Abstract
Objective:
We analyzed trends in obesity prevalence, and trends in control of cardiometabolic risk factors among National Health and Nutrition Examination Survey participants with diabetes from 1999 through 2020.
Methods:
Adults who were 20 years or older and reported having received a diagnosis of diabetes from a physician were included.
Results:
The prevalence of overall obesity, obesity class II, and obesity class III increased from 46.9%, 14.1% and 10.3% in 1999-2002 to 58.1%, 16.6%, and 14.8% in 2015-2020, respectively. The prevalence of participants who achieved glycemic control (HbA1c<7%) increased from 42.5% in 1999-2002 to 51.8% in 2007-2010, then decreased to 48.0% in 2015-2020. The prevalence of participants who achieved blood pressure control (<140/90 mmHg) or achieved non-HDL cholesterol control (<130 mg/dL) increased throughout the study periods. The prevalence of participants who met all three risk factor goals increased from 8.3% in 1999-2002 to 21.2% in 2011-2014, and then decreased to 18.5 in 2015-2020. Participants with obesity showed worsening glycemic control and lipid control than participants with normal weight.
Conclusions:
There were increasing trends in prevalence of obesity, blood pressure control and lipid control from 1999-2002 to 2015-2020. Obese participants showed worsening glycemic control and lipid control than normal weight participants.
Keywords: Obesity prevalence trends, US NHANES surveys, US adults with diabetes, Cardiometabolic risk factor trends, Impact of rising obesity rates
Introduction
Diabetes is one of the fastest growing public health problems in the U.S. (1). The total number of people with diabetes is projected to increase from 32.2 million in 2021 to 36.3 million in 2045 (2). Diabetes is the seventh leading cause of death in the U.S. (3, 4) and a leading cause of cardiovascular disease (CVD), blindness, kidney disease, and lower extremity amputations (5-10). The total estimated cost for diabetes in 2017 was $359 billion in the U.S. (11). To prevent CVD and other complications, the American Diabetes Association (ADA) recommends that adults with type 2 diabetes maintain levels of HbA1c <7.0%, blood pressure <140/90 mmHg, and low-density lipoprotein (LDL) cholesterol <100 mg/dL (12-14).
Obesity prevalence is also rapidly increasing in the U.S. The age-adjusted prevalence of obesity increased from 30.5% to 42.4%, in the NHANES surveys conducted from 1999–2000 through 2017–2018 (15). Even more concerning is the increase in the prevalence of severe obesity (body mass index [BMI] ≥ 40 kg/m2) from 4.7% to 9.2% in this same time period (15). Obesity is the leading driver for the development of type 2 diabetes (16-19), and more than 50% patients with type 2 diabetes have obesity in the U.S. (20-23). Although the prevalence of obesity among U.S. adults has increased during the last twenty years, very few studies have assessed trends in prevalence of overweight and obesity among patients with diabetes in the National Health and Nutrition Examination Survey (NHANES) (20). Moreover, we found no studies that looked at the more severe degrees of obesity in patients with diabetes and the relationship between classes of obesity and control of cardiometabolic risk factors. The aim the present study was to analyze national trends in obesity prevalence, and also assess trends in control of cardiometabolic risk factors among patients with diabetes from 1999 through 2020.
Methods
Participants
The NHANES program of the National Center for Health Statistics, Centers for Disease Control and Prevention includes a series of cross-sectional nationally representative health examination surveys (24). In each survey cycle, a nationally representative sample of the US non-institutionalized civilian population is selected using a complex, stratified, multistage probability cluster sampling design. We used data from the NHANES for the years 1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, 2009-2010, 2011-2012, 2013-2014, 2015-2016, and 2017-2020. To minimize the effects of small sample size, we pooled survey years into 4-year intervals (1999 through 2002, 2003 through 2006, 2007 through 2010, 2011 through 2014, and 2015 through 2020). The 2015-2020 dataset consisted of data from 2015 up until the COVID-19 pandemic in March 2020 that consequently ended data collection for the 2019-2020 cycle. The response rate was 76.0% in 1999-2000 and declined to 46.9% during 2017-2020.
The present study included all participants who were nonpregnant and 20 years of age or older and who reported a diagnosis of diabetes from a physician. The final sample comprised 6605 adults after excluding participants with incomplete data on body mass index (BMI) and other any variables required for this analysis. The Pennington Biomedical Research Center institutional review board reviewed this study and determined that the deidentified data of NHANES was exempt from need for IRB approval.
Measurements
Self-administered questionnaires were completed by participants. The questionnaire included questions on participants’ age, sex (male or female), ethnicity (non-Hispanic white, Mexican-American, non-Hispanic black, or other), education level (high school or less, some college, or college degree), and smoking status (never smoker, past smoker, or current smoker). Participants reported if they had taken prescription medication in the past 30 days. The reported medications were divided into three main categories: glucose-lowering, blood pressure-lowering, and lipid-lowering.
