Progress in Chronic Disease Prevention Trends in Diabetes Mellitus Mortality

In 1985, diabetes mellitus (DM) was the seventh leading cause of death in the United States (1) and the 13th leading cause of years of potential life lost (YPLL) before age 65 (2), accounting for 128,229 (1.1%) of all YPLL. However, because these statistics are based on underlying cause of death, they understate the overall impact of DM on mortality. Specifically, diabetes is selected as the underlying cause on approximately one quarter of the death certificates on which it appears in any field (see Figure 1 on p. 779) (3) and is recorded on only about half of the certificates for persons who have the disease at the time of death (3). Thus, DM contributes to a much larger number of deaths than it directly causes.

National mortality rates for 1970-1985 were analyzed to evaluate trends for diabetes as an underlying cause of death and for total DM-related mortality.* National Center for Health Statistics (NCHS) numbers of resident DM deaths (eighth and ninth revision International Classification of Diseases (ICD) rubric 250) were used for numerators. (The comparability ratio for the revision from ICD-8 to ICD-9 for ICD rubric 250 is 0.9991 (CI 0.98-1.02) (4); because the ratio is near unity, no adjustment for comparability was made.) Numbers of deaths for which DM was listed anywhere on the death certificate were used to compute total DM-related mortality rates. The rates were age-adjusted by the direct method, using the estimated U.S. resident population in 1980 as the standard.

Mortality rates based on the U.S. resident population provide one measure of the public health impact of DM. To determine diabetic persons' risks of dying from their disease, mortality rates were also calculated for the U.S. population known to have DM. The DM prevalence estimates from 1976, 1980, and 1984 (5) (available from the National Health Interview Survey) were multiplied by the corresponding estimated U.S. resident population (6,7) to estimate the number of persons known to have DM for these years. This latter estimate served as the denominator in calculating mortality rates for persons known to have DM.

From 1970 through 1985, age-adjusted rates declined for both DM as an underlying cause of death (Figure 1) and total DM-related mortality (Figure 2). The greatest decline occurred between 1970 and 1979, when the average annual decrease in rates for DM as an underlying cause of death was 3.7% (Figure 1) and for total DM-related mortality, 3.0% (Figure 2); between 1979 and 1985, the average annual changes in rates were -0.2% (Figure 1) and +0.4% (Figure 2). Crude rates also declined for both methods of coding DM mortality during 1970-1985.

For 1980-1985, average age-specific mortality rates for DM, both underlying cause and total DM-related, increased with age (Figure 3). Nearly all DM deaths occurred after age 44. For all age groups after age 44, total DM-related mortality rates were 3.3 to 4.2 times higher than those for DM as an underlying cause of death.

Race-specific age-adjusted rates for total DM-related deaths (U.S. residents used as denominator) were highest for blacks (Figure 4). From 1970 to 1979, rates for all four race/sex groups declined. Between 1979 and 1985, however, rates for white males, black males, and black females increased annually an average of 0.6%, 2.1%, and 1.6%, respectively; rates for white females did not change.

In contrast to the results for mortality rates among U.S. residents (Figure 4), the highest rates of total DM-related mortality for persons known to have diabetes occurred for white males (Figure 5). Although rates for all four race/sex groups decreased during the period, they increased slightly for white males after 1980. Reported by: Technology and Operational Research Br, Div of Diabetes Translation, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Analyses of national death certificate data indicate that age-adjusted mortality rates for DM have decreased from 1970 to 1985 and that most of the decrease occurred between 1970 and 1979. These analyses (Figure 3) also demonstrate that rates based on underlying cause of death, the usual measure of DM mortality, reflected only about one quarter of the deaths to which DM may have contributed.  The decline in DM-associated mortality may reflect 1) changes in the death certification process, e.g., persons who complete death certificates may be less likely to list diabetes where it would be selected as the underlying or contributory cause of death, and 2) improved treatment for DM and DM-related conditions from 1970 to 1985, resulting in longer survival for persons with diabetes (8).

Age-specific mortality rates indicate that DM mortality increases with age and may reflect the prevalence of diabetes in older populations (9). For example, in 1980, 40% of all persons with known diabetes were aged greater than or equal to65 years; 84% were aged greater than or equal to45 years.

Analyses of trends among race/sex groups for total DM-related mortality indicate that among U.S. residents, blacks have the highest mortality rates, possibly reflecting a greater prevalence of diabetes among blacks. Among persons known to have diabetes, white males have higher mortality rates than blacks. Further investigation of these patterns should address the effect of sampling variability and confounding (e.g., age).

References

1. National Center for Health Statistics. Advance report of final mortality statistics, 1985. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1987; DHHS publication no. (PHS)87-1120. (Monthly vital statistics report; vol 36, no. 5). 2.CDC. Table V. Estimated years of potential life lost before age 65 and cause-specific mortality, by cause of death--United States, 1985. MMWR 1987;36:235. 3.Harris MI, Entmacher PS. Mortality from diabetes. In: Diabetes in America: diabetes data compiled 1984. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1985:XXIX-1-48; NIH publication no. 85-1468. 4.National Center for Health Statistics. Estimates of selected comparability ratios based on dual coding of 1976 death certificates by the eighth and ninth revisions of the International Classification of Diseases. Hyattsville, Maryland: US Department of Health, Education, and Welfare, Public Health Service, 1980; DHEW publication no. (PHS)80-1120. (Monthly vital statistics report; vol 28, no. 11 suppl). 5.National Center for Health Statistics. Prevalence of known diabetes among black Americans. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1987:9; DHHS publication no. (PHS)87-1250. (Advance data from vital and health statistics; no.130). 6.Bureau of the Census. Preliminary estimates of the population of the United States, by age, sex, and race: 1970 to 1981. Washington, DC: US Department of Commerce, Bureau of the Census, 1982. (Current population reports; series P-25, no. 917). 7.Bureau of the Census. United States population estimates, by age, sex, and race: 1980 to 1987. Washington, DC: US Department of Commerce, Bureau of the Census, 1988. (Current population reports; series P-25, no. 1022). 8.Harris MI. Commentary: the death rate decline for diabetes. Stat Bull Metrop Insur Co 1985;66:10-1. 9.Metropolitan Life and affiliated companies. Diabetes mortality sharply declined in past decade. Stat Bull Metrop Insur Co 1985;66:1. *The underlying cause of death is selected according to standard criteria (including order) that determine which cause or contributing factor listed on the death certificate takes precedence over others that may be listed. Mortality statistics are usually based on underlying cause of death. However, multiple cause of death data available from NCHS allows for mortality statistics based on all mentions of a condition on death certificates.

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