After a decade of progress, diabetes risk factor control either has stalled and reversed among U.S. adults, according to an updated trends study from the Johns Hopkins Bloomberg School of Public Health. Reinvigorating the use of first-line therapies is key to getting care and outcomes back on track, investigators say.

The researchers analyzed data from 1999 to 2018 using the National Health and Nutrition Examination Survey, or NHANES. Their aim was to shine new light on national treatment trends and to identify those most likely to have untreated risk factors. 

Diabetes control improved from 1999 to the early 2010s but then flatlined and worsened, reported first author Michael Fang, Ph.D. Specifically, glycemic control declined after 2010, whereas lipid (cholesterol) control leveled off. The NHANES participants also had a decrease in blood-pressure control after 2014. The latter finding is in line with a recent decline in blood-pressure control in the general U.S. population, Fang noted.

The culprit? “Suboptimal treatment probably contributed to worsening diabetes control in our study participants,” Fang wrote. For example, after large increases between 1999 and 2010, use of any glucose-lowering, blood-pressure–lowering, and statin medication plateaued. Combination therapy also declined among participants with diagnosed diabetes and uncontrolled blood pressure, and it flatlined after 2010 among those with poor glycemic control, he reported.

The findings may foreshadow a population-level increase in diabetes-related illness, Fang and colleagues cautioned.

“Recent evidence suggests that a resurgence in diabetic complications may already be underway,” Fang wrote. Rates of hyperglycemic emergencies and amputations of the feet or legs began increasing among U.S. adults with diabetes before 2010, for example, and rates of end-stage renal disease, stroke, and acute myocardial infarction have remained steady since then.

The clinical takeaway? Evidence has shown that first line therapies remain underused, Fang and colleagues proposed. For example, between 2015 and 2018, only 56% of adults with diabetes were using statins, 59% were using metformin, and 60% were using an ACE inhibitor or ARB. Increasing the use of these therapies is “an important practical first step” in regaining progress lost, they concluded. 

Full findings were published Thursday in the New England Journal of Medicine.