For all surveys, weight, height, and blood pressure were measured in a mobile examination center using standardized techniques and equipment. BMI was calculated as weight in kilograms divided by height in meters squared. The participants were classified in five BMI categories: <25.0 kg/m2 (normal weight), 25.0-29.9 kg/m2 (overweight), 30-34.9 kg/m2 (obese class I), 35-39.9 kg/m2 (obese class II), and ≥40 kg/m2 (obese class III).(25) The participants’ waist circumferences were also measured and recorded to determine if they were categorized as central obesity (waist circumference ≥102 cm in men, or ≥88 cm in women).(25) HbA1c was measured with the use of high-performance liquid chromatograph method. Serum total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides were measured enzymatically. Non-HDL cholesterol was calculated as total measured cholesterol minus HDL cholesterol.
Modified ADA goals for cardiovascular disease risk factor control were defined as: HbA1c <7.0%, blood pressure <140/90 mmHg, and non-HDL cholesterol <130 mg/dL (because partial data on LDL cholesterol was available for the sample population) (12-14).
Statistical analysis
One-way ANOVA and chi-square tests were used to compare the baseline mean levels of continuous variables and the prevalence of categorical variables across 5 discrete 4-year cycles of the continuous NHANES (1999-2002, 2003-2006, 2007-2010, 2011-2014, and 2015-2020). Temporal trends across 5 discrete 4-year cycles in mean values of HbA1c, diastolic or systolic blood pressure and non-HDL cholesterol by total samples or by different BMI categories (normal weight, overweight, obesity I, obesity II, and obesity III) and waist circumference categories (normal weight and central obesity) were tested by use of the General Linear Model after adjustment for age, sex and race. Differences in mean values of HbA1c, diastolic or systolic blood pressure and non-HDL cholesterol based on different BMI categories by each 4-year cycle were also tested by use of the General Linear Model after adjustment for age, sex and race. We estimated prevalence of risk factor control and medication use and adjusted for age, sex and race. Linear trends across 5 discrete 4-year cycles or based on different BMI categories in whole samples or subgroups analyses were tested using a General Linear Model or Logistic Regression. Statistical significance was P <0.05. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA) and SAS version 9.4 (Cary, North Carolina, USA), and used recommended sample weight that account for complex sample design and survey nonresponse.
Results
Table 1 shows baseline characteristics of participants with diagnosed diabetes from 1999-2002 to 2015-2020. Age, racial distribution and smoking habits remained stable during 1999-2020. The percentages of participants with a college degree, means values of BMI, waist circumference, diastolic blood pressure significantly increased; however, mean values of systolic blood pressure and non-HDL cholesterol significantly decreased between 1999-2002 and 2015-2020. The mean BMI increased from 31.0 kg/m2 in 1999-2002 to 32.6 kg/m2 in 2015-2020. The prevalence of obesity class I, obesity class II, and obesity class III increased from 22.5%, 14.1% and 10.3% in 1999-2002 to 26.5%, 16.6%, and 14.8% in 2015-2020, but the decreased trends were found in the prevalence of normal weight (17.1% in 1999-2002 and 12.7% in 2015-2020) and overweight (35.9% in 1999-2002 and 29.2% in 2015-2020) (Figure 1a), respectively. The prevalence of central obesity also increased from 72.9% in 1999-2002 to 79.1% in 2015-2020 (Figure 1b).
Table 1.
Characteristics of adult NHANES participants with diagnosed diabetes, 1992-2002 to 2015-2020
| 1999-2002 | 2003-2006 | 2007-2010 | 2011-2014 | 2015-2020 | P for differences | |
|---|---|---|---|---|---|---|
| No. of participants | 834 | 959 | 1391 | 1349 | 2072 | |
| Age, mean (SD), y | 61.9 (13.4) | 62.6 (13.7) | 62.2 (12.8) | 61.3 (13.0) | 61.9 (12.7) | 0.215 |
| Race a, % | <0.001 | |||||
| Non-Hispanic white | 35.4 | 40.6 | 38.0 | 33.7 | 29.6 | |
| Mexican American | 29.0 | 25.1 | 19.0 | 13.8 | 16.8 | |
| Non-Hispanic black | 25.3 | 27.5 | 27.1 | 30.1 | 27.0 | |
| Other | 10.3 | 6.8 | 15.9 | 22.5 | 26.5 | |
| Sex, % | 0.089 | |||||
