Diabetes ABCS Goals by State: Only 26.4% of Adults Met All Four, 2017–2018

At a glance

• Known before: managing A1C (blood sugar), blood pressure and cholesterol, and not smoking — the ABCS — helps prevent diabetes complications, but little was known about how each state was doing.
• Found here: in 2017‒2018, too few U.S. adults with self-reported diabetes met the goals. Only 26.4% met all four.
• What follows: health departments can use these state estimates to plan how to reach the goals and cut complications.

Why the ABCS

Diabetes raises the risk of heart, nerve, kidney, eye and other complications, and it is costly: diagnosed diabetes cost the United States an estimated $327 billion in 2017. Complications can be prevented or delayed by managing:

National figures existed, but no study had estimated them for every state. This is the first for all 50 states and the District of Columbia.

How it was estimated

The analysis covered adults aged 20 or older told by a provider that they had diabetes (not gestational diabetes). It combined three surveys:

• the Behavioral Risk Factor Surveillance System (BRFSS), 2017–2018 — state data on who has diabetes;
• the American Community Survey (ACS), 2017–2018 — used to weight BRFSS to each state's population by age, sex, race, insurance, education and income (raking);
• the National Health and Nutrition Examination Survey (NHANES), 2009–2018 — measured A1C, blood pressure and cholesterol, used to impute those values for BRFSS respondents from traits both surveys share.

Nonsmokers were people who had not smoked 100 or more cigarettes in their lifetime or did not smoke at the time of the survey.

What was found

• Most states fell within the 90% confidence interval of the national figure; all did for A1C. DC's cholesterol figure was above it.
• Of the four goals, not smoking was met most often and cholesterol least — and states varied most on smoking.

Estimated share of adults with self-reported diabetes meeting each ABCS goal, by state, 2017–2018. CDC, MMWR.

In context

• Earlier national studies: in 2007–2012 NHANES data, 21.3% of adults with diagnosed diabetes met all ABCS goals. The National Diabetes Statistics Report found that in 2013–2016, 19.2% met goals of A1C below 7.0%, blood pressure below 140/90, non-HDL cholesterol below 130 and nonsmoking — and 36.4% met a looser set (A1C below 8.0%, non-HDL cholesterol below 160). Those studies used somewhat different targets.
• Why it matters: in the UK Prospective Diabetes Study, intensive blood-sugar control in type 2 diabetes cut A1C by 11% over 10 years and the risk of small-vessel complications by 25%. Lower blood pressure and cholesterol, and not smoking, reduce heart and blood-vessel complications.
• Why states differ: perhaps access to care and social and economic factors. Lacking health coverage and using few services have been tied to poor diabetes control, and people of higher socioeconomic status tend to manage diabetes better.

Limitations

• People in institutions weren't included.
• Self-reported data can carry diagnosis, recall and social desirability bias.
• Imputed values are less precise than direct measurements, and not all bias can be removed.
• Reasons for state differences weren't examined.

What states can do

The share of adults meeting the ABCS goals is still too low. CDC works with states — its Diabetes State Burden Toolkit estimates the health and economic toll of diabetes in each state, and it funds state health departments to reduce complications (DP18–1815). Tracking ABCS by state can show gaps in care. Direct measurement is more precise but costlier; imputation is more practical but can't reflect each state's own programs and policies. Either way, health departments can use these estimates to plan.

Sources

Based on "Imputed State-Level Prevalence of Achieving Goals To Prevent Complications of Diabetes in Adults with Self-Reported Diabetes — United States, 2017–2018," by Yu Chen, Deborah Rolka, Hui Xie and Sharon Saydah of CDC, Morbidity and Mortality Weekly Report, CDC; a work of the United States government in the public domain.