482 Diabetes Care Volume 38, March 2015

Tobin M. Abraham,1 Karol M. Pencina,2 Trends in Diabetes Incidence: The Michael J. Pencina,3,4 and Framingham Study Caroline S. Fox1,5,6 Diabetes Care 2015;38:482–487 | DOI: 10.2337/dc14-1432

OBJECTIVE and type 2 diabetes continue to increase in prevalence in the U.S. Whether diabetes incidence continues to increase in recent times is less well documented. We examined trends in diabetes incidence over the previous four decades.

RESEARCH DESIGN AND METHODS Framingham Heart Study participants ages 40–55 years and free of diabetes at baseline (n = 4,795; mean age 45.3 years; 51.6% women) were followed for the development of diabetes in the 1970s, 1980s, 1990s, and 2000s. Diabetes was defined as either fasting glucose ‡126 mg/dL or use of antidiabetes medication. EPIDEMIOLOGY/HEALTH SERVICES RESEARCH Poisson regression was used to calculate sex-specific diabetes incidence rates for a 47-year-old individual in each decade. Rates were also calculated among obese, , and normal weight individuals.

RESULTS The annualized rates of diabetes per 1,000 individuals were 2.6, 3.8, 4.7, and 3.0 (women) and 3.4, 4.5, 7.4, and 7.3 (men) in the 1970s, 1980s, 1990s, and 2000s, respectively. Compared with the 1970s, the age- and sex-adjusted relative risks of 1Division of Endocrinology, Diabetes and Hyper- diabetes were 1.37 (95% CI 0.87–2.16; P = 0.17), 1.99 (95% CI 1.30–3.03; P =0.001), tension, Brigham and Women’s Hospital and – P Harvard Medical School, Boston, MA and 1.81 (95% CI 1.16 2.82; = 0.01) in the 1980s, 1990s, and 2000s, respectively. 2Statistics and Consulting Unit, Department of Compared with the 1990s, the relative risk of diabetes in the 2000s was 0.85 (95% Mathematics and Statistics, , CI 0.61–1.20; P = 0.36). Boston, MA 3Duke Clinical Research Institute, Duke Univer- CONCLUSIONS sity, Durham, NC 4Department of Biostatistics and Bioinformatics, In our community-based sample, the risk of new-onset diabetes continued to be Duke University, Durham, NC higher in the 2000s compared with the 1970s. In the past decade, diabetes in- 5National Heart, Lung, and Blood Institute’s cidence remained steady despite the ongoing trend of rising adiposity. Framingham Heart Study, Framingham, MA 6National Heart, Lung, and Blood Institute, Bethesda, MD Recent studies indicate that prevalence of both prediabetes and overt diabetes Corresponding author: Caroline S. Fox, foxca@ continues to rise in the U.S. (1–3). This increasing prevalence may be due to an nhlbi.nih.gov. increase in diabetes incidence, improved survival among individuals with diabetes, Received 9 June 2014 and accepted 16 November or a combination of these factors. 2014. The trends in prediabetes and diabetes prevalence have paralleled high rates of This article contains Supplementary Data online overweight and obesity, which are leading risk factors for the development of di- at http://care.diabetesjournals.org/lookup/ suppl/doi:10.2337/dc14-1432/-/DC1. abetes (4,5). Recent data, however, suggest the prevalence of obesity among adults, which was increasing from the 1970s through the early 2000s, may have leveled off A slide set summarizing this article is available online. in the past few years (4,6,7). Specifically, data from the National Health and Nutri- © 2015 by the American Diabetes Association. tion Examination Survey (a large nationally representative sample) suggested that Readers may use this article as long as the work the prevalence of obesity, while high, did not change significantly between 2003 and is properly cited, the use is educational and not 2004 and 2011 and 2012 (6). for profit, and the work is not altered. care.diabetesjournals.org Abraham and Associates 483