| Male | 48.7 | 48.7 | 49.5 | 49.8 | 54.1 | |
| Female | 51.3 | 51.3 | 50.5 | 50.2 | 45.9 | |
| Education level, % | <0.001 | |||||
| High school or less | 71.2 | 65.0 | 64.0 | 56.2 | 52.2 | |
| Some college | 19.9 | 22.8 | 24.6 | 27.1 | 30.2 | |
| College graduate | 8.9 | 12.2 | 11.4 | 16.7 | 17.7 | |
| Smoking status, % | 0.130 | |||||
| Never | 49.4 | 47.5 | 52.7 | 50.5 | 51.6 | |
| Past | 34.5 | 35.2 | 29.5 | 33.4 | 33.1 | |
| Current | 16.1 | 17.2 | 17.8 | 16.1 | 15.4 | |
| Body mass index, mean (SD), kg/m 2 | 31.0 (6.63) | 31.5 (7.42) | 32.6 (7.52) | 32.2 (7.56) | 32.6 (7.78) | <0.001 |
| Waist circumference, mean (SD), cm | 106 (14.7) | 107 (15.5) | 109 (15.4) | 109 (16.2) | 110 (16.5) | <0.001 |
| Blood pressure, mean (SD), mm Hg | ||||||
| Diastolic | 69.4 (16.4) | 67.3 (16.0) | 67.4 (14.6) | 68.8 (14.3) | 72.0 (13.0) | <0.001 |
| Systolic | 138 (22.5) | 135 (22.9) | 133 (20.8) | 131 (19.5) | 132 (20.9) | <0.001 |
| HbA1c, mean (SD), % | 7.65 (1.97) | 7.33 (1.79) | 7.33 (1.70) | 7.49 (1.87) | 7.52 (1.80) | <0.001 |
| Non-HDL cholesterol, mean (SD), mg/dL | 158±50.5 | 145±49.6 | 135±45.5 | 133±47.3 | 126±44.9 | <0.001 |
| Body mass index category b, % | <0.001 | |||||
| Normal weight | 17.1 | 16.4 | 12.7 | 15.1 | 12.7 | |
| Overweight | 35.9 | 31.3 | 27.3 | 28.7 | 29.2 | |
| Obese class I | 22.5 | 26.6 | 29.0 | 27.4 | 26.7 | |
| Obese class II | 14.1 | 14.4 | 16.8 | 14.0 | 16.6 | |
| Obese class III | 10.3 | 11.4 | 14.2 | 14.8 | 14.8 | |
| Waist circumference category c, % | <0.001 | |||||
| Normal waist circumference | 27.1 | 22.8 | 19.0 | 22.3 | 20.9 | |
| Central obesity | 72.9 | 77.2 | 81.0 | 77.7 | 79.1 |
Abbreviation: Non-HDL cholesterol, non-high-density lipoprotein cholesterol.
Race was determined by self-report in fixed categories. The “other” group included other non-Hispanic races or multiple races.
The participants were classified in five body mass index categories: <25.0 (normal weight), 25.0-29.9 (overweight), 30-34.9 (obese class I), 35-39.9 (obese class II), and ≥40 (obese class III).
Center obesity was defined as waist circumference ≥102 in men and ≥88 in women.
Figure 1.
Prevalence of overall obesity, obesity class II, and obesity class III (Figure 1a) and central obesity (Figure 1b) among adult NHANES participants with diagnosed diabetes, 1999–2002 to 2015–2020. Central obesity is defined as waist circumference ≥102 cm in men, or ≥88 cm in women.
Table 2 shows the age-, sex- and race-adjusted mean values of HbA1c, blood pressure, non-HDL cholesterol across 5 discrete 4-year cycles or by different BMI/waist circumference categories. The average levels of HbA1c and diastolic blood pressure of participants both followed a non-linear trend, with decreases from the 1999-2002 to the 2007-2010 time period, after which each showed increases. The average levels of systolic blood pressure and non-HDL cholesterol each decreased consistently from 1999-2002 through 2015-2020. HbA1c levels showed a very clear decreasing trend for normal weight participants, decreasing from 7.85% in 1999-2000 to 7.26% in 2015-2020. For participants of a BMI classification of overweight or obesity, their HbA1c levels followed a similar decreasing trend until the 2007-2010 period, after which the A1C levels increased again. There were no significant differences in HbA1c levels among participants across different BMI groups in each 4-year cycle. Across all BMI classifications, diastolic blood pressure of participants first decreased before increasing, with the inflection point varying between the 2003-2006 period to the 2011-2014 period. Systolic blood pressure in normal weight participants remained mostly stable, unlike participants who had overweight or obesity, which all showed decreases from 137-140 mmHg in 1999-2002 to 129-133 mmHg in 2015-2020. The mean values of systolic blood pressure were lower among participants with obesity in 2011-2014 or among participants with increased waist circumference in 2007-2010 and 2015-2020 than those with normal waist circumference. Across all weight classifications, participants showed a consistent decrease in non-HDL cholesterol from the 1999-2002 period to the 2015-2020 period. Participants with obesity had a higher levels of non-HDL cholesterol than participants with normal weight or overweight in 2011-2020.
Table 2.
