Clinical Pearls & Morning Reports

Posted by Carla Rothaus

Published June 9, 2021


What trends in the treatment of diabetes between 1999 and 2018 were noted in the analysis by Fang et al.?

Fang et al. conducted a study to update national trends in risk-factor control in U.S. adults with diabetes, assess trends in treatment, and identify population subgroups most likely to have untreated risk factors. To accomplish these aims, they analyzed nearly two decades of data (1999 to 2018) from the National Health and Nutrition Examination Survey (NHANES). Read the NEJM Special Article here.

Clinical Pearls

Q: What is the NHANES?

A: The NHANES is a series of nationally representative, cross-sectional studies designed to monitor the health of the U.S. population. Participants are selected from the U.S. noninstitutionalized, civilian population with the use of a complex, stratified, multistage probability-cluster sampling design for in-home interviews and visits to a mobile examination center. This study included all participants in the NHANES from 1999 through 2018 who were nonpregnant and 20 years of age or older and who reported having ever received a diagnosis of diabetes from a physician (other than during pregnancy) (6653 participants).

Q: Summarize the findings of the analysis of Fang et al. regarding risk-factor control for patients with diabetes from 1999 to 2018.

A: After large improvements from 1999 to 2010, diabetes control stalled and worsened in the United States. In line with recent research, updated estimates in the study showed that glycemic control declined after 2010, while lipid control leveled off. In addition, the study showed a decrease in blood-pressure control that emerged after 2014, paralleling a recent decline in blood pressure control in the general U.S. population.

Morning Report Questions 

Q: What trends in the treatment of diabetes between 1999 and 2018 were noted in the analysis by Fang et al.?

A: The use of any glucose-lowering medication increased by 8.6 percentage points (95% CI, 3.2 to 13.8) from 1999–2002 to 2007–2010 and then leveled off. From 1999 to 2018, there was an increase in the use of metformin, insulin, and newer agents (e.g., sodium–glucose cotransporter 2 inhibitors) and a decrease in the use of sulfonylureas and thiazolidinediones. The use of any blood-pressure–lowering medication rose 15.9 percentage points (95% CI, 10.1 to 21.8) from 1999–2002 to 2007–2010 and then stabilized. The use of diuretics and calcium-channel blockers remained stable from 1999 to 2018, whereas the use of beta-blockers and angiotensin-converting–enzyme inhibitors or angiotensin-receptor blockers rose. Statin use increased by 27.6 percentage points (95% CI, 21.5 to 33.6) from 1999–2002 to 2011–2014 before leveling off.

Q: What subgroups of the population were found to be more likely to be untreated when risk-factor targets were not achieved?

A: Fang et al. found that younger adults, Mexican Americans, and persons without health insurance were more likely to be untreated (monotherapy or combination therapy) 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.

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