Study finds ‘marked improvements’ in diabetes management from 1999 to 2016

The proportion of U.S. adults with diabetes who met recommendations for blood pressure, low-density lipoprotein (LDL) cholesterol levels, medication usage, physical activity, and preventive practices increased substantially in recent years, a study found.

The study evaluated trends in diabetes management among nonpregnant U.S. adults from 1999 to 2016 using three nationally representative, serial, cross-sectional surveys: the National Health and Nutrition Examination Survey (n=5,800), the National Health Interview Survey (n=48,519), and the Behavioral Risk Factor Surveillance System (n=741,497). The main measures were the American Diabetes Association's general recommendations for glycemic and cardiovascular risk factor control, medication usage, physical activity, preventive practices, and dietary intake. Results were published online on Jan. 2 by the Journal of General Internal Medicine.

From 1999 to 2016, the proportion of U.S. adults with diabetes who attained glycemic control, defined as an HbA1c level less than 7.0%, followed a quadratic trend (49.6% in 1999-2004 to 58.6% in 2005-2010 to 55.8% in 2011-2016; P<0.05 for trend). During the study period, there was a consistent increase in the proportion of those who met the recommended targets of below 140/90 mm Hg for blood pressure (66.8% to 73.4%; P=0.002 for trend) and below 100 mg/dL (2.6 mmol/L) for LDL cholesterol (37.5% to 56.3%, P=0.02 for trend). The proportion who attained glycemic, blood pressure, and lipid control also followed a quadratic trend (13.3% in 1999-2004 to 24.8% in 2005-2010 to 20.2% in 2011-2016; P<0.05 for trend).

During the study period, the use of antidiabetic, antihypertensive, and statin medications among eligible patients increased by 8.6, 5.0, and 24.0 percentage points, respectively (P<0.05 for trends). The attainment of physical activity goals also grew during the study period. While aerobic inactivity declined by 7.1 percentage points, adherence to recommendations on aerobic activity (≥150 min/wk) and resistance training (≥2 times/wk) grew by 3.4 and 3.2 percentage points, respectively (P<0.05 for trends). Engagement in recommended preventive practices consistently increased for six out of eight outcomes (annual dental examination, annual foot examination, annual vaccination for influenza, vaccination for pneumonia, vaccination for hepatitis B, and testing HbA1c levels at least twice per year). The two exceptions were eye examination, which was high but remained unchanged, and diabetes education, which increased slightly and then declined slightly. Conversely, trends in the attainment of dietary intake targets were unchanged or declined during the study period. Adherence to recommendations on intake of saturated fat (<10% of total daily calories) and sodium (<2,300 mg/d) fell by 6.5 and 5.2 percentage points, respectively (P<0.05 for trends).

Limitations of the study include its focus on standard, rather than individualized, treatment goals and the fact that dietary, physical activity, and preventive practices were based on self-reported data, among other limitations. In addition, guideline-recommended therapeutic targets changed during the study period, potentially impacting the comparability of adherence over time.

“In conclusion, there were marked improvements … across a broad range of diabetes management from 1999 to 2016 among US adults,” the study author wrote. “Nonetheless, some gains in glycemic control were lost, and the attainment of dietary targets did not improve over time. Therefore, while much progress has been made, there are still critical gaps in diabetes care.”