There are few estimates of trends in later. Generation 3 participants from overweight (BMI 25 to ,30 kg/m2), diabetes incidence in recent times (8). the first examination (2002–2005) formed class 1 obesity (BMI 30 to ,35 kg/m2), Some existing estimates focus on a sin- the sample for the 2000s. Incident diabe- or class 2 obesity (BMI $35 kg/m2)d gle ethnic group or age group and thus tes was assessed ;6 years later at the and calculated diabetes incidence rates may not apply to the general adult pop- second examination (2008–2011). for a 47-year-old individual within each ulation (9,10). Other estimates are One individual who was included in BMI category for each decade. based on self-reported diabetes, which the previous report from our cohort in Using the 1970s as the reference pe- may underestimate the true incidence the 1970s was excluded from the present riod, we calculated overall and sex- (11,12). We previously reported diabe- analysis due to missing BMI (8). A total specific age-adjusted relative risks of tes incidence in our cohort in the 1970s, of 3,103 unique individuals from the incident diabetes in the 1980s, 1990s, 1980s, and 1990s (8), and in the current Offspring Cohort (n = 1,587 women) con- and 2000s. We also calculated overall study, we seek to update these inci- tributed to 1,308, 1,551, and 1,663 and sex-specific age- and BMI-adjusted dence estimates in the context of the person-examinations in the 1970s, 1980s, relative risks of incident diabetes in the obesity epidemic. In the Framingham and 1990s, respectively. A total of 1,692 1980s, 1990s, and 2000s. Additionally, Heart Study, screening for diabetes is unique individuals from the Generation wecalculatedtherelativeriskofinci- conducted at each examination, along 3Cohort(n = 889 women) were observed dent diabetes in the 2000s compared with measures of adiposity such as in the 2000s. Thus, the overall sample with the 1990s. BMI. Thus, our study is able to provide consisted of a total of 4,795 unique indi- Finally, we characterized individuals reliable estimates of diabetes incidence viduals (n =2,476women). who developed diabetes and individuals and furthermore to assess the associa- who remained free of diabetes based on tions of overweight and obesity to the Assessment of Outcome demographics and standard cardiovas- Incident diabetes was defined as a fast- observed trends. cular risk factors including status, ing plasma glucose $126 mg/dL or use blood pressure, and . of glucose-lowering medication at the RESEARCH DESIGN AND METHODS All analyses were performed using follow-up examination. In a secondary Study Sample SAS version 9.3. analysis, we defined individuals with The Framingham Heart Study is a com- “diagnosed diabetes” cases if they were munity-based of cardiovas- Secondary Analyses treated with a glucose-lowering agent at To evaluate the possibility that differences cular disease and risk factors that has the time of the follow-up examination. in incidence in the 2000s were attribut- been in continuous operation since able to the shorter accrual time (6-year 1948 beginning with the Original Co- Metabolic Risk Factor Assessment follow-up vs. 8-year follow-up in other hort. Recruitment of the Offspring Co- Key metabolic risk factors were mea- decades), we performed a sensitivity hort began in 1971; participants were fi sured at the clinic exam. BMI, de ned analysis by expanding the age range in invited back for a second examination as weight in kilograms (assessed using a the 2000s to include individuals from 8yearsaftertheinitialexamandsub- Detecto scale; Detecto, Webb City, MO) ages 40 to 57 years at baseline. sequently