Fewer US adults with diabetes achieving glycemic, BP targets since 2010
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The percentage of U.S. adults with diabetes meeting glycemic and blood pressure control targets declined from 2010 to 2018 after steadily increasing from 1999 to 2010, according to data published in The New England Journal of Medicine.
Elizabeth Selvin, PhD, MPH, professor in the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health, said the findings show action is needed to improve glycemic control in people with diabetes to reverse recent trends.
“This is a wake-up call,” Selvin told Healio. “We are seeing a worsening of diabetes control at the national level. We are seeing a reversal of previous progress. Millions of Americans with diabetes are now at higher risk for complications.”
Selvin and colleagues conducted a cross-sectional analysis of 6,653 participants in the National Health and Nutrition Examination Survey from 1999 to 2018 aged 20 years or older who were not pregnant and reported being diagnosed with diabetes. Glycemic control was defined as having an HbA1c of less than 7%. BP control was defined as having a mean systolic and diastolic BP of less than 140/90 mm Hg. Lipid control was defined as having a non-HDL cholesterol level of less than 130 mg/dL and an LDL cholesterol level of less than 100 mg/dL. Participants self-reported age, sex, race and ethnicity, education, family income, health insurance status, smoking status and age at diabetes diagnosis. Medication use during the past 30 days was ascertained by reviewing pill bottles. Survey years were pooled into 4-year intervals: 1999 to 2002, 2003 to 2006, 2007 to 2010, 2011 to 2014 and 2015 to 2018.
Glycemic, BP control declining since 2010
Trends for glycemic, BP and lipid control were all nonlinear. The percentage of participants achieving glycemic targets increased from 44% in 1999-2002 to 57.4% in 2007-2010 before declining to 50.5% in 2015-2018. Similarly, BP control increased from 64% in 1999-2002 to a peak of 74.2% in 2011-2014 before dropping to 70.4% in 2015-2018. The percentage of adults achieving lipid targets increased from 25.3% in 1999-2002 to 52.3% in 2007-2010 and 55.7% in 2015-2018. The proportion of participants achieving glycemic, BP and lipid control more than doubled from 9% in 1999-2002 to 24.9% in 2007-2010 before plateauing at 22.2% in 2015-2018.
“There is evidence from national data that we are seeing a resurgence of diabetes complications,” Selvin said. “The backing off on glucose and blood pressure control may be part of the reason we are seeing increases in some complications of diabetes. These findings are concerning and suggest we need to do a better job with controlling diabetes.”
Medication use levels off after 2010
The use of glucose-lowering medication increased by 8.6 percentage points from 1999-2002 to 2007-2010 before leveling off. There was an increase in the use of metformin, insulin and newer agents and a decrease in sulfonylureas and thiazolidinediones during the study period. The use of BP-lowering medications increased 15.9 percentage points from 1999-2002 to 2007-2010 before leveling off. The use of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers increased during the study while the use of diuretics and calcium channel blockers was stable. Statin use increased 27.6 percentage points from 1999-2002 to 2011-2014 before leveling off.
The percentage of adults using combination glucose-lowering therapy increased until 2007-2010 in the study cohort and among those with poor glycemic control. The use of combination BP-lowering therapy declined after 2007-2010 both overall and among those with high BP. Younger adults, Mexican Americans and people without health insurance were less likely to receive treatment if they were unable to meet glycemic, BP or lipid targets. Non-Hispanic Black adults were less likely to receive combination therapy when they did not reach glycemic targets, but more likely to receive combination therapy when they missed BP targets, compared with white adults.
“Younger persons and other high-risk patients with diabetes may especially benefit from enhanced medication access and uptake,” the researchers wrote. “We found that younger adults, Mexican Americans and persons without health insurance were more likely to be untreated when risk-factor targets were not achieved. These gaps are especially troubling given that rates of diabetes-related complications are higher in racial or ethnic minorities and uninsured populations and that type 2 diabetes that develops during young adulthood has a more aggressive clinical course than diabetes that occurs in later life.”
For more information:
Elizabeth Selvin, PhD, MPH, can be reached at eselvin@jhu.edu.
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