Mortality Trends in Men and Women with Diabetes, 1971 to 2000
Edward W. Gregg, PhD; Qiuping Gu, MD, PhD; Yiling J. Cheng, MD, PhD; K.M. Venkat Narayan, MD, MSc, MBA; and
Catherine C. Cowie, PhD
Background: Whether mortality rates among diabetic adults or
excess mortality associated with diabetes in the United States has
declined in recent decades is not known.
Objective: To examine whether all-cause and cardiovascular dis-
ease mortality rates have declined among the U.S. population with
and without self-reported diabetes.
Design: Comparison of 3 consecutive, nationally representative co-
Setting: Population-based health surveys (National Health and Nu-
trition Examination Surveys I, II, and III) with mortality follow-up
Patients: Survey participants age 35 to 74 years with and without
Measurements: Diabetes was determined by self-report for each
survey (1971–1975, 1976–1980, and 1988–1994), and mortality
rates were determined through 1986, 1992, and 2000 for the 3
Results: Among diabetic men, the all-cause mortality rate de-
creased by 18.2 annual deaths per 1000 persons (from 42.6 to
24.4 annual deaths per 1000 persons; P ? 0.03) between 1971 to
1986 and 1988 to 2000, accompanying decreases in the non-
diabetic population. Trends for cardiovascular disease mortality par-
alleled those of all-cause mortality, with 26.4 annual deaths per
1000 persons in 1971 to 1986 and 12.8 annual deaths per 1000
persons in 1988 to 2000 (P ? 0.06). Among women with diabetes,
however, neither all-cause nor cardiovascular disease mortality de-
clined between 1971 to 1986 and 1988 to 2000, and the all-cause
mortality rate difference between diabetic and nondiabetic women
more than doubled (from a difference of 8.3 to 18.2 annual deaths
per 1000 persons). The difference in all-cause mortality rates by sex
among people with diabetes in 1971 to 1986 were essentially
eliminated in 1988 to 2000.
Limitations: Diabetes was assessed by self-report, and statistical
power to examine the factors explaining mortality trends was lim-
Conclusions: Progress in reducing mortality rates among persons
with diabetes has been limited to men. Diabetes continues to
greatly increase the risk for death, particularly among women.
Ann Intern Med. 2007;147:149-155.
For author affiliations, see end of text.
ity are major public health successes in the United States
over the past 40 years (1). These have been attributed to
decreases in CVD risk factors, as well as advances in med-
ical management and revascularization, among persons
with diagnosed CVD (2, 3). Aggressive management of
CVD risk factors has been shown to be particularly effec-
tive among persons with diabetes, and implementation of
these findings into practice along with aggressive diabetes
care should, in theory, result in increased longevity among
persons with diabetes (4–9).
The quality of diabetes care and levels of certain CVD
risk factors have improved among the U.S. population
with diagnosed diabetes (10, 11). Whether reductions in
mortality have occurred among persons with diabetes,
however, remains unclear. Although regional studies of
persons with diabetes suggest that rates of all-cause mortal-
ity and cardiovascular complications have declined in re-
cent decades (12–15), the only nationally representative
study to examine trends in mortality rates of adults with
diabetes found no improvement between 1971 and 1992
(16). However, no national studies of mortality trends of
the U.S. diabetic population have extended through the
1990s, a period of major advances in clinical diabetes man-
agement, leaving the question of whether longevity in this
population has improved (4, 11, 17).
Thus, we assembled data from 3 consecutive nation-
he decrease in cardiovascular disease (CVD) mortality
rates and the accompanying increases in overall longev-
ally representative cohorts to assess whether all-cause and
CVD mortality have declined among the U.S. population
with diabetes and whether the disparity in mortality rates
between persons with and without diabetes has decreased.
Study Design and Population
The National Health and Nutrition Examination Sur-
vey (NHANES) is a series of independent, nationally rep-
resentative health surveys of the U.S. noninstitutionalized
population conducted from 1971 to 1975 (NHANES I),
1976 to 1980 (NHANES II), and 1988 to 1994
(NHANES III) (18–20). Each survey used a stratified,
multistage probability design that sampled, interviewed,
and examined participants to determine their health status.
Editors’ Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Editorial comment. . . . . . . . . . . . . . . . . . . . . . . . . . 208
Summary for Patients. . . . . . . . . . . . . . . . . . . . . . . I-10
Conversion of figures and tables into slides
Annals of Internal Medicine
7 August 2007 Annals of Internal Medicine Volume 147 • Number 3 149
Current Author Addresses: Drs. Gregg and Cheng: Division of Diabe-
tes Translation (K-10), Centers for Disease Control and Prevention,
4770 Buford Highway NE, Atlanta, GA 30341-3727.
Dr. Gu: National Center for Health Statistics, Centers for Disease Con-
trol and Prevention, Metro IV Building, 3311 Toledo Road, Hyattsville,
Dr. Narayan: The Rollins School of Public Health, Room 730, Emory
University, 1518 Clifton Road NE, Atlanta, GA 30322.
Dr. Cowie: National Institute of Diabetes and Digestive and Kidney
Diseases, National Institutes of Health, 6707 Democracy Boulevard,
Room 691, Bethesda, MD 20892-5460.
Author Contributions: Conception and design: E.W. Gregg, K.M.V.
Analysis and interpretation of the data: E.W. Gregg, Q. Gu, Y.J. Cheng,
K.M.V. Narayan, C.C. Cowie.
Drafting of the article: E.W. Gregg.
Critical revision of the article for important intellectual content: E.W.
Gregg, Y.J. Cheng, K.M.V. Narayan, C.C. Cowie.
Final approval of the article: E.W. Gregg, Y.J. Cheng, K.M.V. Narayan,
Statistical expertise: Q. Gu.
Obtaining of funding: E.W. Gregg, C.C. Cowie.
Administrative, technical, or logistic support: E.W. Gregg, K.M.V.
Collection and assembly of data: Q. Gu, Y.J. Cheng.
Annals of Internal Medicine
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