every 4 years thereafter. Re- divided by the square of the height in To assess whether diabetes detection cruitment of the Third Generation meters, was calculated. Waist circumfer- is improving, we calculated rates of di- Cohort began in 2001. The first exami- ence was measured at the level of the agnosed diabetes for each decade. nation cycle lasted from 2002 through umbilicus and reported to the nearest 2005. The second examination cycle quarter inch. Smoking status and alcohol Assessment of Bariatric Surgery lasted from 2008 through 2011. consumption were assessed via physician Because of the reported increases in To ensure an overlapping age distri- interview. Seated systolic and diastolic bariatric surgery in the 2000s (13), we bution across all decades, we limited the blood pressures were measured on site conducted a chart review to determine current analysis to participants ages 40 manually using a mercury column sphyg- the number of participants who had un- to 55 years who were free of diabetes at momanometer. Total was dergone bariatric surgery. We selected the baseline examination. Prevalent di- measured on fasting morning samples. all participants who had lost .20% of abetes was defined as fasting glucose was defined as systolic their body weight between baseline $126 mg/dL or on treatment with insu- blood pressure $140 mmHg, diastolic blood and follow-up examination. Fifteen par- lin or other antidiabetes agent. Off- pressure $90 mmHg, or on treatment. ticipants were identified in this manner; spring participants ages 40–55 years we then performed a detailed chart re- and free of diabetes at exam 1, which Statistical Analyses view on these individuals to determine ran from 1971 to 1975, formed the sam- Sex-specific mean age and BMI were cal- whether they had undergone a bariatric ple for the 1970s. Using the same selec- culated for each decade. To adjust for procedure. Of these, five had had a bar- tion criteria, offspring participants from difference in follow-up time between iatric procedure, and two of the five had the second examination (1979–1983) cohorts, we used Poisson regression developed diabetes in the interval, formed the sample for the 1980s, and with duration of follow-up as an offset which then resolved after weight loss. participants from the fourth examina- to calculate overall and sex-specifican- tion (1987–1991) formed the sample nualized diabetes incidence rates for a RESULTS for the 1990s. For the 1970s, 1980s, and 47-year-old individual in each decade. The mean age ranged from 46.0 years in 1990s, assessment of incident diabetes Next, we stratified individuals by BMI the 1970s to 45.9 years in the 2000s. The was performed at an exam ;8years categorydnormal (BMI ,25 kg/m2), mean BMI per decade were 25.0, 24.8, 484 The Framingham Heart Study Diabetes Care Volume 38, March 2015

25.6, and 26.4 kg/m2 among women and adiposity, we calculated diabetes incidence 1,000 men (95% CI 5.4–10.4). These re- 26.9, 27.0, 27.8, and 28.0 kg/m2 among stratified by normal, overweight, or obese sults are nearly identical to the primary men in the 1970s, 1980s, 1990s, and BMI(Fig.1).Amongclass1obeseindivid- analysis. Therefore, this shorter accrual 2000s respectively (Table 1). uals (BMI 30 to ,35 kg/m2), the annual- period is unlikely to explain our findings. ized rates of diabetes for a 47-year-old The annualized rates of diagnosed di- Overall Diabetes Incidence individual per 1,000 people were 7.0, abetes per 1,000 for a 47-year-old indi- The overall annualized rates of diabetes 8.0, 14.1, and 7.5 in the 1970s, 1980s, vidual increased steadily with each per 1,000 individuals were 3.0, 4.1, 6.0, 1990s, and 