Understanding the rise in diabetes deaths

More than 100,000 Americans died of diabetes for the second consecutive year in 2021. This marks an upward trend since the start of the COVID-19 pandemic, with diabetes deaths up 17 percent in 2020 and 15 percent in 2021 compared with pre-pandemic levels (87,647 deaths in 2019), according to a Reuters analysis of provisional death data from the U.S. Centers for Disease Control and Prevention. The CDC estimates that 37.3 million Americans (11.3 percent of the population) have diabetes, and 96 million adults have prediabetes.

Diabetes is a chronic disease in which the body’s ability to regulate blood sugar levels is impaired. Type 1 diabetes occurs when the pancreas stops producing insulin, the hormone that allows glucose to move from the bloodstream to cells. In Type 2 diabetes, the pancreas produces insulin, but the body’s cells can’t effectively use it. Type 2 accounts for 90-95 percent of all diabetes cases.

Here are some questions and answers about the rise in diabetes deaths in the United States.

Why are so many Americans dying of Type 2 diabetes? Dr. Fernando Ovalle, an endocrinologist and professor at the University of Alabama at Birmingham School of Medicine, attributed the steady increase in diabetes deaths to a combination of increased obesity, poor nutrition, and decreased physical activity. “All those three things together somehow are contributing to a very significant increase in diabetes and its complications,” he said.

Healthcare access also plays a role. Dr. Guy Alonso, a pediatric endocrinologist at Children’s Hospital Colorado and professor at the University of Colorado School of Medicine, said his patients often jump through hoops to receive their insulin prescriptions. “We have an unnecessarily complex system for getting treatments that work in patients’ hands,” Alonso said. He expressed frustration with insurance companies frequently changing the insured’s brand of insulin without communicating to the patient’s pharmacy, causing the patient to see a sudden spike in the cost of the medication. Dr. Ziad Dimachkie, an internist at J.W. Ruby Memorial Hospital and professor at West Virginia University, commented on the high costs of insulin: “Routinely, patients are not able to buy the insulin they are prescribed and will have to take either different forms that may not work as well for them, or many times will quietly ration their insulin.”

Can the increase in Type 2 diabetes deaths since 2020 be linked to COVID-19? Although diabetes is a known risk factor for serious COVID-19 complications, the Reuters analysis excluded deaths attributed directly to COVID-19. However, Ovalle speculated about a few ways the coronavirus’s spread could have indirectly affected diabetes deaths. First, COVID-19 produces inflammation throughout the body. “We’ve known for a long time that inflammation in general causes insulin resistance,” he said. Second, delaying or completely avoiding hospital visits for fear of getting a COVID-19 infection could have prevented those with severe diabetes from getting emergency healthcare, ultimately resulting in more deaths. And for those with less severe diabetes cases, allowing the disease to progress unchecked for the past two years could have also resulted in more deaths.

Alonso said pediatric data indicates that delayed care for diabetes during the COVID-19 pandemic has led to poorer outcomes. He added that children have gained a lot of weight during the pandemic, and those who gained the most weight were already overweight or obese. This puts them at increased risk of severe diabetes. He believes that trend is likely to have occurred in adults, as well.

How can individuals lower their risk of developing severe Type 2 diabetes? Ovalle explained that a small number of Type 2 diabetes patients, perhaps because of their genetic makeup, rely on insulin treatments regardless of their lifestyle choices. But in most cases, patients with Type 2 diabetes won’t see an improvement in their condition without also making lifestyle changes. “We have really good doctors, really good access to drugs, we have great tertiary care institutions,” he said. “But if people are going to be eating fried chicken and eating lots of bread every day, then they’re going to be really big, and obviously, that’s not going to work.”

Alonso placed some onus on the healthcare system to minimize risk: “We don’t do prevention well enough.” Patients with prediabetes need practical interventions to prevent their condition from worsening, such as getting set up with a dietician or an easily followed exercise plan.

What kind of public policy could help reduce the risk of Type 2 diabetes? Ovalle would like to see more diabetes messaging geared to children. Most messaging surrounding diabetes, such as the CDC’s “Do I Have Prediabetes” campaign, is targeted at adults, many of whom already have diabetes. “[If] they already have the problem, [then] they can only patch things, and maybe they don’t have the time, and it’s very expensive to deal with it,” he said.