Trends in means values HbA1c, blood pressure and non-HDL cholesterol among adult NHANES participants with diagnosed diabetes by different body mass index and waist circumference categories, 1992-2002 to 2015-2020 a
| 1999-2002 | 2003-2006 | 2007-2010 | 2011-2014 | 2015-2020 | P for differences | |
|---|---|---|---|---|---|---|
| HbA1c, mean (SE), % | ||||||
| Total participants | 7.68 (0.06) | 7.39 (0.06) | 7.34 (0.05) | 7.46 (0.05) | 7.49 (0.04) | 0.001 |
| Body mass index category b | ||||||
| Normal weight | 7.85 (0.18) | 7.71 (0.17) | 7.42 (0.16) | 7.36 (0.15) | 7.26 (0.13) | 0.050 |
| Overweight | 7.67 (0.11) | 7.32 (0.11) | 7.34 (0.09) | 7.31 (0.09) | 7.53 (0.07) | 0.035 |
| Obese class I | 7.70 (0.13) | 7.33 (0.11) | 7.40 (0.09) | 7.59 (0.09) | 7.52 (0.08) | 0.131 |
| Obese class II | 7.54 (0.16) | 7.26 (0.15) | 7.28 (0.11) | 7.60 (0.13) | 7.51 (0.09) | 0.209 |
| Obese class III | 7.50 (0.19) | 7.44 (0.17) | 7.24 (0.12) | 7.47 (0.12) | 7.57 (0.10) | 0.339 |
| P for differences | 0.324 | 0.273 | 0.311 | 0.247 | 0.438 | |
| Waist circumference category c, % | ||||||
| Normal waist circumference | 7.66 (0.14) | 7.56 (0.15) | 7.58 (0.13) | 7.43 (0.12) | 7.47 (0.10) | 0.756 |
| Central obesity | 7.63 (0.08) | 7.32 (0.07) | 7.29 (0.06) | 7.47 (0.06) | 7.50 (0.05) | 0.001 |
| P for differences | 0.740 | 0.690 | 0.112 | 0.295 | 0.421 | |
| Diastolic blood pressure, mean (SE), mmHg | ||||||
| Total participants | 69.5 (0.51) | 67.8 (0.49) | 67.6 (0.38) | 68.5 (0.39) | 71.8 (0.32) | <0.001 |
| Body mass index category | ||||||
| Normal weight | 66.3 (1.40) | 64.9 (1.40) | 66.1 (1.22) | 68.1 (1.12) | 69.9 (1.03) | 0.029 |
| Overweight | 69.9 (0.84) | 67.6 (0.86) | 67.4 (0.73) | 67.0 (0.73) | 70.7 (0.59) | <0.001 |
| Obese class I | 69.0 (1.02) | 67.1 (0.91) | 67.7 (0.66) | 69.9 (0.70) | 72.0 (0.57) | <0.001 |
| Obese class II | 70.3 (1.33) | 70.2 (1.24) | 67.4 (0.88) | 69.8 (1.00) | 72.1 (0.74) | 0.002 |
| Obese class III | 72.8 (1.65) | 70.6 (1.55) | 69.7 (1.04) | 68.3 (1.08) | 75.1 (0.84) | <0.001 |
| P for differences | 0.229 | 0.091 | 0.768 | 0.041 | 0.011 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 72.0 (0.86) | 69.3 (0.90) | 69.2 (0.78) | 68.9 (0.73) | 71.5 (0.61) | 0.004 |
| Central obesity | 70.8 (0.54) | 69.3 (0.51) | 68.2 (0.38) | 69.6 (0.41) | 72.3 (0.32) | <0.001 |
| P for differences | 0.742 | 0.083 | 0.563 | 0.041 | 0.040 | |
| Systolic blood pressure, mean (SE), mmHg | ||||||
| Total participants | 138 (0.75) | 135 (0.72) | 133 (0.56) | 132 (0.57) | 132 (0.46) | <0.001 |
| Body mass index category | ||||||
| Normal weight | 137 (2.00) | 135 (2.00) | 136 (1.75) | 138 (1.62) | 136 (1.46) | 0.706 |
| Overweight | 139 (1.23) | 138 (1.26) | 135 (1.07) | 131 (1.06) | 133 (0.87) | <0.001 |
| Obese class I | 137 (1.56) | 134 (1.38) | 131 (1.01) | 131 (1.06) | 131 (0.87) | 0.016 |
| Obese class II | 140 (1.94) | 133 (1.79) | 131 (1.28) | 130 (1.45) | 130 (1.07) | <0.001 |
| Obese class III | 137 (2.32) | 131 (2.18) | 131 (1.45) | 129 (1.52) | 129 (1.18) | 0.021 |
| P for differences | 0.478 | 0.351 | 0.058 | 0.002 | 0.320 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 137 (1.53) | 136 (1.60) | 135 (1.38) | 133 (1.30) | 134 (1.09) | 0.292 |
| Central obesity | 138 (0.88) | 134 (0.83) | 132 (0.63) | 131 (0.67) | 131 (0.53) | <0.001 |
| P for differences | 0.384 | 0.137 | 0.007 | 0.228 | 0.019 | |
| Non-HDL cholesterol, mean (SE), mg/dL | ||||||
| Total participants | 158 (1.66) | 145 (1.54) | 136 (1.28) | 133 (1.29) | 126 (1.05) | <0.001 |
| Body mass index category | ||||||
| Normal weight | 153 (4.23) | 141 (4.02) | 129 (3.73) | 126 (3.55) | 115 (3.14) | <0.001 |
| Overweight | 162 (2.77) | 148 (2.76) | 135 (2.45) | 130 (2.41) | 126 (1.94) | <0.001 |
| Obese class I | 155 (3.43) | 145 (2.95) | 136 (2.34) | 137 (2.43) | 131 (1.99) | <0.001 |
| Obese class II | 160 (4.47) | 148 (4.12) | 141 (3.21) | 137 (4.55) | 127 (2.62) | <0.001 |
| Obese class III | 153 (4.81) | 140 (4.24) | 137 (3.23) | 133 (3.06) | 127 (2.52) | <0.001 |
| P for differences | 0.368 | 0.222 | 0.205 | 0.058 | 0.001 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 160 (3.87) | 140 (4.01) | 134 (3.46) | 127 (3.27) | 123 (2.75) | <0.001 |
| Central obesity | 158 (2.08) | 149 (1.95) | 137 (1.49) | 135 (1.57) | 128 (1.24) | <0.001 |
| P for differences | 0.856 | 0.047 | 0.638 | 0.307 | 0.452 |
Abbreviation: Non-HDL cholesterol, non-high-density lipoprotein cholesterol.
