Excess diabetes mellitus-related deaths during the COVID-19 pandemic in the United States

Abstract

Background: Diabetes mellitus (DM) is a critical risk factor for severe SARS-CoV-2 infection, and SARS-CoV-2 infection contributes to worsening glycemic control. The COVID-19 pandemic profoundly disrupted the delivery of care for patients with diabetes. We aimed to determine the trend of DM-related deaths during the pandemic.

Methods: In this serial population-based study between January 1, 2006 and December 31, 2021, mortality data of decedents aged ≥25 years from the National Vital Statistics System dataset was analyzed. Decedents with DM as the underlying or contributing cause of death on the death certificate were defined as DM-related deaths. Excess deaths were estimated by comparing observed versus expected age-standardized mortality rates derived from mortality during 2006-2019 with linear and polynomial regression models. The trends of mortality were quantified with joinpoint regression analysis. Subgroup analyses were performed by age, sex, race/ethnicity, and state.

Findings: Among 4·25 million DM-related deaths during 2006-2021, there was a significant surge of more than 30% in mortality during the pandemic, from 106·8 (per 100,000 persons) in 2019 to 144·1 in 2020 and 148·3 in 2021. Adults aged 25-44 years had the most pronounced rise in mortality. Widened racial/ethnic disparity was observed, with Hispanics demonstrating the highest excess deaths (67·5%; 95% CI 60·9-74·7%), almost three times that of non-Hispanic whites (23·9%; 95% CI 21·2-26·7%).

Interpretation: The United States saw an increase in DM-related mortality during the pandemic. The disproportionate rise in young adults and the widened racial/ethnic disparity warrant urgent preventative interventions from diverse stakeholders.

Funding: National Natural Science Foundation of China.

Keywords: Disparity; Epidemiology; Mortality; Predictive analysis; Temporal trend.

Figure 1

Temporal trends in diabetes mellitus (DM)-related deaths and excess deaths during the COVID-19 pandemic, by sex, further stratified by age. (A) Overall population, (B) Female, (C) Male, (D) Aged at 25–44 years old in overall population, (E) Aged at 25–44 years old in female, (F) Aged at 25–44 years old in male, (G) Aged at 45–64 years old in overall population, (H) Aged at 45–64 years old in female, (I) Aged at 45–64 years old in male, (J) Aged more than 65 years old in overall population, (K) Aged more than 65 years old in female, (L) Aged more than 65 years old in male. DM-related deaths rates (per 100,000 persons) increased across all subgroups during the pandemic. The observed mortality rates were above the predicted mortality rates (dashed horizontal line). Depicted by purple bars, DM-related deaths associated with COVID-19 was almost or more than 50% across the subgroups during pandemic. COVID-19 related decedent was defined as DM-related death with COVID-19 recorded as one of the causes on the death certificate.

Figure 2

Causes of deaths related to diabetes mellitus (DM) presented by (A) the proportion and (B) the age-standardized mortality rate (ASMR) of different causes of death. The change in proportion of causes of death after the emergence of SARS-CoV-2 infection and the absolute change of all causes of death were shown.

Figure 3

State-level variation and local Moran-spatial autocorrelation analysis of diabetes mellitus (DM)-related deaths during the COVID-19 Pandemic. State-level Variation of mortality in 2020 (A) and 2021 (B); Local Moran-spatial autocorrelation analysis of DM-related deaths in both 2020 (C) and 2021 (D) showed a positive spatial autocorrelation with high DM-related mortality clustered in the Eastern U.S.