Analytic Sample
A total of 5536 adults aged 20 years or older who reported a diagnosis of diabetes participated in an NHANES examination from 2005 to 2018 and were eligible for inclusion in the present study (weighted mean age, 60.2 years, standard error [SE] ± 0.27; female, 50.1%) (Table 1). Because the data relating to apo B, non-HDL cholesterol level, LDL cholesterol, and/ or A1C were missing for some participants; therefore, the sample sizes vary slightly among these outcomes. LDL levels were calculated using the Friedewald formula. To calculate LDL cholesterol values by the formula, participants were excluded for whom total cholesterol or HDL cholesterol data were unavailable or whose triglyceride levels exceeded 400 mg/dL. More than half of the subjects had been told that they had diabetes for the first time when they were aged 40 to 59 years, while nearly one in five of the subjects was between aged 20 and 39 years.
Table 1
Sociodemographic characteristics of US adults with diabetes by NHANES survey cycle, 2005 to 2018
Characteristics
|
No. of Participants (Weighted %) *
|
|
2005–2006
|
2007–2008
|
2009–2010
|
2011–2012
|
2013–2014
|
2015–2016
|
2017–2018
|
Overall
|
|
(n = 513)
|
(n = 782)
|
(n = 775)
|
(n = 720)
|
(n = 764)
|
(n = 881)
|
(n = 921)
|
(n = 5356)
|
Age group, y †
|
|
|
|
|
|
|
|
|
20–39
|
36 (10.2)
|
54 (9.3)
|
40 (7.1)
|
44 (6.5)
|
40 (6.5)
|
66 (9.3)
|
40 (7.1)
|
320 (7.9)
|
40–59
|
152 (39.7)
|
226 (39.4)
|
221 (36.6)
|
230 (38.8)
|
256 (39.1)
|
257 (33.4)
|
238 (33.6)
|
1580 (36.8)
|
≥ 60
|
313 (50.2)
|
483 (51.4)
|
497 (56.3)
|
441 (54.7)
|
451 (54.3)
|
545 (57.3)
|
626 (59.3)
|
3356 (55.3)
|
Sex
|
|
|
|
|
|
|
|
|
Male
|
243 (43.9)
|
384 (47.7)
|
389 (50.4)
|
367 (49.1)
|
367 (48.4)
|
459 (53.2)
|
491 (53.4)
|
2700 (49.9)
|
Female
|
270 (56.1)
|
398 (52.3)
|
386 (49.6)
|
353 (50.9)
|
397 (51.6)
|
422 (46.8)
|
430 (46.6)
|
2656 (50.1)
|
Race/ethnicity
|
|
|
|
|
|
|
|
|
Mexican American
|
113 (8.6)
|
133 (7.7)
|
164 (9.6)
|
76 (8.2)
|
131 (9.9)
|
201 (11.3)
|
142 (9.3)
|
960 (9.4)
|
Non-Hispanic white
|
193 (61.5)
|
309 (63.8)
|
284 (58.8)
|
224 (59.3)
|
277 (62.5)
|
232 (57.7)
|
307 (61.6)
|
1826 (60.7)
|
Non-Hispanic black
|
171 (18.4)
|
229 (18.1)
|
190 (17.2)
|
253 (16.9)
|
195 (14.7)
|
205 (14.3)
|
211 (11.3)
|
1454 (15.4)
|
Other‡
|
36 (11.5)
|
111 (10.4)
|
137 (14.4)
|
167 (15.6)
|
161 (12.8)
|
243 (16.8)
|
261 (17.8)
|
1116 (14.6)
|
Education level
|
|
|
|
|
|
|
|
|
Less than high school
|
198 (27.1)
|
332 (30.4)
|
303 (29.4)
|
254 (25.5)
|
229 (20.9)
|
282 (20.6)
|
241 (15.8)
|
1839 (23.4)
|
High school
|
128 (27.3)
|
180 (25.9)
|
152 (20.1)
|
154 (26.3)
|
181 (24.2)
|
189 (21.1)
|
212 (29.4)
|
1196 (24.9)
|
More than high school
|
187 (45.6)
|
270 (43.7)
|
320 (50.5)
|
312 (48.2)
|
354 (54.9)
|
410 (58.3)
|
468 (54.8)
|
2321 (51.7)
|
Ratio of family income to poverty, %
