diabetes-related complications decreasing

NEJM with recent article on the trend in diabetes-related complications from 1990 to 2010 (see dm complic decrease nejm 2014 in dropbox, or DOI: 10.1056/NEJMoa1310799), comparing age-standardized incidence of lower-extremity amputation, end-stage renal disease (ESRD), acute MI, stroke, and death from hyperglycemic crisis (either DKA or hyperosmolar hyperglycemic state). results:

        --acute MI: -67.8% (95.6 fewer cases per 10,000 persons per year)

        --death from hyperglycemic crisis: -64.4% (2.7 fewer cases per 10,000 persons per year)

        --stroke: -52.7% (58.9 fewer cases per 10,000 persons per year)

        --amputations: -51.4% (30 fewer cases per 10,000 persons per year)

        --ESRD: -28.3% (7.9 fewer cases per 10,000 persons per year)

        --these rate reductions were first noted in 1995 and were consistent thereafter. 

        --the greatest decline in absolute and relative terms was in people >75 yo (except from ESRD): ie, the difference between rates of disease in older people vs younger narrowed considerably

        --of note, the decline was dramatically more pronounced in diabetics vs nondiabetics: in diabetics, acute MI had 2x the decline, stroke 10x, amputation 4x, ESRD decreased 28.3% as noted above, but increased 65% in nondiabetics

so, what does all this mean??  good news overall (for a change), but should be tempered by the fact that a larger % of the population has diabetes [eg, only the rates for hyperglycemic crisis (-42%) and MI (-32.3%) decreased when the increase in diabetes incidence factored in, rates of amputation and stroke did not change, and ESRD increased by 90.9%)]. clearly a lot of things changed during this time period: there was better blood pressure control, improved lipid levels and more aggressive use of highly effective statins, decreased smoking, decreased A1c levels (which, i believe, also parallels increased and more aggressive use of metformin, the drug with the best data for lowering macrovascular complications), improved hospital care (and better ability to handle the hyperglycemic crises), dietary changes (fewer trans fats), improved management of renal disease and peripheral vascular disease. also, maybe earlier detection of diabetes and more aggressive risk factor management at an earlier stage? 

so, what this really means is that despite the dramatic increases in diabetes incidence (MMWR came out with data comparing 1995-7 vs 2005-7, finding a doubling!! of the age-adjusted rate of diabetes in the US, from 4.8 to 9.1 cases/1000 people in only one decade), we are basically compensating for diabetic medical complications by advances in many medical and social aspects of care (decreased smoking, better medications, higher percentages of people controlling risk factors), with a combination of significant improvements in heart disease, breaking even in amputation and stroke, and losing ground in ESRD.