Linda S. Geiss

Prevalence of Diabetes and Impaired Fasting Glucose in Adults in the U.S. Population National Health and Nutrition Examination Survey 1999–2002

OBJECTIVE—The purpose of this study was to examine the prevalences of diagnosed and undiagnosed diabetes, and impaired fasting glucose (IFG) in U.S. adults during 1999–2002, and compare prevalences to those in 1988–1994. RESEARCH DESIGN AND METHODS—The National Health and Nutrition Examination Survey (NHANES) contains a probability sample of adults aged ≥20 years. In the NHANES 1999–2002, 4,761 adults were classified on glycemic status using standard criteria, based on an interview for diagnosed diabetes and fasting plasma glucose measured in a subsample. RESULTS—The crude prevalence of total diabetes in 1999–2002 was 9.3% (19.3 million, 2002 U.S. population), consisting of 6.5% diagnosed and 2.8% undiagnosed. An additional 26.0% had IFG, totaling 35.3% (73.3 million) with either diabetes or IFG. The prevalence of total diabetes rose with age, reaching 21.6% for those aged ≥65 years. The prevalence of diagnosed diabetes was twice as high in non-Hispanic blacks and Mexican Americans compared with non-Hispanic whites (both P < 0.00001), whereas the prevalence of undiagnosed diabetes was similar by race/ethnicity, adjusted for age and sex. The prevalence of diagnosed diabetes was similar by sex, but prevalences of undiagnosed diabetes and IFG were significantly higher in men. The crude prevalence of diagnosed diabetes rose significantly from 5.1% in 1988–1994 to 6.5% in 1999–2002, but the crude prevalences were stable for undiagnosed diabetes (from 2.7 to 2.8%) and IFG (from 24.7 to 26.0%). Results were similar after adjustment for age and sex. CONCLUSIONS—Although the prevalence of diagnosed diabetes has increased significantly over the last decade, the prevalences of undiagnosed diabetes and IFG have remained relatively stable. Minority groups remain disproportionately affected.

Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988–1994 and 2005–2006

OBJECTIVE—We examined the prevalences of diagnosed diabetes, and undiagnosed diabetes and pre-diabetes using fasting and 2-h oral glucose tolerance test values, in the U.S. during 2005–2006. We then compared the prevalences of these conditions with those in 1988–1994. RESEARCH DESIGN AND METHODS—In 2005–2006, the National Health and Nutrition Examination Survey included a probability sample of 7,267 people aged ≥12 years. Participants were classified according to glycemic status by interview for diagnosed diabetes and by fasting and 2-h glucoses measured in subsamples. RESULTS—In 2005–2006, the crude prevalence of total diabetes in people aged ≥20 years was 12.9%, of which ∼40% was undiagnosed. In people aged ≥20 years, the crude prevalence of impaired fasting glucose was 25.7% and of impaired glucose tolerance was 13.8%, with almost 30% having either. Over 40% of individuals had diabetes or pre-diabetes. Almost one-third of the elderly had diabetes, and three-quarters had diabetes or pre-diabetes. Compared with non-Hispanic whites, age- and sex-standardized prevalence of diagnosed diabetes was approximately twice as high in non-Hispanic blacks (P < 0.0001) and Mexican Americans (P = 0.0001), whereas undiagnosed diabetes was not higher. Crude prevalence of diagnosed diabetes in people aged ≥20 years rose from 5.1% in 1988–1994 to 7.7% in 2005–2006 (P = 0.0001); this was significant after accounting for differences in age and sex, particularly in non-Hispanic blacks. Prevalences of undiagnosed diabetes and pre-diabetes were generally stable, although the proportion of total diabetes that was undiagnosed decreased in Mexican Americans. CONCLUSIONS—Over 40% of people aged ≥20 years have hyperglycemic conditions, and prevalence is higher in minorities. Diagnosed diabetes has increased over time, but other conditions have been relatively stable.

Changes in Diabetes-Related Complications in the United States, 1990–2010

BACKGROUND Preventive care for adults with diabetes has improved substantially in recent decades. We examined trends in the incidence of diabetes-related complications in the United States from 1990 through 2010. METHODS We used data from the National Health Interview Survey, the National Hospital Discharge Survey, the U.S. Renal Data System, and the U.S. National Vital Statistics System to compare the incidences of lower-extremity amputation, end-stage renal disease, acute myocardial infarction, stroke, and death from hyperglycemic crisis between 1990 and 2010, with age standardized to the U.S. population in the year 2000. RESULTS Rates of all five complications declined between 1990 and 2010, with the largest relative declines in acute myocardial infarction (-67.8%; 95% confidence interval [CI], -76.2 to -59.3) and death from hyperglycemic crisis (-64.4%; 95% CI, -68.0 to -60.9), followed by stroke and amputations, which each declined by approximately half (-52.7% and -51.4%, respectively); the smallest decline was in end-stage renal disease (-28.3%; 95% CI, -34.6 to -21.6). The greatest absolute decline was in the number of cases of acute myocardial infarction (95.6 fewer cases per 10,000 persons; 95% CI, 76.6 to 114.6), and the smallest absolute decline was in the number of deaths from hyperglycemic crisis (-2.7; 95% CI, -2.4 to -3.0). Rate reductions were larger among adults with diabetes than among adults without diabetes, leading to a reduction in the relative risk of complications associated with diabetes. When expressed as rates for the overall population, in which a change in prevalence also affects complication rates, there was a decline in rates of acute myocardial infarction and death from hyperglycemic crisis (2.7 and 0.1 fewer cases per 10,000, respectively) but not in rates of amputation, stroke, or end-stage renal disease. CONCLUSIONS Rates of diabetes-related complications have declined substantially in the past two decades, but a large burden of disease persists because of the continued increase in the prevalence of diabetes. (Funded by the Centers for Disease Control and Prevention.).

Prevalence of and Trends in Diabetes Among Adults in the United States, 1988-2012

IMPORTANCE Previous studies have shown increasing prevalence of diabetes in the United States. New US data are available to estimate prevalence of and trends in diabetes. OBJECTIVE To estimate the recent prevalence and update US trends in total diabetes, diagnosed diabetes, and undiagnosed diabetes using National Health and Nutrition Examination Survey (NHANES) data. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional surveys conducted between 1988-1994 and 1999-2012 of nationally representative samples of the civilian, noninstitutionalized US population; 2781 adults from 2011-2012 were used to estimate recent prevalence and an additional 23,634 adults from 1988-2010 were used to estimate trends. MAIN OUTCOMES AND MEASURES The prevalence of diabetes was defined using a previous diagnosis of diabetes or, if diabetes was not previously diagnosed, by (1) a hemoglobin A1c level of 6.5% or greater or a fasting plasma glucose (FPG) level of 126 mg/dL or greater (hemoglobin A1c or FPG definition) or (2) additionally including 2-hour plasma glucose (2-hour PG) level of 200 mg/dL or greater (hemoglobin A1c, FPG, or 2-hour PG definition). Prediabetes was defined as a hemoglobin A1c level of 5.7% to 6.4%, an FPG level of 100 mg/dL to 125 mg/dL, or a 2-hour PG level of 140 mg/dL to 199 mg/dL. RESULTS In the overall 2011-2012 population, the unadjusted prevalence (using the hemoglobin A1c, FPG, or 2-hour PG definitions for diabetes and prediabetes) was 14.3% (95% CI, 12.2%-16.8%) for total diabetes, 9.1% (95% CI, 7.8%-10.6%) for diagnosed diabetes, 5.2% (95% CI, 4.0%-6.9%) for undiagnosed diabetes, and 38.0% (95% CI, 34.7%-41.3%) for prediabetes; among those with diabetes, 36.4% (95% CI, 30.5%-42.7%) were undiagnosed. The unadjusted prevalence of total diabetes (using the hemoglobin A1c or FPG definition) was 12.3% (95% CI, 10.8%-14.1%); among those with diabetes, 25.2% (95% CI, 21.1%-29.8%) were undiagnosed. Compared with non-Hispanic white participants (11.3% [95% CI, 9.0%-14.1%]), the age-standardized prevalence of total diabetes (using the hemoglobin A1c, FPG, or 2-hour PG definition) was higher among non-Hispanic black participants (21.8% [95% CI, 17.7%-26.7%]; P < .001), non-Hispanic Asian participants (20.6% [95% CI, 15.0%-27.6%]; P = .007), and Hispanic participants (22.6% [95% CI, 18.4%-27.5%]; P < .001). The age-standardized percentage of cases that were undiagnosed was higher among non-Hispanic Asian participants (50.9% [95% CI, 38.3%-63.4%]; P = .004) and Hispanic participants (49.0% [95% CI, 40.8%-57.2%]; P = .02) than all other racial/ethnic groups. The age-standardized prevalence of total diabetes (using the hemoglobin A1c or FPG definition) increased from 9.8% (95% CI, 8.9%-10.6%) in 1988-1994 to 10.8% (95% CI, 9.5%-12.0%) in 2001-2002 to 12.4% (95% CI, 10.8%-14.2%) in 2011-2012 (P < .001 for trend) and increased significantly in every age group, in both sexes, in every racial/ethnic group, by all education levels, and in all poverty income ratio tertiles. CONCLUSIONS AND RELEVANCE In 2011-2012, the estimated prevalence of diabetes was 12% to 14% among US adults, depending on the criteria used, with a higher prevalence among participants who were non-Hispanic black, non-Hispanic Asian, and Hispanic. Between 1988-1994 and 2011-2012, the prevalence of diabetes increased in the overall population and in all subgroups evaluated.