2000s, respectively (Table 3). decade: 0.6 (95% CI 0.3–1.3) in the and 5.5 in the 1970s, 1980s, 1990s, and Among class 2 obese individuals (BMI 1970s, 1.4 (95% CI 0.8–2.2) in the 1980s, 2000s, respectively (Table 1). The age- $35 kg/m2), the annualized rates were 2.2 (95% CI 1.5–3.2) in the 1990s, and 3.0 adjusted relative risks of diabetes were 11.7, 18.8, 21.7, and 26.7 per 1,000 in (95% CI 2.1–4.3) in the 2000s. 1.37 (95% CI 0.87–2.16; P = 0.17) in the each successive decade. Thus, among 1980s, 1.99 (95% CI 1.30–3.03; P , 0.01) class 1 obese, incidence rates were higher CONCLUSIONS in the 1990s, and 1.81 (95% CI 1.16–2.82; in the 1990s than in the 2000s, but among In our community-based cohort, we ob- P = 0.01) in the 2000s, using the 1970s are class 2 obese that trend was reversed. served that the risk of incident diabetes the reference period (Table 2). The number of individuals with class 2 was higher in the 1990s compared with Compared with the 1990s, the age- obesity in each decade was relatively the 1970s. Diabetes incidence contin- adjusted relative risk of diabetes inci- small, yielding wider CIs. ued to be higher in the 2000s compared dence in the 2000s was 0.85 (95% CI with the 1970s. Mean BMI has increased 0.61–1.20; P =0.36). Characterization of Individuals With with each decade, and diabetes inci- fi Incident Diabetes dence remains highest among obese in- Sex-Speci c Diabetes Incidence fi The annualized diabetes rates for a 47- Cardiovascular risk factor pro les describ- dividuals. Notably, even among obese year-old woman per 1,000 individuals ing individuals who developed incident individuals, diabetes incidence rates in- were 2.6, 3.8, 4.7, and 3.6 in the 1970s, diabetes in each decade are presented creased in the 1990s and 2000s com- 1980s, 1990s, and 2000s (Table 1). The as a descriptive analysis (Table 4). pared with the 1970s. Thus, rates of corresponding rates in men were 3.4, incident diabetes remained higher in 4.5, 7.4, and 7.5. Secondary Analyses the 2000s compared with the 1970s, We considered that the shorter follow- Among women the decade-specific, likely related to ongoing high prevalence up time in the 2000s (6 years) compared age-adjusted relative risks of diabetes of obesity. with the other decades (8 years) may with 1970s as a reference were 1.45, While there are some published stud- have led to underestimation of the 1.80, and 1.37 in the 1980s, 1990s, and ies reporting an increase in diabetes in- true diabetes incidence in the 2000s. 2000s (Table 2). Among men the corre- cidence in the 1990s (8,10), there are To assess this possibility, we conducted a sponding relative risks were 1.32 (P = few other estimates of trends in U.S. di- sensitivity analysis expanding the baseline 0.36), 2.16 (P , 0.01), and 2.20 (P , 0.01). abetes incidence in the 2000s in the age range to 40–57 years in the 2000s published literature. Data from the Na- (Supplementary Table 1). In this analysis, Diabetes Incidence by BMI Category tional Health Interview Survey from To evaluate the association between the diabetes incidence rates were 3.6 per 1997–2003 showed an increase in dia- the risk of diabetes and increasing 1,000 women (95% CI 2.3–5.6) and 7.5 per betes incidence from 4.9 per 1,000 in- dividuals in 1997 to 6.9 per 1,000 individuals in 2004 (14). There are sev- Table 1—Baseline characteristics and annualized rates of incident diabetes for eral possible explanations for their re- a 47-year-old individual ported increase in diabetes incidence, 1970s 1980s 1990s 2000s while we observed no increase over a Women, n 656 786 862 889 similar time frame. Their data are based Age, years 46 (4) 47 (5) 47 (4) 46 (4) on self-report of