|
|
|
|
|
|
|
|
|
< 1.3
|
160 (21.6)
|
247 (23.1)
|
247 (22.7)
|
279 (29.4)
|
274 (26.7)
|
305 (24.1)
|
228 (17.3)
|
1740 (23.4)
|
1.3–3.0
|
173 (34.2)
|
254 (32.4)
|
238 (31.2)
|
205 (31.9)
|
199 (25.7)
|
264 (28.8)
|
308 (31.5)
|
1641 (30.5)
|
> 3.0
|
144 (38.3)
|
190 (34.6)
|
210 (37.8)
|
155 (31.7)
|
237 (41.7)
|
215 (37.3)
|
267 (41.3)
|
2418 (37.8)
|
Missing
|
36 (5.8)
|
91 (10.0)
|
80 (8.3)
|
81 (7.0)
|
54 (5.9)
|
97 (9.7)
|
118 (9.9)
|
557 (8.2)
|
Take diabetic pills
|
|
|
|
|
|
|
|
|
Yes
|
354 (69.0)
|
589 (72.2)
|
580 (73.6)
|
527 (73.5)
|
536 (70.1)
|
617 (72.6)
|
685 (72.0)
|
3888 (71.9)
|
No
|
156 (34.5)
|
187 (27.1)
|
191 (25.9)
|
192 (26.4)
|
226 (29.8)
|
259 (27.1)
|
236 (28.0)
|
1447 (27.8)
|
Age first told
|
|
|
|
|
|
|
|
|
20–39
|
91 (24.2)
|
120 (21.6)
|
99 (16.5)
|
124 (18.3)
|
135 (19.7)
|
165 (19.7)
|
135 (17.6)
|
869 (19.4)
|
40–59
|
223 (48.0)
|
328 (49.9)
|
358 (52.8)
|
327 (55.3)
|
366 (55.8)
|
403 (54.9)
|
463 (56.2)
|
2468 (53.7)
|
≥ 60
|
144 (27.7)
|
232 (28.6)
|
225 (30.6)
|
188 (26.5)
|
182 (24.5)
|
201 (25.4)
|
212 (26.2)
|
1384 (26.8)
|
Abbreviations: NHANES, National Health and Nutrition Examination Survey.
* Percentages were adjusted for NHANES survey weights.
† Numbers may not sum to the total number of participants because of missing data.
‡ “Other” includes race/ethnicity other than Mexican American, non-Hispanic white, and non-Hispanic black, including multiracial.
|
Table 2
Age-adjusted percentage of achieving apo B < 90 mg/dL among U.S. adults with diabetes aged ≥ 20 years, 2005–2016
|
2005–2006
|
2007–2008
|
2009–2010
|
2011–2012
|
2013–2014
|
2015–2016
|
P for linear trend
|
|
apo B < 90 mg/dL
|
apo B < 90 mg/dL
|
apo B < 90 mg/dL
|
apo B < 90 mg/dL
|
apo B < 90 mg/dL
|
apo B < 90 mg/dL
|
Total
|
28.8 (20.0 to 37.6)
|
51.0 (32.9 to 69.1)
|
53.7 (37.1 to 70.3)
|
42.4 (30.6 to 54.2)
|
50.1 (36.4 to 63.9)
|
47.3 (33.7 to 60.8)
|
0.184
|
Age group, y
|
|
|
|
|
|
|
|
20–39
|
10.1 (-12.2 to 32.5)
|
44.9 (4.5 to 85.2)
|
55.5 (19.7 to 91.3)
|
38.3 (12.5 to 64.0)
|
48.5 (20.2 to 76.8)
|
43.5 (16.4 to 70.7)
|
0.044
|
40–59
|
40.3 (29.8 to 50.8)
|
46.5 (31.8 to 61.3)
|
47.4 (31.3 to 63.6)
|
33.2 (22.3 to 44.1)
|
47.9 (38.4 to 57.3)
|
44.8 (32.7 to 56.9)
|
0.490
|
≥ 60
|
42.8 (34.9 to 50.7)
|
68.9 (62.7 to 75.0)
|
60.7 (54.9 to 66.4)
|
64.3 (50.6 to 77.9)
|
56.5 (50.1 to 62.9)
|
57.6 (47.2 to 67.9)
|
0.559
|
Sex
|
|
|
|
|
|
|
|
Male
|
39.5 (21.1 to 57.9)
|
65.3 (47.8 to 82.7)
|
61.2 (43.3 to 79.1)
|
57.0 (43.7 to 70.2)
|
75.5 (70.9 to 80.1)
|
51.1 (28.1 to 74.2)
|
0.995
|
Female
|
21.7 (14.8 to 28.6)
|
34.8 (25.9 to 43.7)
|
31.5 (22.4 to 40.5)
|
29.5 (18.3 to 40.7)
|
41.1 (23.6 to 58.6)
|
43.2 (29.3 to 57.2)
|
0.044
|
Race/ethnicity
|
|
|
|
|
|
|
|
Mexican American
|
20.6 (8.8 to 32.3)
|
63.9 (58.2 to 69.7)
|
51.0 (36.1 to 65.9)
|
21.5 (11.5 to 31.6)
|
30.5 (18.2 to 42.8)
|
42.4 (24.8 to 60.0)
|
0.173
|
Non-Hispanic white
|
28.2 (18.3 to 38.0)
|
57.4 (32.0 to 82.8)
|
58.8 (37.3 to 80.2)
|
40.1 (20.2 to 60.1)
|
49.6 (30.9 to 68.3)
|
48.4 (20.4 to 76.5)
|
0.936
|
Non-Hispanic black
|
28.2 (20.9 to 35.5)
|
40.2 (21.1 to 59.3)
|
30.0 (22.2 to 37.9)
|
51.1 (29.6 to 72.6)
|
71.9 (62.1 to 81.7)
|
44.0 (27.0 to 60.9)
|
0.038
|
Other
|
39.2 (6.3 to 72.1)
|
58.2 (41.4 to 75.0)
|
46.9 (18.4 to 75.4)
|
44.8 (20.9 to 68.7)
|
72.5 (63.0 to 82.0)
|
70.8 (62.7 to 79.0)
|
0.217
|
apo B, apolipoprotein B. |
Age-Adjusted Trends in Mean Levels of Apo B, Non-HDL cholesterol, and LDL Cholesterol
Supplementary Table 1 shows the age-adjusted mean levels of apo B and trend in mean levels of apo B. The age-adjusted mean levels of apo B for all adults with diabetes declined from 102 mg/dL (95% CI, 95 to 110 mg/dL) in 2005–2006 to 95 mg/dL (95% CI, 88 to 102 mg/dL) in 2015–2016 (β, − 0.90 mg/dL [95% CI, − 1.90 to 0.10 mg/dL] per year), but the linear trend did not reach statistical significance (P = 0.077 for linear trend) (Supplementary Table 1 and Fig. 1). From 2005 to 2018, a significant linear decreasing trend was observed in the age-adjusted mean non-HDL cholesterol level for all adults with diabetes (from 143 mg/dL (95% CI, 135 to 151) mg/dL in 2005–2006 to 136 mg/dL (95% CI, 127 to 144) mg/dL in 2017–2018) (P = 0.004) (Supplementary Table 2 and Fig. 1). The age-adjusted mean LDL cholesterol level for all adults with diabetes was not significantly improved from 107 mg/dL (95% CI, 96 to 117) mg/dL in 2005–2006 to 105 mg/dL (95% CI, 98 to 112) mg/dL in 2015–2016 (P = 0.138 for linear trend) (Supplementary Table 4 and Fig. 1).
In subgroup analyses by age, sex and race/ethnicity, significant declining trends in age-adjusted mean levels of apo B and non-HDL cholesterol were generally observed for patients aged 60 years or older, for Mexican Americans, and for non-Hispanic blacks. Also, a declining trend in mean non-HDL cholesterol level was observed for women (P = .014). No statistically significant declining trends in the age-adjusted mean LDL cholesterol levels were observed for both men and women, all race/ethnicity subgroups, and every age group except for patients aged 60 years or older.
Age-adjusted Trends In Geometric Mean Concentrations Of A1c
From 2005 to 2018, the age-adjusted geometric mean concentration of A1C was not significantly reduced for all adults with diabetes from 7.3% (95% CI, 6.9–7.7%) in 2005–2006 to 7.1% (95% CI, 6.7–7.5%) in 2017–2018, and the linear trend was not statistically significant (P = 0.202 for linear trend) (Supplementary Table 6). Also, there is no statistically significant change in the age-adjusted geometric mean concentrations of A1C for every age group, both men and women, and all race/ethnicity subgroups.
Age-Adjusted Trends in the Percentage of Participants Meeting Apo B, Non-HDL Cholesterol, and LDL Cholesterol Goals
The age-adjusted percentage of participants with diagnosed diabetes who had a level of apo B < 90 mg/dL increased from 28.8% (95% CI, 20.0–37.6%) in 2005–2006 to 47.3% (95% CI, 33.7–60.8%) in 2015–2016, but the linear trend was not statistically significant (P = 0.184) (Table 2 and Supplementary Fig. 1). From 2005 to 2018, there was an increasing linear trend in the age-adjusted percentage of patients who achieved the non-HDL cholesterol goal of levels < 130 mg/dL for all adults with diabetes, from 42.4% (95% CI, 31.2–53.7%) in 2005–2006 to 54.2% (95% CI, 45.7–62.7%) in 2017–2018, but the trend were also not significant (P = 0.098) (Supplementary Table 3 and Supplementary Fig. 1). From 2005 to 2016, the age-adjusted proportion of patients who achieved the LDL cholesterol goal of levels < 100 mg/dL did not significantly increase in all adults with diabetes (P = 0.379) (Supplementary Table 4 and Supplementary Fig. 1).
In subgroup analyses by age, sex and race/ethnicity, a linear increase was observed in the age-adjusted proportion of all adults with diabetes who achieved the apo B goal of levels < 90 mg/dL or the non-HDL Cholesterol goal of levels < 130 mg/dL among women but not among men. The increase in the age-adjusted proportion of all adults with diabetes who had the apo B goal of levels < 90 mg/dL was observed for patients aged 20 to 39 years (P = 0.044) and for non-Hispanic blacks (P = 0.038). The age-adjusted proportion of patients meeting the non-HDL cholesterol goal of levels < 130 mg/dL increased significantly for those aged 60 years or older (P = 0.031), and for Mexican Americans (P = 0.029). The age-adjusted proportion of patients meeting the LDL cholesterol goal of levels < 100 mg/dL did not significantly increase for every age group, both sexes, and every racial/ethnic group.
Furthermore, the age-adjusted percentage of participants with diagnosed diabetes who met the more aggressive apo B goal of levels < 80 mg/dL was 33.6% (95% CI, 18.7–48.5%) in 2015–2016. The age-adjusted percentage of patients who achieved the more aggressive LDL cholesterol goal of levels < 70 mg/dl was 10.9% (95% CI, 7.7–14.1%) in 2015–2016. The age-adjusted percentage of patients who achieved the more aggressive non-HDL cholesterol goal of levels < 100 mg/dl was 23.0% (95% CI, 14.7–31.4%) in 2017–2018.
Age-Adjusted Trends in the Percentage of Participants Achieving Glycemic Goals or Showing Poor Glycemic Control
From 2005 to 2018, the age-adjusted percentage of adults with diabetes who achieved the A1C target concentration of < 7% increase from 53.1% (95% CI, 44.7–61.5%) in 2005–2006 to 55.3% (95% CI, 41.8–68.8%) in 2017–2018, but the change was not statistically significant (P = 0.275) (Table 3 and Supplementary Fig. 2). Also, the age-adjusted percentage of participants showing poor glycemic control for adults with diabetes improved slightly from 23.2% (95% CI, 15.9–30.4%) in 2005–2006 to 16.1% (95% CI, 9.4–22.7%) in 2017–2018, but there were no statistically significance (P = 0.996) (Supplementary Table 7 and Supplementary Fig. 2).
Table 3
Age-adjusted percentage of achieving hemoglobin A 1c concentration < 7% among U.S. adults with diabetes aged ≥ 20 years, 2005–2018
|
2005–2006
|
2007–2008
|
2009–2010
|
2011–2012
|
2013–2014
|
2015–2016
|
2017–2018
|
P for linear trend
|
A1C < 7%
|
A1C < 7%
|
A1C < 7%
|
A1C < 7%
|
A1C < 7%
|
A1C < 7%
|
A1C < 7%
|
Total
|
53.1 (44.7 to 61.5)
|
53.4 (42.5 to 64.3)
|
51.0 (39.0 to 63.0)
|
51.5 (41.4 to 61.7)
|
49.1 (40.9 to 57.4)
|
57.6 (51.7 to 63.4)
|
55.3 (41.8 to 68.8)
|
0.275
|
Age group, y
|
|
|
|
|
|
|
|
|
20–39
|
46.7 (27.8 to 65.7)
|
52.6 (30.3 to 75.0)
|
48.5 (24.2 to 72.7)
|
48.2 (22.9 to 73.5)
|
50.1 (33.0 to 67.3)
|
70.3 (60.7 to 80.0)
|
62.6 (35.4 to 89.7)
|
0.136
|
40–59
|
52.4 (39.5 to 65.2)
|
53.8 (43.2 to 64.5)
|
49.9 (36.7 to 63.0)
|
50.8 (40.1 to 61.5)
|
43.3 (34.4 to 52.1)
|
44.4 (33.8 to 55.1)
|
46.4 (34.2 to 58.6)
|
0.113
|
≥ 60
|
65.2 (53.8 to 76.6)
|
54.1 (46.5 to 61.6)
|
57.2 (50.2 to 64.2)
|
58.4 (49.3 to 67.4)
|
56.8 (47.2 to 66.4)
|
56.8 (48.7 to 64.8)
|
56.9 (47.3 to 66.5)
|
0.423
|
Sex
|
|
|
|
|
|
|
|
|
Male
|
47.8 (34.8 to 60.8)
|
49.4 (36.3 to 62.5)
|
45.4 (29.2 to 61.6)
|
49.4 (36.1 to 62.7)
|
50.4 (38.1 to 62.6)
|
48.6 (35.6 to 61.7)
|
54.6 (40.2 to 69.0)
|
0.124
|
Female
|
57.7 (47.1 to 68.2)
|
56.4 (44.4 to 68.4)
|
58.3 (42.8 to 73.7)
|
53.5 (37.3 to 69.8)
|
49.9 (37.0 to 62.7)
|
63.9 (58.7 to 69.1)
|
58.8 (42.3 to 75.3)
|
0.838
|
Race/ethnicity
|
|
|
|
|
|
|
|
|
Mexican American
|
54.8 (35.1 to 74.5)
|
48.4 (32.9 to 63.8)
|
44.7 (23.8 to 65.5)
|
26.2 (16.1 to 36.2)
|
48.5 (30.2 to 66.8)
|
33.1 (19.1 to 47.1)
|
50.5 (32.8 to 68.2)
|
0.824
|
Non-Hispanic white
|
49.3 (36.0 to 62.7)
|
52.2 (37.5 to 67.0)
|
53.6 (37.7 to 69.5)
|
59.2 (42.5 to 75.8)
|
47.6 (36.9 to 58.3)
|
70.8 (61.9 to 79.6)
|
55.3 (31.3 to 79.4)
|
0.414
|
Non-Hispanic black
|
43.9 (32.5 to 55.2)
|
54.1 (36.5 to 71.8)
|
46.9 (26.2 to 67.7)
|
50.1 (31.8 to 68.4)
|
52.0 (39.5 to 64.5)
|
46.6 (39.4 to 53.8)
|
50.6 (35.4 to 65.7)
|
0.961
|
Other
|
64.6 (36.6 to 92.5)
|
76.0 (65.5 to 86.5)
|
46.8 (24.6 to 69.1)
|
46.5 (33.3 to 59.7)
|
51.8 (32.1 to 71.5)
|
65.7 (56.0 to 75.4)
|
70.4 (65.3 to 75.4)
|
0.351
|
In the subgroup analyses, the proportion of patients who achieved the A1C goals of < 7% was not statistically significant changes over the 14-year period for every age group, both men and women, and all race/ethnicity subgroups. Similar trends over this 14-year period were observed in the proportion of those who achieved the A1C of > 9%.
Age-Adjusted Trends in the Percentage of Participants Achieving All Three Lipids Goals and the Glycemic Goal
Among all adults with diagnosed diabetes, the percentages of patients who achieved the apo B goal of < 90 mg/dL, the non-HDL cholesterol goal of < 130 mg/dl, the LDL cholesterol goal of < 100 mg/dl, and the A1C target of < 7% increased from 15.2% (95% CI, 7.4–23.0%) in 2005–2006 to 30.6% (95% CI, 18.1–43.1%) in 2015–2016, but the trend was not reach statistically significant (P < 0.396) (Supplementary Table 8 and Supplementary Fig. 2).
In the subgroup analyses, Mexican Americans and non-Hispanic blacks were less likely to meet all four goals than non-Hispanic whites, and men were less likely to achieve all four goals than women.
The proportion of all diabetic adults with at least one optimal level—either for apo B, non-HDL cholesterol, LDL cholesterol, or A1C—increased from 66.9% (95% CI, 55.4–78.5%) in 2005–2006 to 73.3% (95% CI, 65.4–81.1%) in 2015–2016, but the trend was also not statistically significant (P < 0.996).
We also found that the percentages of patients who were achieving all of the more aggressive goals (i.e., apo B < 80 mg/dL, non-HDL cholesterol < 100 mg/dl, LDL cholesterol < 70 mg/dl, and A1C < 7%) was 3.9% (95% CI, 1.8–5.9%) in 2015–2016.