The Evolving Diabetes Burden in the United States

Diabetes was first described in ancient times with the cardinal symptoms of polyuria, polydipsia, and polyphagia (1). The use of uniform diagnostic criteria provided a means to reliably track the disease and unveiled a worldwide epidemic that emerged during the second half of the 20th century and is now extending into the 21st century (2-4). This report examines the evolution of the diabetes epidemic in the United States and the burden imposed by its complications. Classification of Diabetes Mellitus There are 3 major types of diabetes (5). Type 1 diabetes usually involves children and was previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes. It develops when the bodys immune system destroys pancreatic cells, which make insulin. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes in the United States. Type 2 diabetes, previously called noninsulin-dependent diabetes mellitus or adult-onset diabetes, usually begins as insulin resistance, in which target tissues do not use insulin properly. It accounts for approximately 90% to 95% of all diagnosed cases of diabetes. Gestational diabetes is glucose intolerance diagnosed during pregnancy with return to a normal metabolic state after delivery. Other, lesser types of diabetes result from specific genetic conditions (such as maturity-onset diabetes of youth), surgery, drugs, malnutrition, infections, and other illnesses; these account for 1% to 5% of all diagnosed cases of diabetes (5). Diagnosis of Diabetes Uniform diagnostic criteria for diabetes were first recommended by the American Diabetes Association and the World Health Organization in 1979 and 1980 and were updated in the late 1990s (5, 6). Currently, when typical symptoms of diabetes are present (for example, polyuria, polydipsia, or unexplained weight loss), a casual (that is, at any time without regard to the last meal) plasma glucose level of 11.1 mmol/L (200 mg/dL) or greater confirms the diagnosis. In addition, the diagnosis can be made with a fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater or an oral glucose tolerance test with a 2-hour value of 11.0 mmol/L (200 mg/dL) or greater. A positive diagnostic test result should be followed by a repeated test on a different day to confirm the clinical diagnosis. In contrast, for epidemiologic studies, a single fasting plasma glucose or 2-hour oral glucose tolerance test measurement is used to estimate the prevalence of diabetes in a population. Tracking the Diabetes Epidemic Currently, 3 periodic national surveys track diabetes prevalence in the United States. The National Health Interview Survey and National Health and Nutrition Examination Survey (NHANES) use national population-based samples and query persons in face-to-face interviews about whether they have been told by their health care provider that they have diabetes. A third survey, the Behavioral Risk Factors Surveillance System, asks a similar question of state-based population samples during telephone interviews of residents. Unlike the other 2 surveys, NHANES includes a laboratory-based examination that measures glucose levels and identifies persons with undiagnosed diabetes. All 3 surveys provide national estimates of the prevalence of diagnosed diabetes. Only the Behavioral Risk Factors Surveillance System provides state-based estimates, and only NHANES provides estimates of undiagnosed diabetes. Prevalence In 2002, an estimated 6.3% of the U.S. population (about 18.2 million persons) had diabetes (7). Diabetes affects various sociodemographic groups unequally. According to data from the National Health Interview Survey, persons 65 years of age or older make up almost 40% of all persons with diagnosed diabetes, and the prevalence in this age group is more than 10 times that in persons younger than 45 years of age (8). Minority race and ethnic groups, including black persons, Hispanic persons, and Native Americans, are disproportionately affected; the prevalence of diagnosed diabetes is generally 2 to 4 times higher in these groups than in the majority population (Figure 1) (7, 8). Figure 1. Prevalence of diagnosed diabetes in people 20 years of age and older by age and race or ethnicity, United States, 2002. The longest running of the surveys, the National Health Interview Survey, found a 4- to 8-fold increase over the last half-century in the number of persons who received a diagnosis of diabetes (1.6 million in 1958 and 12.1 million in 2000) and the prevalence of diagnosed diabetes in the United States (0.9% in 1958 and 4.4% in 2000) (Figure 2) (8, 9). Increases occurred across all demographic categories, including sex, race or ethnicity, and age (8). Between 1990 and 2001, data from the Behavioral Risk Factors Surveillance System indicate that the largest relative increases in diagnosed diabetes occurred in persons 30 to 39 and 40 to 49 years of age (95% and 83%, respectively); increases in other age groups were 40% in