The improved long-term outlook for adults after receiving a diagnosis of diabetes is one of the most important clinical and public health successes in recent decades. During the early 1990s, patients with diabetes had reductionsinlifespanof7to10yearsandanincreasedrisk oflower-extremityamputation(LEA)vsthosewithoutdiabetes (58 vs 3 cases/10 000 persons/year, respectively) and kidney failure (28 vs 2 cases/10 000 persons/year). 1 Risk of cardiovascular events, which caused the most deaths, also was higher among persons with diabetes vs thosewithoutdiabetes(141vs38hospitalizationsforacute myocardial infarction [AMI] per 10 000 persons/year). 1 Butthroughmultifacetedimprovementsindiabetescare, riskfactormanagement,self-managementeducationand support, and better integration of care, these risk differences were reduced by 28% to 68% across a range of complications between 1990 and 2010, with gains most notable for reductions in AMI, stroke, and death due to hyperglycemia. 1,2 Although the excess morbidity risk remained too high and the reduction in cardiovascular disease mortality led to new types of complications and causesofdeath, 3 acontinuedreductionintheoverallpublic health burden caused by diabetes seemed promising.However, in an unanticipated new challenge to these improvements, a resurgence of diabetes complications has appeared in national statistics and in the epidemiology literature. Between 2010 and 2015, an increase in diabetes-related LEAs occurred nationally, reversing more than one-third of the 20-year decline in only 5 years. 4,5 For hyperglycemic crisis, annual emergency department visits almost doubled between 2009 and 2015 (from 16.2 to 29.4 per 1000), hospitalizations increased by 73% (from 15.3 to 26.6 per 1000), and deaths increased by 55% (from 15.7 to 24.2 per 1000). 4 For endstage kidney disease, AMI, and stroke, the long-term improvements stalled after 2010. Updated national statistics indicate that the recent increase in complication rates is occurring in young and middle-aged adults (Figure ), among whom the risk of hyperglycemic crisis, AMI, stroke, and LEAs each increased by more than 25% during only 5 years. Although the rebound in rates has been most apparent in young adults (aged 18-44 years), middle-aged adults (aged 45-64 years) have higher ab-

RESULTSAge-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women. CONCLUSIONSAfter a two-decade decline in lower-extremity amputations, the U.S. may now be experiencing a reversal in the progress, particularly in young and middle-aged adults.Rates of lower-extremity amputations among adults with diabetes are an important index of comprehensive diabetes care as they are influenced by glycemic control, cardiovascular risk factor management, early detection of diabetes-related complications, and diabetes self-care management (1-6). National surveillance data showed that rates of nontraumatic lower-extremity amputations (NLEAs) declined by about half between 1990 and 2010, accompanying reductions in other diabetes-related

ObjectiveTo determine whether diabetes prevalence and incidence has remained flat or changed direction during the past 5 years.Research design and methodsWe calculated annual prevalence and incidence of diagnosed diabetes (type 1 and type 2 combined) for civilian, non-institutionalized adults aged 18–79 years using annual, nationally representative cross-sectional survey data from the National Health Interview Survey from 1980 to 2017. Trends in rates by age group, sex, race/ethnicity, and education were calculated using annual percentage change (APC).ResultsOverall, the prevalence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.4%) from 1990 to 2009 to a peak of 8.2 per 100 adults (95% CI 7.8 to 8.6), and then plateaued through 2017. The incidence of age-adjusted, diagnosed diabetes did not change significantly from 1980 to 1990, but increased significantly (APC 4.8%) from 1990 to 2007 to 7.8 per 1000 adults (95% CI 6.7 to 9.0), and then decreased significantly (APC −3.1%) to 6.0 (95% CI 4.9 to 7.3) in 2017. The decrease in incidence appears to be driven by non-Hispanic whites with an APC of −5.1% (p=0.002) after 2008.ConclusionsAfter an almost 20-year increase in the national prevalence and incidence of diagnosed diabetes, an 8-year period of stable prevalence and a decrease in incidence has occurred. Causes of the plateauing and decrease are unclear but the overall burden of diabetes remains high and deserves continued monitoring and intervention.

To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings.