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CME / ABIM MOC / CE

Is Adult Diabetes Prevalence Rising?

  • Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 4/28/2023
  • Valid for credit through: 4/28/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for primary care physicians, endocrinologists, nurses, physician assistants, nurse practitioners, pharmacists, and other clinicians who care for adults at risk for diabetes.

The goal of this activity is for members of the healthcare team to be better able to assess recent trends in the prevalence of diabetes and, specifically, lean diabetes in the United States.

Upon completion of this activity, participants will:

  • Evaluate the clinical characteristics of lean diabetes
  • Assess recent trends in the prevalence of diabetes and, specifically, lean diabetes in the United States
  • Outline implications for the healthcare team.


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News Author

  • Mitchel L. Zoler, PhD

    Freelance writer, Medscape

    Disclosures

    Mitchel L. Zoler, PhD, has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine

    Disclosures

    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development L.L.C.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Yaisanet Oyola, MD, has no relevant financial relationships.

Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

    The European Union of Medical Specialists (UEMS)-European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 credit™ into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

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    Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Support of MOC” program in Section 3 of the Royal College’s MOC Program.​

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  • Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) (Universal Activity Number: JA0007105-0000-23-153-H01-P).

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    Medscape, LLC has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.25 AAPA Category 1 CME credits. Approval is valid until 4/28/2024. PAs should only claim credit commensurate with the extent of their participation.

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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CME / ABIM MOC / CE

Is Adult Diabetes Prevalence Rising?

Authors: News Author: Mitchel L. Zoler, PhD; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/28/2023

Valid for credit through: 4/28/2024

processing....

Clinical Context

Most clinicians and certainly most patients have a mental picture of type 2 diabetes (T2D) that includes diabetes, and the authors of the current study noted that approximately 89% of adults with diabetes have overweight or obesity. Yet the prevalence of lean diabetes, defined as T2D in persons with a body mass index (BMI) < 25 kg/m2, may be increasing, and lean diabetes has important clinical characteristics distinct from the majority of patients with T2D. A review by George and colleagues, which appeared in the May 15, 2015 issue of the World Journal of Diabetes,[1] addressed these issues.

Lean diabetes usually is diagnosed around age 40 years, and it is more common among men compared with women. Although the diagnosis of type 1 diabetes should be considered on the presentation of patients with elevated blood glucose levels and BMI < 25 kg/m2, islet cell autoantibodies are not encountered in patients with lean diabetes. Still, insulin sensitivity is better in lean diabetes vs T2D, in general, and the pathology of lean diabetes is more dependent on reduced insulin secretion. Although it might seem that lean patients with T2D would be at lower risk for complications of diabetes, this does not appear to be the case.

The current study by Adesoba et al performed an important analysis of diabetes prevalence in the United States, with a focus on lean diabetes.

Study Synopsis and Perspective

The prevalence of diabetes among lean US adults (BMI < 25 kg/m2) significantly increased from 2015 to 2020, whereas diabetes prevalence stayed flat among people with overweight or obesity, showed data from telephone surveys of more than 2.6 million American adults.

The new study results showed that in lean adults, the prevalence of diabetes rose from 4.5% in 2015 to 5.3% in 2020, a nearly 18% relative increase over the 6 years.

In contrast, among overweight and obese American adults, the prevalence of diabetes was 14% in 2015 and 14.3% in 2020, a nonsignificant difference during the 6-year window, reported researchers from the Department of Health Policy and Management at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, in a recent report published in Diabetes Care.[2]

"We find it interesting that within the time period of our study only lean adults experienced an increase in diabetes prevalence. More studies are needed to elucidate what may be causing this," said Taiwo P. Adesoba, lead researcher on the study, in an interview.

A Signal for Broader Diabetes Screening?

The results suggest a need to better understand the increasing prevalence of diabetes among people with lower BMI and raise the issue of "whether we need to provide more resources to certain populations to ensure that everyone has access to regular diabetes screening," said Clare C. Brown, PhD, senior author of the report, who is also at the University of Arkansas for Medical Sciences.

Although the American Diabetes Association (ADA) now recommends routine serial diabetes screening for all asymptomatic adults starting when people reach the age of 35 years (and starting at a younger age in adults with risk factors including elevated weight),[3] this standard has only been in place since 2022.

In addition, the US Preventive Services Task Force 2021 recommendations[4] called for diabetes screening for asymptomatic people aged 35 to 70 years only if they have obesity or are overweight (BMI ≥25 and ≥30 kg/m2).

Despite this, one possible explanation for the observed rise in diabetes prevalence among asymptomatic US adults with normal weight is increased screening of these people.

"Many clinicians follow the ADA screening guidelines. It is possible that the noted increased prevalence of lean diabetes is due, to some degree, to wider adoption of these screening recommendations”, commented Dan V. Mihailescu, MD, interim chief of endocrinology at Cook County Health in Chicago, Illinois, who was not involved with the new report.

The authors of another recent study have also determined that using age, rather than weight, as the primary screening tool for diabetes would be the easiest, and most equitable, approach to capturing the most cases possible, as reported by Medscape Medical News. The researchers, from Northwestern University Feinberg School of Medicine, Chicago, Illinois, also call for screening from age 35 years upwards for all US adults.

"All major racial and ethnic minority group develop diabetes at lower weights than White adults, and it's most pronounced for Asian Americans," said the lead author of that report, Matthew J. O'Brien, MD.

Mihailescu, too, supports the concept of more liberal screening.

"Broader routine screening for diabetes has very little risk but could identify people with disease who may not present with typical risk factors. I hope that more primary care practitioners adopt the ADA screening guideline" and initiate screening in all adults once they reach 35 years old regardless of their BMI, he said.