persons 18 to 29 years of age, 49% in persons 50 to 59 years of age, 42% in persons 60 to 69 years of age, and 33% in persons 70 years of age or older (10, 11). Although the magnitude of the increase varied, the prevalence of diagnosed diabetes among adults increased in every state in the United States (Figure 3). Trends are also disturbing in children and adolescents, in whom type 2 diabetes is increasingly being recognized, but as yet less commonly than type 1 diabetes (12). Studies of estimates of the incidence of type 1 diabetes in the United States, which are limited by sparse data, do not find a consistent patternsome show an increase, some show a decrease, and some remain unchanged (13). Figure 2. Prevalence of diagnosed diabetes and the number of people with diagnosed diabetes in the United States, 1958 to 2000. Figure 3. Prevalence of diagnosed diabetes (including gestational diabetes) by state in the United States, 1990 to 2001. The NHANES found that diabetes is undiagnosed in approximately one third of all persons with diabetes and that this fraction has changed little over time (14). Many factors may have affected these uptrends in the prevalence of diabetes, including changes in diagnostic criteria, improved or enhanced detection, decreasing mortality, changes in demographic characteristics of the population (for example, aging), and growth in minority populations in whom the prevalence and incidence of diabetes are increasing. Diabetes Complications Morbidity Cardiovascular Disease Data on cardiovascular disease among the diabetic population are scant. However, in 2000, 37.2% of diabetic persons age 35 years and older reported receiving a diagnosis of a cardiovascular disease (8). Prevalence of ischemic heart disease among persons with diabetes was about 14 times the rate among those without diabetes in persons 18 to 44 years of age (2.7% vs. 0.2 %), 3 times as high in persons 45 to 64 years of age (14.3% vs. 4.7%), and almost twice as high in those 65 years of age or older (20% vs. 12%) (15). Other studies have shown that the absolute rates of cardiovascular disease in persons with diabetes are higher in men than in women (as in the general population), but the relative risk (comparing those with and without diabetes) is higher in women than in men (relative risk, 2 to 4 for women and 1.5 to 2.5 for men) (16, 17). Eye, Kidney, and Lower-Extremity Disease Visual impairment and blindness are major disabling complications of diabetes. Diabetic retinopathy, the leading cause of blindness (visual acuity 20/200) in persons age 20 to 64 years, accounts for 12% of all new cases of blindness and leads to 12 000 to 24 000 new cases each year in the United States (18). Considerable visual impairment (best corrected [for example, with glasses] visual acuity in either eye < 20/40) among persons with diabetes is much more common than blindness and is associated with reduced functional status. A national population-based survey based on self-reports found that 25% of all persons with diabetes had considerable visual impairment, approximately double the proportion among persons without diabetes (19). Impairment among persons with diabetes can have several causes. Some are specific to diabetes, such as macular edema and diabetic retinopathy, and others are not specific to diabetes but occur more commonly in diabetic than in nondiabetic persons. Examples of conditions not specific to diabetes are cataracts (32% vs. 20% in persons 65 to 74 years of age) and glaucoma (6.0% vs. 2.3% in persons 65 to 74 years of age) (20-23). In the United States in 2000, diabetic nephropathy accounted for more than 40% of new cases of end-stage renal disease (that is, kidney failure that requires dialysis or transplantation) (8). Persons with diabetes are the fastest-growing group of recipients of dialysis and transplantation (8). Several factors may account for the increase in incidence, including greater recognition of the etiologic role of diabetes, more use of treatments for end-stage renal disease, a true increase in the incidence of diabetes-related end-stage renal disease, or a combination of these factors. Lower-extremity disease, which includes peripheral neuropathy and peripheral arterial disease or both, results in elevated rates of lower-extremity amputations among persons with diabetes. An estimated 15% of persons with diabetes will have a diabetic foot ulcer during their lifetime (24); of these, 6% to 43% will ultimately undergo a lower-extremity amputation (25). Among persons with diabetes who have had an amputation, as many as 85% may have had a preceding foot ulcer (25). Currently, more than half of all nontraumatic lower-extremity amputations in the United States occur among people with diagnosed diabetes (8). An analysis of the 1999 to 2000 NHANES found that an estimated 8.1% of the diabetic population age 40 years or older have peripheral arterial disease (defined as an ankle to brachial artery blood pressure ra