diabetes and thus are 2 BMI, kg/m 25.0 (4.3) 24.8 (4.5) 25.6 (5.3) 26.4 (6.0) less reliable than data obtained through Incident diabetes, n 13 24 32 19 directly measured fasting plasma glu- Annualized rate per cose values and physician-reviewed 1,000 (95% CI) 2.6 (1.5–4.5) 3.8 (2.5–5.7) 4.7 (3.3–6.7) 3.6 (2.3–5.6) medication history. Furthermore, the Men, n* 652 765 801 803 Age, years 46 (4) 47 (5) 47 (4) 46 (4) reported increase in diabetes incidence BMI, kg/m2 26.9 (3.2) 27.0 (3.4) 27.8 (3.9) 28.0 (4.3) in that study could be due to improved Incident diabetes, n 17 28 48 36 detection of diabetes rather than a true Annualized rate per populationchangeinincidence.Incon- 1,000 (95% CI) 3.4 (2.1–5.5) 4.5 (3.1–6.6) 7.4 (5.5–9.9) 7.5 (5.4–10.5) trast, our study followed the same indi- Overall, n 1,308 1,551 1,663 1,692 viduals over time and applied a consistent Incident diabetes, n 30 52 80 55 definition of diabetes that included both Annualized rate per diagnosed and undiagnosed cases. We 1,000 (95% CI) 3.0 (2.1–4.3) 4.1 (3.2–5.5) 6.0 (4.8–7.5) 5.5 (4.2–7.1) conducted a sensitivity of diabetes inci- Data are mean (SD) or n unless otherwise indicated. *Overall sample included 2,476 unique dence limited to diagnosed cases, and women and 2,319 unique men; some individuals were included in more than one decade. we observed an increase in diagnosed care.diabetesjournals.org Abraham and Associates 485

Table 2—Relative risks of incident diabetes for individuals ages 40–55 years free fasting glucose remained unchanged of diabetes in the 1980s, 1990s, and 2000s compared with the 1970s from 25.4% in 1999–2002 to 24.6% in Age-adjusted RR RR with age and BMI 2003–2006 to 27.5% in 2007–2010 (1). (95% CI) P value adjustment (95% CI) P value Because prediabetes is a precursor of Overall overt diabetes, this report that predia- 1970s Ref 1 betes did not change is consistent with 1980s 1.37 (0.87–2.16) 0.17 1.34 (0.85–2.11) 0.20 our findings of stable diabetes incidence 1990s 1.99 (1.30–3.03) ,0.01 1.58 (1.03–2.42) 0.04 in the 2000s compared with the 1990s. 2000s 1.81 (1.16–2.82) 0.01 1.32 (0.84–2.08) 0.22 We also found that diabetes inci- Women dence did not change significantly in 1970s Ref Ref the 2000s compared with the 1990s, de- – – 1980s 1.45 (0.74 2.86) 0.28 1.42 (0.72 2.80) 0.31 spite an increase in mean BMI and de- 1990s 1.80 (0.94–3.44) 0.08 1.40 (0.72–2.70) 0.32 2000s 1.37 (0.67–2.78) 0.38 0.96 (0.47–1.97) 0.92 spite more individuals with class 2 obesity in the 2000s. There are several Men 1970s Ref Ref potential factors that may have contrib- 1980s 1.32 (0.72–2.42) 0.36 1.29 (0.71–2.37) 0.40 uted to the stable diabetes incidence 1990s 2.16 (1.24–3.76) ,0.01 1.68 (0.95–2.95) 0.07 that we observed between the 1990s 2000s 2.20 (1.24–3.92) ,0.01 1.52 (0.84–2.75) 0.16 and the 2000s. One possibility is that Ref, referent; RR, relative risk. we underestimated diabetes in the 2000s because of the shorter accrual time (6 years) compared with the prior diabetes in each successive decade, sug- 8.6 per 1,000 in 2008 (11). However as decades (8 years). We attempted to cor- gesting that detection is indeed improv- discussed above, self-reported diabetes is rect for this in a secondary analysis that ing. Finally, the National Health Interview likely less reliable; in this case, the inci- expanded the age range studied in the Survey includes a broader age range of 18– dence could be underestimated depend- 2000s, which did not significantly alter 79 years. The inclusion of older individuals ing on patient education and access to the results. Thus, the shorter accrual in particular would be expected to yield a health care. time is unlikely to have substantially