title: Deaths Attributable to Diabetes in the United States: Comparison of Data Sources and Estimation Approaches.
abstract: OBJECTIVE
  The goal of this research was to identify the fraction of deaths attributable to diabetes in the United States.
  
  
  METHODS
  We estimated population attributable fractions (PAF) for cohorts aged 30-84 who were surveyed in the National Health Interview Survey (NHIS) between 1997 and 2009 (N = 282,322) and in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2010 (N = 21,814). Cohort members were followed prospectively for mortality through 2011. We identified diabetes status using self-reported diagnoses in both NHIS and NHANES and using HbA1c in NHANES. Hazard ratios associated with diabetes were estimated using Cox model adjusted for age, sex, race/ethnicity, educational attainment, and smoking status.
  
  
  RESULTS
  We found a high degree of consistency between data sets and definitions of diabetes in the hazard ratios, estimates of diabetes prevalence, and estimates of the proportion of deaths attributable to diabetes. The proportion of deaths attributable to diabetes was estimated to be 11.5% using self-reports in NHIS, 11.7% using self-reports in NHANES, and 11.8% using HbA1c in NHANES. Among the sub-groups that we examined, the PAF was highest among obese persons at 19.4%. The proportion of deaths in which diabetes was assigned as the underlying cause of death (3.3-3.7%) severely understated the contribution of diabetes to mortality in the United States.
  
  
  CONCLUSIONS
  Diabetes may represent a more prominent factor in American mortality than is commonly appreciated, reinforcing the need for robust population-level interventions aimed at diabetes prevention and care.
authors.affiliation: Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, Massachusetts, United States of America.
authors.forename: Andrew
authors.identifier: http://orcid.org/0000-0002-8502-3636
authors.initials: A
authors.lastname: Stokes
authors.affiliation: Department of Sociology and Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.
authors.forename: Samuel H
authors.initials: SH
authors.lastname: Preston
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002423:Cause of Death; D003625:Data Collection; D003644:Death Certificates; D048909:Diabetes Complications / Q000401:mortality; D003920:Diabetes Mellitus / Q000401:mortality*; D004522:Educational Status; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006306:Health Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D009749:Nutrition Surveys; D015995:Prevalence; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012907:Smoking / Q000453:epidemiology; D014481:United States / Q000453:epidemiology