Around 38 million people in the United States — or slightly over 11% of the population — have diabetes, according to the National Diabetes Statistics Report. Experts only expect that number to increase, and research suggests that the burden will be especially significant in low to low-middle socioeconomic areas.
Consider the Mississippi Delta, a swath of fertile land in the floodplain of the Mississippi River. It has a rich and diverse cultural heritage, with a minority-majority population, along with significant economic challenges and a persistently high poverty rate. The region also has one of the highest diabetes rates in the country, which has put the healthcare community on alert.
“We are more intensely screening almost everybody,” said Brent Smith, MD, a family physician in Greenville, Mississippi, and a member of the board of directors of the American Academy of Family Physicians.
But diabetes knows no state or county boundary lines. Asha Shajahan, MD, a family medicine physician with Corewell Health in Roseville, Michigan, estimates that at least half of her patients have diabetes. “For the most part, most are overweight,” she added.
Internist Mohan Moreshwar Nadkarni, MD, has been in practice for more than 30 years. He is keenly aware of the increase in patients with diabetes and prediabetes over the years. Today, he sees patients at University of Virginia Health’s largest primary care clinic in Charlottesville, Virginia. He estimates that about 30% of the clinic’s 13,000 patients have diabetes — along with various other chronic health conditions.
“The increase in diabetes can be directly linked to the increase in obesity and the decrease in exercise,” said Nadkarni, who is also University of Virginia Health’s chief of general internal medicine.
Obesity as a Major Driver
Driven by sedentary lifestyles, high-calorie diets, and in some cases, genetics, the obesity epidemic has been a key factor in the rise of type 2 diabetes cases.
“Typically, at least a third of my patients have type 2 diabetes,” said Deborah Lauridsen, MD, a family medicine physician with Orlando Health Physician Associates in Orlando, Florida. “This has steadily increased throughout my years of practice, as the obesity epidemic has become more prevalent.”
A September 2024 report on obesity from Trust for America’s Health noted that the first year in which any state had an adult obesity rate higher than 35% was 2013. Ten years later, 23 states had adult obesity rates at or above 35%. A 2024 data brief from the CDC reported that from August 2021 to August 2023, the prevalence of obesity in adults was 40.3%, with individuals ages 40-59 years reflecting a large majority of that percentage.
However, it is not as simple as just asking patients to eat healthier and exercise more. For example, many low-income areas are food deserts, with a dearth of affordable, healthy food. According to Smith, many people in the Mississippi Delta put in long hard hours in the agriculture and manufacturing industries, but it may not be the kind of activity they need to keep their weight — and their blood sugar levels — down.
Smith hears the frustration in his patients’ voices when they say things like, “I walk all day. That should count.”
“But it doesn’t, not in this situation,” said Smith, who serves as program director of the Mississippi Delta Family Medicine Residency Program in addition to seeing his own patients.
Patients with diabetes or prediabetes need regular aerobic exercise to improve their cardiovascular function, lipid levels, and sensitivity to insulin, as well as resistance training to help with glycemic control and insulin resistance, according to the American Diabetes Association.
Substantive changes, such as addressing the socioeconomic factors that often contribute to diabetes, could help drive the numbers down, but “it’s simple in explanation and daunting in execution,” Smith said.
Some suggest that the advent of more effective medications may eventually turn the tide.
Glucagon-like peptide 1 receptor agonists, such as semaglutide and tirzepatide, have helped a growing number of people with type 2 diabetes shed pounds and get their blood glucose levels under control. However, for now, not everyone has access to these medications, which can be expensive even with insurance coverage.
Opportunities for Screening
While patients with diabetes make up a sizeable proportion of patient panels in many primary care practices, there could be even more undiscovered cases. For instance, more than 38 million people have diabetes, but fewer than 30 million of them know it. Nearly nine million adults with diabetes are undiagnosed, according to the National Diabetes Statistics Report.
Diabetes is often called a “silent killer” because it can cause damage long before any outward signs appear. Without a diagnosis, those nine million people do not get the care they need to prevent damage to their blood vessels and nerves that could lead to serious complications, like heart and kidney damage and diabetic retinopathy.
“So, there are still leaps and bounds to be made in terms of getting everyone who has diabetes diagnosed with it,” said Nadkarni.
Smith is an advocate for intensive screening for diabetes in the primary care setting — that is, making sure that anyone who meets the criteria of being at risk gets screened.
Intensive screening also allows providers to detect prediabetes in their patients. According to the National Diabetes Statistic Report, there are 97.6 million people age > 18 years who have prediabetes. That is 38% of the adult US population.
The American Diabetes Association and US Preventive Services Task Force recently expanded their criteria for who should be screened, with the goal of identifying more patients with type 2 diabetes and prediabetes. For example, in addition to screening patients with risk factors such as obesity, a family history of diabetes, a sedentary lifestyle, and a history of gestational diabetes, guidelines now recommend that screening for type 2 diabetes and diabetes begin at age 35 years, regardless of whether a patient has any other risk factors.
“We’re putting more and more emphasis on catching it at the cusp and catching it so we can prevent it,” said Smith.
Early detection and early treatment also bring along some professional satisfaction, Smith noted. It can be frustrating to figure out how to make major headway for a patient with a more complicated case or end-stage complications, but a committed effort to prevention can reduce the need for that kind of care.