Adjusted for age, sex and race.
The participants were classified in five body mass index categories: <25.0 (normal weight), 25.0-29.9 (overweight), 30-34.9 (obese class I), 35-39.9 (obese class II), and ≥40 (obese class III).
Center obesity was defined as waist circumference ≥102 in men and ≥88 in women.
Age-, sex- and race-adjusted temporal trends in prevalence of glycemic, blood pressure and all risk-factor control were nonlinear, and temporal trends in prevalence of lipid control were linear (Table 3). The prevalence of participants who achieved glycemic control (HbA1c <7%) increased from 42.5% in 1999-2002 to 51.8% in 2007-2010, then decreased to 48.0% in 2015-2020. Participants with obesity showed a lower rate of glycemic control than participants with normal weight or overweight. The prevalence of participants who achieved blood pressure control (<140/90 mmHg) increased from 1999-2002 (53.2%) to 2011-2014 (69.3%) and then decreased in 2015-2020 (65.9%). This trend was found in participants with overweight and all different classes of obesity. Participants with overweight and obesity achieved a higher rate of blood pressure control than the participants with normal weight in 2011-2014. The prevalence of participants who achieved non-HDL cholesterol control (<130 mg/dL) increased throughout the study periods for all weight classifications, participants with normal weight having the highest prevalence of lipid control compared to those with overweight and obesity. The prevalence of participants who met all three ADA goals (HbA1c <7%, blood pressure <140/90 mmHg, and non-HDL cholesterol <130 mg/dL) increased from 8.3% in 1999-2002 to 21.2% in 2011-2014, and then decreased to 18.5 in 2015-2020. This trend was consisted among participants with different weight classifications. There were no differences of participants who met all three ADA goals by different BMI categories.
Table 3.
Prevalence of HbA1c, blood pressure and lipid control among adult NHANES participants with diagnosed diabetes by different body mass index and waist circumference categories, 1992-2002 to 2015-2020 a
| 1999-2002 | 2003-2006 | 2007-2010 | 2011-2014 | 2015-2020 | P for differences | |
|---|---|---|---|---|---|---|
| No. participants | 834 | 959 | 1391 | 1349 | 2072 | |
| HbA1c <7%, % | ||||||
| Total participants | 42.5 | 51.5 | 51.8 | 51.0 | 48.0 | <0.001 |
| Body mass index category b | ||||||
| Normal weight | 47.5 | 47.2 | 50.3 | 55.2 | 55.8 | 0.339 |
| Overweight | 42.5 | 53.0 | 56.3 | 55.1 | 46.3 | <0.001 |
| Obese class I | 42.2 | 52.1 | 47.8 | 49.9 | 47.4 | 0.319 |
| Obese class II | 37.1 | 51.8 | 51.9 | 48.0 | 46.7 | 0.101 |
| Obese class III | 41.3 | 50.5 | 51.9 | 44.5 | 47.6 | 0.451 |
| P for differences | 0.551 | 0.920 | 0.229 | 0.131 | 0.182 | |
| Waist circumference category c, % | ||||||
| Normal waist circumference | 45.1 | 44.6 | 48.9 | 50.2 | 50.1 | 0.592 |
| Central obesity | 40.9 | 52.7 | 51.7 | 51.1 | 47.4 | <0.001 |
| P for differences | 0.077 | 0.192 | 0.737 | 0.581 | 0.094 | |
| Blood pressure <140/90 mmHg, % | ||||||
| Total participants | 53.2 | 61.3 | 65.7 | 69.3 | 65.9 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 55.2 | 59.3 | 65.7 | 54.5 | 61.7 | 0.168 |
| Overweight | 52.2 | 56.4 | 62.1 | 72.1 | 65.3 | <0.001 |
| Obese class I | 56.7 | 64.8 | 69.9 | 70.3 | 66.9 | 0.021 |
| Obese class II | 49.2 | 64.6 | 65.1 | 71.1 | 67.0 | 0.006 |
| Obese class III | 49.2 | 67.0 | 66.0 | 74.2 | 68.2 | 0.005 |
| P for differences | 0.201 | 0.461 | 0.282 | 0.001 | 0.847 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 57.4 | 60.8 | 65.1 | 66.5 | 63.4 | 0.274 |
