Imputed State-Level Prevalence of Achieving Goals To Prevent Complications of Diabetes in Adults with Self-Reported Diabetes — United States, 2017–2018

Diabetes increases the risk for developing cardiovascular, neurologic, kidney, eye, and other complications. Diabetes and related complications also pose a huge economic cost to society: in 2017, the estimated total economic cost of diagnosed diabetes was $327 billion in the United States (1). Diabetes complications can be prevented or delayed through the management of blood glucose (measured by hemoglobin A1C), blood pressure (BP), and non–high-density lipoprotein cholesterol (non-HDL–C) levels, and by avoiding smoking; these are collectively known as the ABCS goals (hemoglobin A1C, Blood pressure, Cholesterol, Smoking) (2–5). Assessments of achieving ABCS goals among adults with diabetes are available at the national level (4,6); however, studies that assess state-level prevalence of meeting ABCS goals have been lacking. This report provides imputed state-level proportions of adults with self-reported diabetes meeting ABCS goals in each of the 50 U.S. states and the District of Columbia (DC). State-level estimates were created by raking and multiple imputation methods (7,8) using data from the 2009–2018 National Health and Nutrition Examination Survey (NHANES), 2017–2018 American Community Survey (ACS), and 2017–2018 Behavioral Risk Factor Surveillance System (BRFSS). Among U.S. adults with diabetes, an estimated 26.4% met combined ABCS goals, and 75.4%, 70.4%, 55.8%, and 86.0% met A1C <8%, BP <140/90 mmHg, non-HDL–C <130 mg/dL and nonsmoking goals, respectively. Public health departments could use these data in their planning efforts to achieve ABCS goal levels and reduce diabetes-related complications at the state level.

This analysis included adults aged ≥20 years who reported having received a diagnosis of diabetes (excluding gestational diabetes) from a health care provider. This report defined ABCS goals as A1C <8%,* BP<140/90 mmHg, non-HDL–C <130 mg/dL, and being a nonsmoker (4). Nonsmokers were defined as those who provided negative responses to questions about smoking (≥100 cigarettes in their lifetime and being a current smoker at the time of the survey). To estimate state-level prevalence, the raking method^† was first used to adjust BRFSS weights to the ACS on age, sex, race, health insurance status, education, and income to reflect the state population characteristics (7). Multiple imputation methods were used (8) to predict the values of A1C, BP, and non-HDL–C for adults with self-reported diabetes in the weight-adjusted BRFSS data.^§ Variables common to both NHANES and BRFSS were used as predictors (i.e., age, sex, race, health insurance status, education, income, body mass index category, and health status).^¶ Prevalence was estimated by averaging the estimates from all imputed data sets,** and standard errors were pooled by combining the within-imputation variance and the between-imputation variance (8). For the nonsmoking goal, the state-level prevalence was estimated directly from weight-adjusted BRFSS data. The national prevalence of each of the ABCS goals was a direct estimate from 2015–2018 NHANES. For prevalence of achieving ABCS goals, 90% confidence intervals (CIs) were calculated to help illuminate meaningful differences while reflecting the uncertainty inherent in these modeled estimates. Analyses were conducted using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^††

Among adults with self-reported diabetes, 26.4% met combined ABCS goals nationally, and state-level estimates ranged from 22.3% to 28.2% (Table). The lowest prevalence was in Wisconsin, and the highest was in Utah. Most of the states varied within the 90% CI of the national prevalence.

For each ABCS goal, nationally, 75.4% met the A1C goal (<8%), 70.4% met the BP goal (<140/90 mmHg), 55.8% met the non-HDL–C goal (<130 mg/dL), and 86.0% met the nonsmoking goal. Among adults with diabetes who attained the A1C goal, the lowest prevalence was 73.7% (Texas), and the highest prevalence (77.2%) was in Alaska; all were within the 90% CI of the national estimate. The lowest prevalence of meeting the BP goal was 62.8% in DC, and the highest (74.8%) was in Alaska. The lowest prevalence of achieving the non-HDL–C goal was 52.8% in Wisconsin, and the highest was 62.8% in DC. The prevalence in DC was above the 90% CI of national prevalence. The lowest prevalence of achieving the nonsmoking goal (79.3%) was in Tennessee, and the highest (91.8%) was in Utah. When comparing the individual goals (Figure), the prevalence of achieving the nonsmoking goal was the highest, and that of achieving the non-HDL–C goal was the lowest. In addition, there was a relatively larger variation among states in achieving the nonsmoking goal than other goals.

Corresponding author: Yu Chen, ppz4@cdc.gov.

¹Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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Abbreviations: A1C = hemoglobin A1C; ACS = American Community Survey; BP = blood pressure; BRFSS = Behavioral Risk Factor Surveillance System; CI = confidence interval; NHANES = National Health and Nutrition Examination Survey; non-HDL–C = non–high-density lipoprotein cholesterol.
* State-level estimates of A1C, BP, and non-HDL–C were created by raking and multiple imputation methods using data from 2009–2018 NHANES, 2017–2018 ACS, and 2017–2018 BRFSS; state-level estimates of nonsmoking were estimated directly from weight-adjusted BRFSS data, and the raking method was first used to adjust 2017–2018 BRFSS weights to the 2017–2018 ACS.
^† ABCS goals were defined as A1C <8%, BP <140/90 mmHg, non-HDL–C <130 mg/dL, and avoiding smoking.
^§ National average prevalence of each goal was a direct estimate from 2015–2018 NHANES.
^¶ Some state-level estimates were below or above the 90% CI of the national prevalence. ABCS goals: Wisconsin; BP goal: Alaska, District of Columbia, Mississippi, Utah, and West Virginia; non-HDL–C goal: District of Columbia; nonsmoking goal: California, Delaware, Florida, Kentucky, Maryland, Missouri, Nebraska, New Hampshire, North Dakota, Tennessee, Utah, Washington, and West Virginia.

FIGURE. Estimated prevalence* of achieving individual goals of ABCS^† among adults with self-reported diabetes — United States, 2017–2018

Abbreviations: A1C = hemoglobin A1C; ABCS = hemoglobin A1C, blood pressure, cholesterol, and avoiding smoking; BP= blood pressure; non-HDL–C= non-high-density lipoprotein cholesterol.

* The percentage intervals for the quantile cutoffs vary because of variations in the distribution of goal achievement.

^† ABCS goals were defined as A1C <8%, BP <140/90 mmHg, non-HDL–C <130 mg/dL and avoiding smoking (current smokers were defined as those who had ≥100 cigarettes in their lifetime and were a smoker at the time of the survey).