im- different estimate than the age range used Looking at recent trends in prediabe- pacted our results from the 2000s. in our study. Consistent with our findings, tes can also help to inform trends in Second, observed differences in the another study reported that self-reported diabetes. The National Health and Nutri- 2000s may represent a “cohort effect.” diabetes incidence in New York City was tion Examination Survey data showed Participants for the 2000s were drawn stabilizing, from 9.4 per 1,000 in 2002 to that prediabetes prevalence based on from a different population (Third Gen- eration) than the participants from the prior decades (Offspring Cohort), and thus, observed differences in the 2000s may reflect a characteristic or exposure that is unique to the Third Generation cohort. Potential factors may include differences in diet or physical activity between cohorts, both of which could affect diabetes risk. Third, increased use of bariatric sur- gery in the 2000s may have affected di- abetes incidence. Bariatric procedures increased 10-fold in the U.S. from ;16,200 in 1994 to 171,000 in 2005 (15). In our population, we identified only five individuals who had had bar- iatric surgery, only two of whom had documented diabetes. However, even if all five individuals would have devel- oped diabetes had they not had bariatric surgery, this would not explain the sta- ble incidence rate between the 1990s and 2000s. Finally, it is possible that the leveling — Figure 1 Annualized rates of diabetes per 1,000 individuals. Age-adjusted annualized rates of of diabetes incidence in the 2000s de- diabetes for a 47-year-old per 1,000 individuals, stratified by normal, overweight, or obese BMI. Error bars represent 95% CIs. Number of participants at risk in the normal, overweight, and spite an increase in mean BMI compared obese categories, respectively, in the 1970s were 585, 542, and 181; in the 1980s: 721, 604, and with the 1990s is partly due to a satura- 226; in the 1990s: 671, 654, and 338; in the 2000s: 651, 637, and 404. tion effect, meaning that the most 486 The Framingham Heart Study Diabetes Care Volume 38, March 2015

Table 3—Annualized rates of diabetes by BMI category for a 47-year-old individual 1970s 1980s 1990s 2000s Normal weight (BMI ,25 kg/m2), n 585 721 671 651 BMI, mean (SD) 22.7 (1.6) 22.5 (1.7) 22.5 (1.7) 22.4 (1.7) Incident diabetes, n 28 7 6 Annualized rate, per 1,000 individuals (95% CI) 0.5 (0.1–1.8) 1.4 (0.7–2.8) 1.3 (0.6–2.8) 1.6 (0.7–3.5) Overweight (BMI 25 to ,30 kg/m2), n 542 604 654 637 BMI, mean (SD) 27.1 (1.4) 27.2 (1.4) 27.3 (1.4) 27.3 (1.4) Incident diabetes, n 17 26 30 14 Annualized rate, per 1,000 individuals (95% CI) 4.1 (2.6–6.6) 5.2 (3.5–7.7) 5.6 (3.9–8.1) 3.7 (2.2–6.2) Class 1 obesity (BMI 30 to ,35 kg/m2), n 149 185 256 265 BMI, mean (SD) 31.9 (1.4) 31.9 (1.3) 32.0 (1.3) 32.0 (1.4) Incident diabetes, n 8122912 Annualized rate, per 1,000 individuals (95% CI) 7.0 (3.5–13.9) 8.0 (4.5–14.2) 14.1 (9.7–20.5) 7.5 (4.3–13.2) Class 2 obesity (BMI $35 kg/m2), n 32 41 82 139 BMI, mean (SD) 37.7 (3.4) 38.8 (3.1) 39.5 (4.4) 39.3 (4.1) Incident diabetes, n 3 6 14 23 Annualized rate, per 1,000 individuals (95% CI) 11.7 (3.8–36.5) 18.8 (8.4–41.9) 21.7 (12.8–36.6) 26.7 (17.7–40.5)