| Central obesity | 52.6 | 61.7 | 66.2 | 69.7 | 67.0 | <0.001 |
| P for differences | 0.594 | 0.339 | 0.292 | 0.762 | 0.248 | |
| Blood pressure <130/80 mmHg, % | ||||||
| Total participants | 31.8 | 37.1 | 41.3 | 44.2 | 43.1 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 35.4 | 37.0 | 36.1 | 36.2 | 41.6 | 0.687 |
| Overweight | 29.5 | 34.5 | 40.0 | 46.9 | 42.4 | <0.001 |
| Obese class I | 34.9 | 39.6 | 43.5 | 42.9 | 43.9 | 0.282 |
| Obese class II | 28.0 | 38.6 | 43.6 | 47.2 | 45.6 | 0.017 |
| Obese class III | 29.7 | 37.6 | 42.0 | 45.5 | 42.2 | 0.219 |
| P for differences | 0.224 | 0.796 | 0.649 | 0.107 | 0.525 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 31.9 | 37.5 | 39.2 | 44.4 | 43.6 | 0.040 |
| Central obesity | 31.8 | 37.3 | 42.0 | 44.8 | 43.7 | <0.001 |
| P for differences | 0.952 | 0.526 | 0.454 | 0.723 | 0.870 | |
| Non-HDL cholesterol <130 mg/dL, % | ||||||
| Total participants | 26.6 | 42.5 | 51.5 | 54.9 | 58.6 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 35.8 | 42.6 | 59.1 | 63.7 | 66.5 | <0.001 |
| Overweight | 23.5 | 40.7 | 51.5 | 57.8 | 58.7 | <0.001 |
| Obese class I | 28.1 | 38.0 | 53.2 | 51.5 | 55.9 | <0.001 |
| Obese class II | 24.4 | 49.2 | 44.5 | 50.2 | 58.0 | <0.001 |
| Obese class III | 26.0 | 50.3 | 47.6 | 51.2 | 56.9 | <0.001 |
| P for differences | 0.107 | 0.043 | 0.207 | 0.143 | 0.061 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 32.6 | 43.4 | 54.3 | 62.6 | 62.0 | <0.001 |
| Central obesity | 24.5 | 40.9 | 50.3 | 52.4 | 57.3 | <0.001 |
| P for differences | 0.007 | 0.757 | 0.587 | 0.050 | 0.607 | |
| All risk factors control d | ||||||
| Total participants | 6.5 | 12.5 | 18.8 | 21.2 | 18.5 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 8.3 | 7.1 | 18.1 | 19.2 | 18.8 | 0.002 |
| Overweight | 5.4 | 14.2 | 19.9 | 25.2 | 18.6 | <0.001 |
| Obese class I | 8.5 | 9.9 | 19.7 | 20.8 | 18.8 | <0.001 |
| Obese class II | 5.5 | 11.7 | 14.5 | 19.4 | 20.1 | 0.002 |
| Obese class III | 5.3 | 22.9 | 20.3 | 17.8 | 15.4 | 0.015 |
| P for differences | 0.547 | 0.001 | 0.461 | 0.411 | 0.748 | |
| Waist circumference category, % | ||||||
| Normal waist circumference | 8.0 | 9.9 | 18.3 | 23.2 | 20.7 | <0.001 |
| Central obesity | 6.2 | 13.2 | 19.1 | 20.9 | 18.4 | <0.001 |
| P for differences | 0.190 | 0.061 | 0.301 | 0.619 | 0.571 |
Abbreviation: Non-HDL cholesterol, non-high-density lipoprotein cholesterol.
Adjusted for age, sex and race.
The participants were classified in five body mass index categories: <25.0 (normal weight), 25.0-29.9 (overweight), 30-34.9 (obese class I), 35-39.9 (obese class II), and ≥40 (obese class III).
Center obesity was defined as waist circumference ≥102 in men and ≥88 in women.
All risk factors control was defined as HbA1c <1%, blood pressure <140/90 mmHg, and non-HDL cholesterol <130 mg/dL.
The percentage of participants who took glucose-lowering medications increased from 84.7% in 1999-2002 to 88.2 % in 2007-2010, then decreased to 82.7% in 2015-2020 (Table 4). The use of blood pressure-lowering medications increased from 51.8% in 1999-2002 to 66.1% in 2007-2010, then stabilized as 62.5% in 2015-2020. The percentage of participants who took lipid-lowering medications increased significantly from 27.8% to 53.9% between 1999-2002 and 2015-2020. In general, participants with obesity were more likely to use glucose-lowering, blood pressure-lowering, and lipid-lowering medications than participants with normal weight or overweight.
Table 4.