Impact of Recent Increase in Incidence on Future Diabetes Burden: U.S., 2005–2050

In an earlier study, we had forecasted 39 million with diagnosed diabetes in 2050 in the U.S. (1,2). However, since then, national diabetes incidence increased (3) and the relative risk of death among people with diabetes declined (4,5). These changes will impact future forecasts. Incorporating these changes, we now project 48.3 million people with diagnosed diabetes in the U.S. in 2050. We also present age-, sex-, and race/ethnicity-specific forecasts, with Bayesian CIs, of the number of people with diagnosed diabetes through 2050. We used a discrete-time (1-year intervals), incidence-based Markov model with three states (no diagnosed diabetes, diagnosed diabetes, and death) (1). In each cycle of the model, projections are developed for 808 population subgroups defined by age, sex, and race/ethnicity. We estimated the age-, sex-, and race/ethnicity-specific prevalence and incidence of diabetes from the U.S. National Health Interview Survey (6–9) and modeled data for 1984–2004 to improve the precision of 2004 estimates. Models were fit using Bayesian methods with improper flat priors applied to logistic regression. We assessed adequacy of model fit using posterior predictive P values (10). Estimated prevalence of diagnosed diabetes for 2000 and 2004 were 4.35 and 5.37%, respectively, and estimated incidence were 0.42 and 0.53% per year, respectively. The age-, sex-, and race/ethnicity-specific 2004 prevalence estimates were combined with U.S. population data for 2004 (11 …

Prevalence of Diabetes and High Risk for Diabetes Using A1C Criteria in the U.S. Population in 1988–2006

