Abstract
Background
Diabetes Mellitus (DM) and liver disease, particularly All Liver Diseases (All-LD), are increasingly interlinked public health concerns in the United States. When coexisting, these conditions contribute synergistically to increased morbidity and mortality, especially among older adults. This study examines mortality trends associated with All-LD and DM from 1999 to 2020, focusing on disparities across sex, race, region, and urban-rural classification.
Methods
Using the CDC-WONDER Multiple Cause of Death database, we identified deaths among U.S. older adults (aged ≥ 65) with death certificates listing both DM and All-LD as either underlying or contributing causes of death. Age-adjusted mortality rates (AAMRs) per 100,000 were calculated, stratified by demographic and geographic variables.
Results
From 1999 to 2020, there were 95,870 deaths related to All-LD and DM, with an overall AAMR of 10.2. The AAMR remained stable from 1999 to 2014 (APC: 0.08%), then rose markedly from 2014 to 2018 (APC: 5.47%) and surged from 2018 to 2020 (APC: 12.42%, p < 0.001). Mortality was higher in males (AAMR: 12.4) than females (8.5), and greatest among American Indian/Alaska Native (AI/AN) and Hispanic populations. Geographically, the West and South had the highest AAMRs.
Conclusion
The mortality burden of coexisting liver disease and diabetes has intensified over the past two decades, particularly in racial minorities, rural areas, and specific states. The sharp increase from 2018 to 2020 represents a period encompassing the COVID-19 pandemic, although the upward trend began prior to its onset, suggesting contributions from additional factors such as rising prevalence of metabolic dysfunction associated steatotic liver disease and increasing alcohol consumption. These findings highlight the need for targeted, equitable public health interventions.
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Introduction
Liver disease and diabetes mellitus (DM) are two major public health concerns that increasingly overlap, worsening both morbidity and mortality in the United States. Liver diseases range from nonalcoholic fatty liver disease (NAFLD) and viral hepatitis to cirrhosis and hepatocellular carcinoma (HCC), many of which are strongly influenced by metabolic dysfunction [1, 2]. Meanwhile, diabetes especially type 2 continues to affect millions of Americans and plays a major role in both microvascular and macrovascular complications [1, 2]. When these two conditions co-occur, they can accelerate liver damage, raise the risk of decompensation, and significantly reduce survival outcomes [3].
The connection between liver disease and DM is well established, with insulin resistance, chronic inflammation, and lipid disturbances contributing to disease progression [4, 5]. Diabetes often exacerbates liver conditions, raising the risk of cirrhosis, HCC, and liver-related mortality, particularly in NAFLD, which is now the most common cause of chronic liver disease in Western countries [4,5,6]. In fact, type 2 diabetes has been found to be an independent predictor of both cirrhosis and HCC in patients with either alcoholic liver disease or NAFLD [6]. Socioeconomic inequalities, lifestyle factors such as poor diet or alcohol use, and limited access to healthcare services further worsen outcomes, particularly among minority populations and rural communities [7, 8].
Despite increasing awareness, there is still a lack of comprehensive national data examining trends in deaths where All-LD and DM were listed as contributing causes over time. Many earlier studies have treated these conditions in isolation or have not analyzed mortality differences across demographic subgroups. With the added disruptions of the COVID-19 pandemic marked by deferred routine care and disproportionate impacts on vulnerable populations the need to study mortality trends and disparities is even more urgent [9, 10].
Therefore, this study aims to analyze national trends in deaths where liver disease and diabetes were listed as contributing causes among U.S. older adults aged 65 and older from 1999 to 2020. We specifically examined death certificates where these conditions were listed as contributing causes to capture the synergistic mortality burden of these comorbidities.
Methods
Study design
The data utilized for this study were sourced from the CDC-WONDER database, a comprehensive repository of death certificates. The dataset spanned from 1999 to 2020. It was used to examine deaths with All-LD and Diabetes Mellitus (DM) listed as causes, employing precise International Classification of Diseases, Tenth Revision (ICD-10) codes [11]. This extensive compilation encompasses death certificates from all 50 states and the District of Columbia. It is an invaluable resource for analyzing mortality trends on various diseases among adults aged 65 and older.
Furthermore, this study utilized de-identified datasets accessible to the public and generated by governmental organizations. Given the characteristics of this data, obtaining institutional review board (IRB) approval was not mandatory. Nevertheless, the research diligently complied with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [12], guaranteeing a high scientific integrity and reliability standard in our findings.