Diabetes Complications in the U.S.: Following the Data to Guide Comprehensive Action

Diabetes and its complications pose a growing public health crisis in the U.S., with far-reaching implications for individuals, health care systems, and society at large. From a health and well-being perspective, diabetes ranked as the fourth leading cause of disability-adjusted life-years (DALYs) in the U.S. in 2021 (1). The 41% increase in DALYs attributable to diabetes from 2011 to 2021 highlights the escalating impact of diabetes on quality of life and longevity (1). The burden on the health care system is equally substantial. In 2020 alone, there were >7.8 million hospitalizations with diabetes as a listed diagnosis, including 1.7 million for major cardiovascular disease and 160,000 for lower-extremity amputations (2). The financial toll is sobering, with the total estimated cost of diagnosed diabetes in the U.S. reaching $412.9 billion in 2022, encompassing both direct medical costs and indirect expenditures (3). At a societal level, the risk of diabetes and its complications is disproportionately higher for socially vulnerable groups, making it a critical issue for achievement of health equity (4).

Data from three key perspectives shed light on priorities and strategies to effectively address the growing crisis of diabetes complications: national surveillance, analytic epidemiology, and real-world interventions (Fig. 1). This commentary draws insights from three articles published in this issue of Diabetes Care, presentations for which occurred at the 2024 Joint American Diabetes Association–Centers for Disease Control and Prevention Symposium—Pressure Points and Future Directions in the Prevention of Acute and Chronic Diabetes-Related Complications. These studies provide timely data on magnitude and trends, risk factors for complications, and approaches to achieve equitable outcomes.  

National surveillance data over the past two decades, as reported by Saelee et al. (5), reveal concerning trends in diabetes-related complications. After steady declines since 2000, hospitalizations for heart failure, stroke, nontraumatic lower-extremity amputations, and end-stage renal disease began rising in the 2009–2012 period. Hyperglycemic crisis hospitalizations consistently increased throughout the 20-year period from 2000 to 2020. In their analysis of outcomes by race and ethnicity, reductions in inequalities were seen only for end-stage renal disease hospitalizations. Disconcertingly, analyses of outcomes by age indicated a reduction in inequalities that was driven largely by rising complication rates in younger age-groups, particularly those aged 45–64 years. Age patterns suggest that the earlier onset of diabetes in more recent cohorts (6) is beginning to manifest in higher complication rates, presenting a worrying outlook for future health outcomes.

Drawing on analytic epidemiology, Varghese et al. (7) shed light on the complex interplay among urbanicity, race and ethnicity, and glycemic control in relation to vision-threatening diabetic retinopathy, a debilitating complication that affects 5% of those with diabetes. With use of nationwide data from electronic health records in 2015–2023, they found that patients with A1C ≥9.0% or unknown A1C levels were less likely to meet standards of clinical care and more likely to progress to vision-threatening retinopathy compared with patients with A1C <9.0%. Hispanic patients simultaneously faced greater challenges in accessing standard care and experienced faster progression to complications compared with non-Hispanic White patients, and non-Hispanic Black patients reported equivalent receipt of standards of clinical care but faster progression to retinopathy, compared with non-Hispanic White patients. Patients living in urban settings generally receive better standards of clinical care than their counterparts residing in rural settings, yet they also showed higher rates of progression to severe complications. The results show that achieving health care equity for vulnerable communities requires more than just good clinical care—suggesting that we must also understand and address the challenges people face managing their health at home.

From an intervention perspective, Joseph et al. (8) present an exemplary approach to tackling diabetes complications in the real-world. Through a multisector academic-community partnership, they developed the statewide Ohio Diabetes Quality Improvement Project centered on equity. Over 2 years, the intervention successfully reduced the percentage of non-Hispanic Black and Hispanic patients with poor glycemic control (A1C >9%), by 22% and 20%, respectively, and achieved improvements in A1C in all racial and ethnic groups. Notably, the largest absolute and relative reductions were observed among non-Hispanic White patients, demonstrating that equity-focused programs can benefit all demographic groups without detracting from the care received by the majority.

Collectively, these articles demonstrate that 1) addressing diabetes complications requires actions across the entire cascade of care, from primary prevention to the management of advanced complications, and 2) our efforts are significantly enhanced by applying epidemiologic data to guide and evaluate impacts of interventions, programs, and policies.

First, the importance of primary prevention efforts to prevent the onset of diabetes across the life course is reinforced by surveillance data reported by Saelee et al. (5) and others (9) regarding the rise of diabetes complications in adults aged 18–64 years. The life course perspective encourages us to expand beyond the later adulthood period when complications arise to additionally consider earlier periods of life when root causes of diabetes risk tend to emerge. Identifying and addressing diabetes risk earlier in the life course—beginning with the gestational period (10)—is imperative to disrupt the alarming rise in diabetes among young people aged <20 years (6). Younger age at onset leads to longer disease duration, and also adults with diabetes aged <65 years on average exhibit poorer engagement with care and glycemic control (11). This convergence is likely to precipitate earlier health decline and exacerbate vulnerability to complications. Without serious attention to primary prevention, the rise in diabetes complications among younger adults is likely to continue.

Alongside primary prevention, improvement of secondary prevention efforts to better manage modifiable cardiometabolic risk factors among people with diabetes is warranted. Epidemiologic investigation from Varghese et al. (7) demonstrates the relationship between glycemic control and progression of retinopathy, reinforcing the importance of disease control in prevention of complications (12). Nearly half (47.4%) of adults with diabetes have high A1C levels (2). Moreover, most adults with diabetes have at least one other comorbidity that places them at high risk for complications, with 80.6% having high blood pressure (2). These statistics on the high burden of uncontrolled glycemia and treatable comorbidities in people with diabetes, in combination with surveillance data showing the resurgence of diabetes complications (5), highlight the need for strengthening secondary prevention through comprehensive disease management.

Second, there are tremendous benefits of using epidemiologic data to tailor diabetes management approaches to vulnerable populations, as demonstrated by Joseph et al. (8). Similarly, comprehensive, community-oriented diabetes management programming by the Indian Health Service stands out as an exemplary model of data-informed response to a public health crisis (13). Their efforts reduced the incidence of end-stage renal disease among American Indian and Alaska Native populations (14). Both the Ohio Diabetes Quality Improvement Project and the Indian Health Service used epidemiologic data to identify health equity priorities and built collaborations among researchers, communities, and policymakers to ensure that evidence-based care reached the most vulnerable patients.

In conclusion, the rising tide of diabetes complications in the U.S. demands that we link data resources across community and clinic settings to build more effective interventions, programs, and policies for primary and secondary prevention across the life course. To drive meaningful progress, we must also fully leverage and further develop our data infrastructure to monitor the ultimate impact of intervention efforts on population-level outcomes. The time for action is now—the health of our nation depends on it.