OBJECTIVE We examined prevalences of previously diagnosed diabetes and undiagnosed diabetes and high risk for diabetes using recently suggested A1C criteria in the U.S. during 2003–2006. We compared these prevalences to those in earlier surveys and those using glucose criteria. RESEARCH DESIGN AND METHODS In 2003–2006, the National Health and Nutrition Examination Survey included a probability sample of 14,611 individuals aged ≥12 years. Participants were classified on glycemic status by interview for diagnosed diabetes and by A1C, fasting, and 2-h glucose challenge values measured in subsamples. RESULTS Using A1C criteria, the crude prevalence of total diabetes in adults aged ≥20 years was 9.6% (20.4 million), of which 19.0% was undiagnosed (7.8% diagnosed, 1.8% undiagnosed using A1C ≥6.5%). Another 3.5% of adults (7.4 million) were at high risk for diabetes (A1C 6.0 to <6.5%). Prevalences were disproportionately high in the elderly. Age-/sex-standardized prevalence was more than two times higher in non-Hispanic blacks and Mexican Americans versus non-Hispanic whites for diagnosed, undiagnosed, and total diabetes (P < 0.003); standardized prevalence at high risk for diabetes was more than two times higher in non-Hispanic blacks versus non-Hispanic whites and Mexican Americans (P < 0.00001). Since 1988–1994, diagnosed diabetes generally increased, while the percent of diabetes that was undiagnosed and the percent at high risk of diabetes generally decreased. Using A1C criteria, prevalences of undiagnosed diabetes and high risk of diabetes were one-third that and one-tenth that, respectively, using glucose criteria. CONCLUSIONS Although A1C detects much lower prevalences than glucose criteria, hyperglycemic conditions remain high in the U.S., and elderly and minority groups are disproportionately affected.

Prevalence of Diabetic Retinopathy in the United States, 2005-2008

CONTEXT The prevalence of diabetes in the United States has increased. People with diabetes are at risk for diabetic retinopathy. No recent national population-based estimate of the prevalence and severity of diabetic retinopathy exists. OBJECTIVES To describe the prevalence and risk factors of diabetic retinopathy among US adults with diabetes aged 40 years and older. DESIGN, SETTING, AND PARTICIPANTS Analysis of a cross-sectional, nationally representative sample of the National Health and Nutrition Examination Survey 2005-2008 (N = 1006). Diabetes was defined as a self-report of a previous diagnosis of the disease (excluding gestational diabetes mellitus) or glycated hemoglobin A(1c) of 6.5% or greater. Two fundus photographs were taken of each eye with a digital nonmydriatic camera and were graded using the Airlie House classification scheme and the Early Treatment Diabetic Retinopathy Study severity scale. Prevalence estimates were weighted to represent the civilian, noninstitutionalized US population aged 40 years and older. MAIN OUTCOME MEASUREMENTS Diabetic retinopathy and vision-threatening diabetic retinopathy. RESULTS The estimated prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was 28.5% (95% confidence interval [CI], 24.9%-32.5%) and 4.4% (95% CI, 3.5%-5.7%) among US adults with diabetes, respectively. Diabetic retinopathy was slightly more prevalent among men than women with diabetes (31.6%; 95% CI, 26.8%-36.8%; vs 25.7%; 95% CI, 21.7%-30.1%; P = .04). Non-Hispanic black individuals had a higher crude prevalence than non-Hispanic white individuals of diabetic retinopathy (38.8%; 95% CI, 31.9%-46.1%; vs 26.4%; 95% CI, 21.4%-32.2%; P = .01) and vision-threatening diabetic retinopathy (9.3%; 95% CI, 5.9%-14.4%; vs 3.2%; 95% CI, 2.0%-5.1%; P = .01). Male sex was independently associated with the presence of diabetic retinopathy (odds ratio [OR], 2.07; 95% CI, 1.39-3.10), as well as higher hemoglobin A(1c) level (OR, 1.45; 95% CI, 1.20-1.75), longer duration of diabetes (OR, 1.06 per year duration; 95% CI, 1.03-1.10), insulin use (OR, 3.23; 95% CI, 1.99-5.26), and higher systolic blood pressure (OR, 1.03 per mm Hg; 95% CI, 1.02-1.03). CONCLUSION In a nationally representative sample of US adults with diabetes aged 40 years and older, the prevalence of diabetic retinopathy and vision-threatening diabetic retinopathy was high, especially among Non-Hispanic black individuals.