Prevalence of glucose-lowering, blood pressure-lowering, lipid-lowering medications used among adult NHANES participants with diagnosed diabetes, 1992-2002 to 2015-2020
| 1999-2002 | 2003-2006 | 2007-2010 | 2011-2014 | 2015-2020 | P for differences | |
|---|---|---|---|---|---|---|
| Glucose-lowering medications | ||||||
| Total participants | 84.7 | 85.4 | 88.2 | 84.2 | 82.7 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 75.8 | 80.3 | 85.5 | 78.5 | 80.2 | 0.266 |
| Overweight | 85.8 | 82.6 | 85.2 | 84.6 | 83.8 | 0.823 |
| Obese class I | 83.9 | 89.4 | 89.3 | 85.1 | 81.5 | 0.004 |
| Obese class II | 91.2 | 88.1 | 88.2 | 84.9 | 85.2 | 0.390 |
| Obese class III | 93.2 | 90.8 | 94.0 | 85.8 | 80.1 | <0.001 |
| P for differences | <0.001 | 0.004 | <0.001 | 0.072 | 0.226 | |
| Blood pressure-lowering medications | ||||||
| Total participants | 51.8 | 60.2 | 66.1 | 61.9 | 62.5 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 35.3 | 46.6 | 54.6 | 48.1 | 48.0 | 0.011 |
| Overweight | 51.0 | 55.3 | 60.3 | 56.5 | 58.1 | 0.121 |
| Obese class I | 55.4 | 61.7 | 69.3 | 66.4 | 62.5 | 0.007 |
| Obese class II | 63.6 | 70.0 | 71.3 | 70.2 | 69.5 | 0.633 |
| Obese class III | 66.4 | 77.1 | 72.7 | 73.5 | 72.1 | 0.540 |
| P for differences | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 | |
| Lipid-lowering medications | ||||||
| Total participants | 27.8 | 40.1 | 49.0 | 55.3 | 53.9 | <0.001 |
| Body mass index category | ||||||
| Normal weight | 21.4 | 37.3 | 44.6 | 50.7 | 49.4 | <0.001 |
| Overweight | 31.5 | 35.5 | 47.6 | 54.3 | 55.8 | <0.001 |
| Obese class I | 29.4 | 40.8 | 52.3 | 55.9 | 54.9 | <0.001 |
| Obese class II | 25.2 | 50.7 | 50.6 | 58.4 | 54.8 | <0.001 |
| Obese class III | 31.3 | 46.3 | 46.6 | 57.1 | 49.2 | 0.001 |
| P for differences | 0.136 | 0.024 | 0.132 | 0.049 | 0.176 |
Adjusted for age, sex and race.
The participants were classified in five body mass index categories: <25.0 (normal weight), 25.0-29.9 (overweight), 30-34.9 (obese class I), 35-39.9 (obese class II), and ≥40 (obese class III).
Discussion
The present study found that trends in overweight and obesity in the population of US adults with diagnosed diabetes demonstrated an increase in those with more severe obesity from 1999-2002 to 2015-2020, mirroring trends in the US population at large. The decrease in prevalence of those with normal weight represents a shifting of the population distribution in those with diabetes that is also similar to the US population as a whole (15). The increase in prevalence of patients with more severe obesity is of concern in this population with diabetes. The Guidelines for Bariatric Surgery and Cardiovascular Risk Factors has suggested that surgical therapy be proposed as a treatment option to patients with BMI >35 kg/m2 in persons with diabetes (26). This is 34.4% of the population we studied in 2015-2020, up from 24.4% in 1999-2002.
Our study also showed improving trends in blood pressure control and lipid control from 1999-2002 to 2015-2020, despite worsening adiposity. Glycemic control improved from 1999-2002 to 2007-2010, but worsened after 2011. Participants with obesity showed worsening glycemic control (46.7-47.5% vs. 55.2-55.8%, P <0.05) and lipid control (52.4-58.7% vs. 63.7-66.5%, P <0.05) than others with normal weight during 2011-2020. Participants with obesity showed the almost same rate for intensive blood pressure control (<130/80 mmHg) than others with normal weight or overweight. Large increases in trends of use of medication from 1999-2002 to 2015-2020, especially use of blood pressure-lowering, and lipid-lowering medication, explain some of the improving trends in blood pressure control and lipid control. However, glycemic control was not optimal during 2015-2020, despite the advances in glycemic care including the utility of continuous glucose monitoring (CGM) (27) and use of several new second-line glucose-lowering drugs, i.e. glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors (14, 28). The reduction in the prevalence of glucose-lowering medication use (88.2 % in 2007-2010 to 82.7% in 2015-2020) is unexplained, especially in the face of availability of new medications during this period. Perhaps cost would explain the disparity in use of glucose-lowering medications versus lipid lowering or antihypertension medications. However worsening glycemia may not be explained entirely by reduction in medication use as the pressure of continued weight gain is almost certainly contributing to dysglycemia (28).
