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The Risk Factor Responsible for Half of America’s Diabetes Cases

Jun 19, 2021
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Brenda Oppong, PharmD Candidate, LECOM School of Pharmacy

Approximately 30% to 53% of diabetes mellitus cases in the United States can be attributed to obesity. 

Over the last few decades, the burden of obesity on the prevalence of diabetes has been substantial, demonstrating that obesity remains an influential contributor to diabetes mellitus. The prevalence of diabetes and obesity continues to increase in the United States, making it essential to target the factors that continue to contribute its increase. In a study recently published in the Journal of the American Heart Association, Cameron et al. determined the excess risk of diabetes Mellitus associated with the risk factor obesity and changes over time.  


A high percentage of diabetes in the United States can be attributed to obesity with significant public health policy implications. Therefore, this study was conducted to determine the population attributable fraction (PAF) that accounts for the excess risk and prevalence of diabetes mellitus associated with obesity. The results vary by sex-race/ethnicity, with non-Hispanic White women demonstrating the highest-burden of obesity.  

The study used the PAF to describe the contribution of obesity to the burden of diabetes. Although prior studies reporting PAF estimates have been conducted in several populations, there are not enough recent PAF estimates of diabetes attributable to obesity in the United States. The reduction of people with obesity could have a meaningful impact on the prevention of diabetes. Estimates of the population burden were provided by Longitudinal data from the Multi-Ethnic Study of Atherosclerosis (MESA; 2000–2017) and serial cross-sectional data from adults in the National Health and Nutrition Examination Survey (NHANES; 2001–2016). Participants who were Mexican American, non-Hispanic Black, and non-Hispanic White without diabetes at baseline were included from MESA. Body mass index and key characteristics such as diet, income, educational level, age, physical activity and study site were used to calculate adjusted and unadjusted hazard ratios for obesity-related diabetes. 

MESA participants had a median age of 61 years. 53.9% were non-Hispanic White, 32.9% were non-Hispanic Black, 13.3% were Mexican, and 46.8% were men. Over a median of 9.2 years of observation, diabetes mellitus occurred in 11.6% of the participants. Diabetes incidence was 20% higher in individuals with obesity than individuals without obesity (7.3%). The individuals were diagnosed with diabetes according to ADA fasting criteria ≥126 mg/dL. Obesity-related diabetes mellitus adjusted hazard ratio was 2.7 (95% CI, 2.2–3.3). PAF adjusted were 0.35 (95% CI, 0.29–0.40) (2001-2004) and 0.41 (95% CI, 0.36–0.46) (2013-2016). These results were greatest among non‐Hispanic White women. 

NHANES cycles consisted of 4 groups (2001–2004, 2005–2008, 2009–2012, and 2013–2016). Participants with and without diabetes mellitus were required for the calculation of PAF. Diabetes was defined by the self-reported use of medications for hypoglycemia or insulin, a fasting glucose of ≥126 mg/dL, or self-reported diagnosis. The prevalence estimation from NHANES, used to calculate PAFs in 2001 to 2004 and 2013 to 2016 survey cycles, showed the overall prevalence of obesity was constantly higher among those with diabetes and increased from 34% (95% CI, 32%–37%) to 41% (95% CI, 39%–44%). Overall, the prevalence of obesity was lower among non-Hispanic white women than non-Hispanic Black and Mexican American women. The results for men differed, as the prevalence of obesity among male participants with diabetes was alike among race/ethnicity. The most significant difference in obesity prevalence between those with diabetes and all participants was observed in non-Hispanic white women. 

Within each sex‐race/ethnicity group, PAF estimates increased over time except for in non-Hispanic White men, where it remained stable. On the other hand, the greatest absolute increase in PAF, increasing from 0.22 (95% CI, 0.12–0.33) in 2001 to 2004 to 0.38 (95% CI, 0.25–0.5) (adjusted) in 2013 to 2016, was shown in Mexican Americans. There were notable differences in diabetes attributable to obesity among sex‐race/ethnicity subgroups. Despite non-Hispanic White women having the lowest prevalence of obesity, this group consistently demonstrating the highest overall PAFs. 

The results highlighted the burden of diabetes and the substantial impact the reduction of obesity at a population level could have on the prevention of diabetes in the United States.  

Practice Pearls 

  • The burden of obesity on the prevalence of diabetes is substantial.
  • Obesity‐attributable diabetes varies by sex‐race/ethnicity.
  • Policy changes should be implemented targeting obesity to reduce the morbidity and mortality related to diabetes.


Natalie A. Cameron, Lucia C. Petito, Quantifying the SexRace/EthnicitySpecific Burden of Obesity on Incident Diabetes Mellitus in the United States, 2001 to 2016: MESA and NHANES. Journal of the American Heart Association, 10 February 2021. 


Brenda Oppong, PharmD Candidate, LECOM School of Pharmacy 

Oluwatayo Ishola, PharmD. Candidate, South College, School of Pharmacy: additional material