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The Disease That May Be a Leading Cause of Death

Survey estimates that diabetes accounts for many more deaths in the United States than are being reported on death certificates — and that diabetes is actually the third leading cause of death.

So when a patient dies from a heart attack, stroke or heart disease that is caused by diabetes or when a patient dies from kidney failure, or if a patient dies 6 months after an amputation, the death certificate does not say that the death was caused by diabetes.  About 12% of deaths in 30- to 84-year-olds from 1997 to 2011 could be attributed to diabetes, the latest data from the National Health Interview Survey (NHIS) and the National Health and Nutrition Examination Survey (NHANES) indicate. But during that time, only 3.3% of death certificates listed diabetes as the underlying cause of death.

The prevalence of diabetes has been rising rapidly throughout the world. Global age-standardized diabetes prevalence increased from an estimated 4.3% in 1980 to 9.0% in 2014 in men, and from 5.0% to 7.9% in women. The United States is no exception to this trend. Using combined criteria of self-reported diagnosis, fasting plasma glucose and hemoglobin A1c, the prevalence of diabetes among adults aged 20+ rose from 8.4% in 1988–94 to 12.1% in 2005–10. Trends are similar when HbA1c is the sole criterion.

Diabetes is associated with many diseases and disabilities, including ischemic heart disease, renal disease, visual impairment, peripheral arterial disease, peripheral neuropathy, and cognitive impairment. And it can increase the risk for many other diseases, even cancer. It is also associated with mortality. In 2010, diabetes was the seventh leading cause of death in the United States. It was listed as the underlying cause of death on 69,091 death certificates (2.8% of total deaths) and appeared in some location on a total of 234,051 death certificates.

The frequency with which diabetes is listed as the underlying cause of death is not a reliable indicator of its actual contribution to the national mortality profile. The sensitivity and specificity of death certificate assignments of diabetes as an underlying cause of death are low, far below those of administrative records or surveys. People who die with diabetes typically have other conditions that may contribute to death. When both diabetes and cardiovascular disease are mentioned on a death certificate, whether or not diabetes is listed as the underlying cause is highly variable and to some extent arbitrary. For example, it is affected by the decedent’s race and sex, whether the death occurs in a hospital, and the number of cardiologists per capita in the area.

An alternative means of estimating the contribution of diabetes to the national mortality profile is to use nationally representative cohorts to identify the excess mortality risk among people with diabetes. That excess risk can be used in combination with the prevalence of diabetes among deaths to estimate the fraction of deaths that would not have occurred in the absence of diabetes.

Responsibility for approximately 12% of deaths would make diabetes the third leading cause of death in the United States in 2010, after diseases of the heart and malignant neoplasms and ahead of chronic lower respiratory diseases and cerebrovascular diseases.

“When we monitor trends in the health of populations and we look at the mortality statistics,” Dr. Stokes, lead author, noted in a statement, “some major threats to U.S. mortality and life expectancy stand out, like drug and alcohol poisonings and suicide. Diabetes didn’t.”  However, these findings show that diabetes is a major contributor to a shorter lifespan and “reinforce the need for robust population-level interventions aimed at diabetes prevention and care,” the researchers concluded.

According to previous reports, in 2010, diabetes was the seventh leading cause of death in the United States, and it was listed as the cause of death on 69,000 death certificates (2.8% of total deaths). However, death certificates list only one underlying cause of death and tend to underestimate diabetes as the cause, especially if the deceased person had both diabetes and cardiovascular disease, they say.

Instead of looking at death certificates, nationally representative surveys may provide a better estimate of the fraction of deaths attributable to diabetes.

Using this approach, other researchers have reported that, based on NHANES data from 1976 to 1980, diabetes was responsible for 3.6% of deaths in the United States, or 5.1% of deaths if undiagnosed diabetes was included (Am J Epidemiol. 2002;156:714-719).

Diabetes may represent a more prominent factor in American mortality than is commonly appreciated, reinforcing the need for robust population-level interventions aimed at diabetes prevention and care.

Practice Pearls:

  • The proportion of deaths attributable to diabetes is much greater than the 3.3–3.7% of deaths in which diabetes is assigned as the underlying cause of death.
  • Responsibility for approximately 12% of deaths would make diabetes the third leading cause of death in the United States in 2010. Today it would be much higher if we looked at the actual cause of death and not just the end result.
  • The prevalence of diabetes has been rising rapidly throughout the world. Global age-standardized diabetes prevalence increased from an estimated 4.3% in 1980 to 9.0% in 2014 in men, and from 5.0% to 7.9% in women.

PLoS ONE. Published online January 25, 2017. Article