Prevalence and Incidence Trends for Diagnosed Diabetes Among Adults Aged 20 to 79 Years, United States, 1980-2012

IMPORTANCE Although the prevalence and incidence of diabetes have increased in the United States in recent decades, no studies have systematically examined long-term, national trends in the prevalence and incidence of diagnosed diabetes. OBJECTIVE To examine long-term trends in the prevalence and incidence of diagnosed diabetes to determine whether there have been periods of acceleration or deceleration in rates. DESIGN, SETTING, AND PARTICIPANTS We analyzed 1980-2012 data for 664,969 adults aged 20 to 79 years from the National Health Interview Survey (NHIS) to estimate incidence and prevalence rates for the overall civilian, noninstitutionalized, US population and by demographic subgroups (age group, sex, race/ethnicity, and educational level). MAIN OUTCOMES AND MEASURES The annual percentage change (APC) in rates of the prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined). RESULTS The APC for age-adjusted prevalence and incidence of diagnosed diabetes did not change significantly during the 1980s (for prevalence, 0.2% [95% CI, -0.9% to 1.4%], P = .69; for incidence, -0.1% [95% CI, -2.5% to 2.4%], P = .93), but each increased sharply during 1990-2008 (for prevalence, 4.5% [95% CI, 4.1% to 4.9%], P < .001; for incidence, 4.7% [95% CI, 3.8% to 5.6%], P < .001) before leveling off with no significant change during 2008-2012 (for prevalence, 0.6% [95% CI, -1.9% to 3.0%], P = .64; for incidence, -5.4% [95% CI, -11.3% to 0.9%], P = .09). The prevalence per 100 persons was 3.5 (95% CI, 3.2 to 3.9) in 1990, 7.9 (95% CI, 7.4 to 8.3) in 2008, and 8.3 (95% CI, 7.9 to 8.7) in 2012. The incidence per 1000 persons was 3.2 (95% CI, 2.2 to 4.1) in 1990, 8.8 (95% CI, 7.4 to 10.3) in 2008, and 7.1 (95% CI, 6.1 to 8.2) in 2012. Trends in many demographic subpopulations were similar to these overall trends. However, incidence rates among non-Hispanic black and Hispanic adults continued to increase (for interaction, P = .03 for non-Hispanic black adults and P = .01 for Hispanic adults) at rates significantly greater than for non-Hispanic white adults. In addition, the rate of increase in prevalence was higher for adults who had a high school education or less compared with those who had more than a high school education (for interaction, P = .006 for <high school and P < .001 for high school). CONCLUSIONS AND RELEVANCE Analyses of nationally representative data from 1980 to 2012 suggest a doubling of the incidence and prevalence of diabetes during 1990-2008, and a plateauing between 2008 and 2012. However, there appear to be continued increases in the prevalence or incidence of diabetes among subgroups, including non-Hispanic black and Hispanic subpopulations and those with a high school education or less.

Changes in diabetes-related complications in the United States.

n engl j med 371;3 nejm.org july 17, 2014 284 was most likely to have been infrequent. Finally, for the study to be methodologically rigorous, stratification of the patients according to the presence or absence of intraabdominal hypertension would have been mandatory at inclusion, with a risk of an underpowered subsequent analysis. We agree with Kimmoun et al. that our results are limited with regard to the vasopressors used; we used norepinephrine. Targeting a high mean blood pressure with the use of epinephrine or dopamine might have caused an increase in the incidence of adverse effects such as newonset arrhythmia1 or lactic acidosis.2 In contrast, one might speculate that infusing vasopressin to increase the mean blood pressure might have been associated with opposite findings: in patients with catecholamine-resistant vasodilatory shock, vasopressin significantly decreased the incidence of a new onset of atrial fibrillation,3 and a post hoc analysis of the Vasopressin and Septic Shock Trial showed a reduced progression to renal failure in vasopressin-treated patients at risk for kidney injury.4 Pierre Asfar, M.D., Ph.D.