Diabetes Type Remained Unconfirmed in Study

The study by Adesoba and colleagues used data collected by the Behavioral Risk Factor Surveillance System,[5] a program run by the Centers for Disease Control and Prevention, using telephone interviews in 2015 to 2020 with a total of 2,630,463 adult US residents.

Respondents self-reported being diagnosed with diabetes. The authors acknowledged the data limitation of not being able to distinguish between type 1 diabetes and T2D but maintained that "type 1 diabetes is unlikely to be the sole cause" of the increasing US prevalence of lean diabetes."

They based this inference on the generally low prevalence of type 1 diabetes among all adults with diabetes -- a prevalence rate they estimated to be about 6% -- and the increasing prevalence of diabetes they found during the 6 years studied among lean adults who were at least 45 years old.

Mihailescu said the lack of more detailed information on diabetes type is a limitation.

"Some of the cases reported as lean diabetes could have been latent autoimmune diabetes of adults (LADA)," he noted in an interview, adding that some studies have reported that 5% to 10% of adults initially diagnosed with T2D actually have LADA.

The upshot is that the numbers reported by Adesoba and colleagues "might represent a significant over-estimation of the actual prevalence of lean diabetes," Mihailescu said.

The study was also limited by its reliance on self-reports of weight and height, he added.

Subgroup Analyses: Diabetes Cases Rise in Certain Racial Groups and in Women

Additional analyses in the report showed that among the 791,445 people with lean diabetes, the adults who were at least 45 years old had a much higher diabetes prevalence: 9.9% in 2020 compared with younger adults, who had a prevalence of just 1.3% in 2020.

Still, the growth in prevalence from 2015 to 2020 seemed unaffected by age, with virtually identical odds ratios for prevalence in 2020 compared with 2015, which was 1.19 in persons aged 45 years or older and 1.2 in younger adults.

A further subgroup analysis showed that people who self-identified as Black had the highest diabetes prevalence by race or ethnicity in every year included in the study, reaching a peak of 9.2% in 2020, with an OR of 1.44 compared with 2015.

Survey participants who identified as Hispanic had prevalence rates that rose from 5.5% in 2015 to 7.2% in 2020, with an OR of 1.32. Among White survey participants, the prevalence rate in 2020 was 4.4%, a significant OR of 1.15 compared with 2015.

Diabetes prevalence also rose much more in women, who had a diabetes prevalence of 5.3% in 2020, an OR of 1.45 compared with 2015, which brought the prevalence rate in women much closer to the rate in men, which was 5.9% in 2020. Among men, the prevalence rate in 2020 did not significantly change from the rate in 2015 of 5.5%.

"We are still learning about lean diabetes, and we need to know more about the genetic and environmental mechanisms that influence insulin secretion, beta-cell mass and survival, and insulin resistance," noted Mihailescu. "Lean diabetes remains an understudied topic, and much more research is needed to better understand it."

The study received no funding. Adesoba, Brown, and Mihailescu have reported no relevant financial relationships.

Study Highlights

  • Investigators drew study data from the Behavioral Risk Factor Surveillance System, which collects information on chronic illnesses and health behaviors of US adults aged ≥ 18 years. The current study by Adesoba et al analyzes data collected by this system between 2015 and 2020.
  • Researchers identified positive cases of diabetes when participants responded that a health professional had told them of the diagnosis of diabetes. The present study excluded cases of gestational diabetes.
  • The main study outcomes were trends in the prevalence of diabetes, particularly lean diabetes. The study outcomes were adjusted to account for age, sex, and race/ethnicity.
  • Study researchers assessed 2,630,463 respondents. The prevalence of diabetes increased from 10.5% of all respondents in 2015 to 11.4% in 2018. It then remained at 11.1% in 2019 and 2020.
  • The prevalence of diabetes increased more substantially in Black and Hispanic adults compared with White adults, but the most significant demographic factor in the increased prevalence of diabetes was age. The prevalence of diabetes increased by 14.3% among persons aged < 45 years during the study period compared with a respective increase of 4.1% among adults at age ≥ 45 years.
  • The prevalence of diabetes in the lean population of the study was 4.5% in 2015 and 5.3% in 2020, a 17.8% increase. The prevalence of lean diabetes increased by 41.5% and 30.9% in the Black and Hispanic study cohorts, respectively.
  • The prevalence of diabetes increased by 6.9% among women during the study period, but there was no such increase among men.
  • Lean diabetes was more common among men compared with women throughout the study period; however, lean diabetes increased by 43.2% among women between 2015 and 2020; again, there was no such increase among men.
  • The substantial increase in the prevalence of diabetes among adults at age < 45 years was not fueled by lean diabetes. Lean diabetes grew more substantially among persons at age ≥ 45 years (17.9%) compared with younger adults (10%) in the obese/overweight category.

Implications for the healthcare team

  • Lean diabetes usually is diagnosed around age 40 years, and it is more common among men compared with women. Islet cell autoantibodies are not encountered in patients with lean diabetes. Still, insulin sensitivity is better in lean diabetes vs T2D, in general, and the pathology of lean diabetes is more dependent on reduced insulin secretion. Although it might seem that lean patients with T2D would be at lower risk for complications of diabetes, this does not appear to be the case.
  • The current study by Adesoba et al found a moderate increase in the prevalence of diabetes among US adults from 2015 to 2020. The increase in lean diabetes specifically was more profound (~ 18%), and lean diabetes was particularly more common among Black and Hispanic adults along with women.
  • The healthcare team should consider screening adults with a body mass index BMI < 25 kg/m2 for diabetes, especially if they have risk factors such as a family history of diabetes.

 

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