susceptible individuals in the 2000s may cigarette smoking and higher rates of in the Framingham cohorts may not be have already acquired diabetes at base- treatment for other modifiable cardio- nationally representative. Due to the line and thus been excluded from the vascular risk factors. age range used in this study (40–55 current analysis. This possibility is plau- Strengths of our study include the years), we would not have captured an sible in the context of high obesity rates. large community-based cohort with di- increase in diabetes incidence at a youn- This phenomenon has been described in rectly measured BMI and fasting blood ger age. the Pima Indian population, for example, glucose as well as robust assessment of In our community-based sample, risk in which diabetes incidence increased other cardiovascular risk factors. We did of diabetes increased in the 1990s and among ages 5–14 years but decreased not rely on self-reported diabetes or 2000s compared with the 1970s. Over among ages 25–34 years over the same height and weight, which can be suscep- the past decade, despite the ongoing time period (16). tible to bias. Some limitations warrant trend of rising obesity, diabetes inci- Our descriptive analysis suggested mention. Our sample is primarily white dence remained relatively stable. that individuals diagnosed with diabetes and thus not generalizable across other in the 2000s seem to have lower rates of ethnicities. Moreover, diabetes trends Funding. The Framingham Heart Study of the National Heart, Lung, and Blood Institute is Table 4—Risk factor profiles by decade for diabetes and no diabetes (ages 40–55 years) supported by contract N01-HC-25195. T.M.A. is supported by a National Institutes of Health– 1970s 1980s 1990s 2000s sponsored T32 training grant. Diabetes, n 30 52 80 55 Duality of Interest. No potential conflicts of Age, years 46 (3.1) 49 (4.8) 48 (4.3) 47 (3.9) interest relevant to this article were reported. Percent women 43.3 46.2 40.0 34.6 Author Contributions. T.M.A. researched BMI, kg/m2 29.6 (4.2) 29.7 (4.8) 31.3 (6.5) 32.9 (6.6) data and wrote the manuscript. K.M.P. and Overweight, % 56.7 50.0 37.5 25.5 M.J.P. performed statistical analysis and reviewed Obesity, % 36.7 34.6 53.8 63.6 and edited the manuscript. C.S.F. researched Current smoking, % 40.0 44.2 32.5 14.6 data and reviewed and edited the manuscript. C.S.F. is the guarantor of this work and, as such, Systolic blood pressure, mmHg 135 (13.2) 131 (14.4) 131 (14.6) 129 (15.6) had full access to all the data in the study and Hypertension, % 63.3 50.0 46.3 45.5 takes responsibility for the integrity of the data Antihypertension treatment, % 20.0 30.8 20.0 30.9 and the accuracy of the data analysis. Total cholesterol, mg/dL 217 (43.9) 220 (37.0) 200 (34.8) 200 (35.3) Lipid-lowering treatment, % 0.0 0.0 3.8 14.6 No diabetes, n 1,278 1,499 1,583 1,637 References Age, years 46 (4.1) 47 (4.7) 47 (4.4) 46 (4.1) 1. Bullard KM, Saydah SH, Imperatore G, et al. Percent women 50.3 50.8 52.4 53.2 Secular changes in U.S. Prediabetes prevalence fi BMI, kg/m2 25.9 (3.8) 25.7 (4.0) 26.5 (4.5) 26.9 (5.2) de ned by hemoglobin A1c and fasting plasma Overweight, % 41.1 38.6 39.4 38.1 glucose: National Health and Nutrition Examina- tion Surveys, 1999-2010. Diabetes Care 2013; Obesity, % 13.3 13.9 18.6 22.5 36:2286–2293 Current smoking, % 39.5 34.6 24.5 13.9 2. Ioannou GN, Bryson CL, Boyko EJ. Prevalence Systolic blood pressure, mmHg 126 (16.6) 123 (15.2) 122 (15.4) 118 (14.4) and trends of insulin resistance, impaired fast- Hypertension, % 28.1 23.8 24.8 21.9 ing glucose, and diabetes. J Diabetes Complica- Antihypertension treatment, % 5.5 9.9 9.2 12.0 tions 2007;21:363–370 Total cholesterol, mg/dL 211 (36.5) 210 (36.6) 203 (37.0) 195 (33.8) 3. Selvin E, Parrinello CM, Sacks DB, Coresh J. Lipid-lowering treatment, % 1.1 0.8 2.0 10.8 Trends in prevalence and control of diabetes in Continuous data are shown as mean (SD). the United States, 1988-1994 and 1999-2010. Ann Intern Med 2014;160:517–525 care.diabetesjournals.org Abraham and Associates 487

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