper provided research assistance.
References (29)
- et al.
Type 2 diabetes: principles of pathogenesis and therapy
Lancet
(2005) - et al.
Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64)
Kidney Int.
(2003) Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14 randomised trials of statins: a meta-analysis
Lancet
(2008)Standards of medical care in diabetes—2008
Diabetes Care
(2008)- National Diabetes Education Program, 4 Steps to Control your Diabetes for Life. NIH Publication 06-5492, October...
- et al.
Thirty-year trends in cardiovascular risk factor levels among US adults with diabetes: National Health and Nutrition Examination Surveys, 1971–2000
Am. J. Epidemiol.
(2004) - et al.
Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes
JAMA
(2004) - et al.
Glycemic control from 1988 to 2000 among US adults with diagnosed type II diabetes
Diabetes Care
(2004) - et al.
Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002
Ann. Intern. Med.
(2006) - et al.
Is glycemic control improving in U.S. adults?
Diabetes Care
(2008)
Trends in A1c concentrations among US adults with diagnosed diabetes from 1999 to 2004
Diabetes Care
Stata Statistical Software, Release 9
Cited by (27)
Trends in lipid profiles and control of LDL-C among adults with diabetes in the United States: An analysis of NHANES 2007–2018
2023, Nutrition, Metabolism and Cardiovascular DiseasesTemporal trends of patients with acute coronary syndrome and multi-vessel coronary artery disease - from the ACSIS registry
2020, International Journal of CardiologyCitation Excerpt :Evidence supporting MV-PCI in NSTE-ACS exist as well yet these are less substantiated [49]. In consistence with previously reported trends [23–28,50] we found that discharge with guideline recommended antithrombotic and lipid lowering pharmacotherapy has increased throughout the investigation period while the proportion of patients discharged on beta-blockers (BB) and angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB) remained constant. With partial agreement with our findings, Makam et al. [50] found an increase in all groups of medications in 11 Massachusetts hospitals, United States, between the years 2001–2011.
Ethnical disparities in temporal trends of acute myocardial infarction (AMI) throughout a decade in Israel. Soroka acute myocardial infarction (SAMI-II) project
2016, International Journal of CardiologyCitation Excerpt :The persistent decrease in an AMI hospitalization rate is in coherence with reports from other parts of the world [8,11,26] and probably reflects the primary and secondary prevention efforts worldwide and in our country. Increased adherence with treatment guidelines [27], improved and earlier management of risk factors overtime [28–31], increased use of cardioprotective medications (e.g. aspirin, beta-blockers, angiotensin-converting-enzyme inhibitor and statins) [26,32,33] and revascularization [27,33–35] have been reported. In the current study we found that the decline in the adjusted AMI incidence was more prominent and steeper among Bedouins throughout the study period.
Temporal trends in acute myocardial infarction: What about survival of hospital survivors? Disparities between STEMI & NSTEMI remain. Soroka acute myocardial infarction II (SAMI-II) project
2016, International Journal of CardiologyCitation Excerpt :These findings are consistent with the findings of previous reports [9,11]. The latter decline could possibly result from increased adherence with treatment guidelines [13,14], improved and earlier management of risk factors overtime [15–18], increased use of cardioprotective medications (e.g. aspirin, beta-blockers and statins) [11,19,20] and increased use of interventions (e.g. PCI and CABG) and particularly the new-generation of DES [21] that reduce the occurrence or the severity of subsequent re-infarctions [13,20,22,23]. The early increase in the incidence of NSTEMI with stabilization thereafter could be attributable, at least partially, to the increased sensitivity and more frequent use of troponin analyses consistent with previous reports [11,24–26].
Primary and Secondary Prevention Strategy for Cardiovascular Disease in Diabetes Mellitus
2011, Cardiology ClinicsCitation Excerpt :So the question arises as to how well this is being incorporated in clinical practice. A recent study reported on the improving trends seen in the management of diabetes mellitus and attendant CV disease based on NHANES data.77 Changes in HbA1c, blood pressure, and total cholesterol were estimated between 1988 and 1994 and between 2005 and 2006 using regression analysis and data from the NHANES.