Evidence from several randomized controlled trials (RCTs) has demonstrated that controlling any single risk factor of HbA1c, blood pressure, or LDL cholesterol by treatment may decrease CVD risk among patients with diabetes (12). However, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) RCT found an unexpected increase in total and CVD mortality in the intensive glycemic treatment arm (<6.0%) (29) and no significant benefit of intensive blood pressure treatment (systolic blood pressure <120 mmHg vs. 140 mmHg) (30) and intensive lipids treatment(31) compared with the standard therapy. Our meta-analyses of prospective studies have indicated positive associations of HbA1c (32-34), LDL cholesterol (35) and blood pressure (36-38) with CVD risk among patients with diabetes. The ADA and the American Heart Association have changed the goal of blood pressure control as <140/90 mmHg for persons with diabetes (13).
The ADA Standards of Medical Care in Diabetes have become more attuned to weight management as a pathway to better diabetes management (39). The trends we demonstrate in higher prevalence of central adiposity, obesity, and more severe obesity from 1999 to 2020 among adults with diabetes in the NHANES support ADA recommendations for more emphasis on weight management as a diabetes treatment strategy. The Look AHEAD trial in 5145 adults with overweight and obesity and type 2 diabetes has shown that intensive lifestyle intervention can result in a weight loss and improvements in many health outcomes, including HbA1c and blood pressure (40-43). These improvements were most prominent during the early years of intervention but despite maintaining modest weight loss there was no reduction in cardiovascular events at median follow-up of 9.6 years (40-43). Two new glucose-lowering drugs, i.e. GLP-1 receptor agonists and SGLT2 inhibitors have shown good weight loss efficacy (44, 45), and the 2022 ADA Standards of Medical Care in Diabetes has recommended that when persons with type 2 diabetes are not at glycemic goals and weight loss is a need, GLP-1 receptor agonists with good weight loss efficacy are the preferred treatment with SGLT2 inhibitors as a second option (14). Thus we need to pay attention on benefits of weight loss in diabetes and importance of “moving upstream in treatment.” More studies are needed to assess the importance of tracking weight and weight loss in persons with diabetes as metrics of interest to assess diabetes control in the future.
There are several strengths in our study, including the large sample size from national surveys, standardized measurements of 2 different indicators of adiposity, and many other adiposity-related risk factors including blood pressure, HbA1c and lipids. There are also several limitations in this study. First, response rates have declined in the NHANES over time. Second, there was a small sample size and low prevalence of risk-factor when we compared data among different BMI groups. Third, non-HDL cholesterol <130 mg/dL was used as definition of lipid control because only partial data on LDL cholesterol was available for the sample population. Fourth, we could not reliably distinguish between type 1 and type 2 diabetes. However, type 2 diabetes makes up more than 90% of diagnosed diabetes cases in the U.S. Thus, we believe this sample to be broadly representative of the population with type 2 diabetes.
Conclusions
Based on the NHANES data from US adults with diagnosed diabetes, the trends in prevalence of overall, class 2 or class 3 obesity increased from 1999-2002 to 2015-2020. There were increased trends in blood pressure control and lipid control from 1999-2002 to 2015-2020 in adults with diagnosed diabetes. Glycemic control improved from 1999-2002 to 2007-2010, however worsened after 2011. Participants with obesity showed worsening glycemic control and lipid control than participants with normal weight. These trends are cause for concern, especially the worsening of glycemic control in the face of advancing adiposity. Addressing weight management in persons with diabetes should be given priority if cardiometabolic risk factor control is to improve in the population with diabetes.
Study Important.
What is already known about this subject?
Obesity is the leading driver of type 2 diabetes risk. Despite the rising prevalence in US adults of obesity, especially more severe obesity, no studies have assessed the impact of rising rates of more severe obesity on measures of cardiometabolic risk factor control in diabetes.
What are the new findings in your manuscript?
Among US adults with diabetes, the prevalence of class 2 and class 3 obesity rose from 1999-2002 to 2015-2020 along with worsening in achievement of glycemic control and lipid control targets.
How might your results change the direction of research or the focus of clinical practice?
The impact of worsening obesity profiles in patients with diabetes is concerning because of lack of optimal cardiometabolic risk factor control. This supports recommendations for more weight-centric diabetes management in persons with obesity and diabetes.
Funding:
Dr Hu was partly supported by the grant from the National Institute of General Medical Sciences (U54GM104940) of the National Institutes of Health and the Louisiana Department of Health. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Disclosures: Dr. Donna Ryan has served as a Scientific Advisor or Consultant to the following companies: Altimmune, Amgen, Boehringer Ingelheim, Calibrate, Carmot, Epitomee, Gila Therapeutics, ifa Celtic, Lilly, Novo Nordisk, real appeal (United Health), Scientific Intake, Wondr Health, Xeno Bioscience, Ysopia, and Zealand. Dr. Ryan has served on the Speakers’ Bureau for Novo Nordisk. Dr. Ryan has received stock options in Epitomee, Calibrate, Roman, and Scientific Intake. Dr. Ryan has served on a Data Safety Monitoring Board for setmelanotide, a medication marketed by Rhythm. No other disclosures were reported.
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