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06-09-2021 | Glycemic control | News

Stalling diabetes control could spell oncoming trouble for USA

Author: Eleanor McDermid


medwireNews: NHANES data indicate that glycemic and blood pressure control in people with diabetes in the USA has deteriorated over recent years, and lipid control has plateaued.

The researchers believe the results “may portend a possible population-level increase in diabetes-related illness moving forward,” and cite research suggesting this may already be under way.

As reported in The New England Journal of Medicine, Elizabeth Selvin (Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA) and colleagues looked at data from adult participants of NHANES surveys from 1999 through 2018 (between 983 and 1718 participants).

They found that control of glycated hemoglobin (HbA1c), blood pressure, and blood lipids improved during the first decade, but then declined after 2010 in the case of the first two measures, or leveled off in the case of lipids.

For example, 44.0% of participants achieved HbA1c below 7% (53 mmol/mol) in 1999–2002, rising to 57.4% in 2007–2010, but then declining again to 50.5% in 2015–2018. The corresponding values for people achieving blood pressure below 140/90 mmHg were 64.0%, 74.2%, and 70.4%.

In line with these trends, the use of diabetes medications rose by 8.6 percentage points until the 2007–2010 period, but then leveled off, although this obscured some shifts such as a rise in use of the newer medication classes and declining use of sulfonylureas and thiazolidinediones. The use of combination glucose-lowering therapies for people not reaching glycemic targets also plateaued after 2010.

The use of blood pressure-lowering medications rose by 15.9 percentage points, before stabilizing after 2010, whereas statin use rose by 27.6 percentage points and did not level off until after 2014.

Selvin and collaborators note that three major trials – ADVANCE, ACCORD, and the VADT – cast doubt on the risk–benefit balance of intensive glucose treatment, and ACCORD also challenged the benefits of intensive blood pressure control.

The decline in glycemic and blood pressure control began shortly after the publication of these trials, they say, suggesting “a shift toward more conservative treatment in the community.”

“The national declines in glycemic and blood-pressure control and the plateauing of lipid control after 2010 have major public health implications,” write the researchers.

They add: “These trends highlight the urgent need for interventions and strategies that safely resume progress in diabetes risk-factor control.”

The study also highlighted that younger adults, certain ethnic groups, and uninsured people were at increased risk for receiving suboptimal treatment.

“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,” say Selvin and team.

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2021 Springer Healthcare Ltd, part of the Springer Nature Group

N Engl J Med 2021; 384: 2219–2228


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