Disability and Diabetes in Adults

Summary

This article reviews findings from national studies of prevalence in diabetes-related disability, presents new data on contemporary trends in disability among people with diabetes across the United States, summarizes risk factors and mechanisms for the excess disability prevalence associated with diabetes, and reviews evidence that disability may be preventable or modifiable.

Cross-sectional and prospective studies have consistently found that people with diabetes have 50%–90% increased risk of disability, including mobility loss, reduced instrumental activities of daily living (IADL) and activities of daily living (ADL), and work disability. The association of diabetes with increased disability risk is multifactorial, with age, longer diabetes duration, obesity, coronary heart disease, lower extremity complications, depression, and stroke among the most consistently observed factors explaining the difference in disability rates between people with and without diabetes. Additionally, several studies have suggested that specific physiological factors, including inflammation, insulin resistance, hyperglycemia, and their contribution to loss of muscle mass, may also mediate the higher diabetes-related disability risk.

Nationally representative data from 2019–2022 show that 21% of adult women with diabetes (vs. 9% of women without diabetes) and 19% of adult men with diabetes (vs. 7% of men without diabetes) reported any disability. For both women and men with diabetes, the prevalence of any disability increased with age, ranging from ~15% for adults age 20–44 years to ~35%–40% for those age ≥75 years. The relative differences in disability prevalence between persons with versus without diabetes decreased with age. In 2019–2022, one-third of adults with diabetes had mobility disability or some mobility difficulty. Among persons with diabetes, there were substantial differences in disability prevalence according to other sociodemographic factors. Notably, the prevalence of any disability among persons with diabetes living below the poverty threshold (poverty income ratio [PIR] <1.0) was double the prevalence among those living above the poverty threshold (PIR ≥1.0): 34% vs. 17%, respectively. The high prevalence of disability among people with diabetes poses substantial burden to people with diabetes, health care and public health systems, employers, and payors.

Lifestyle interventions focused on achieving weight loss and increasing physical activity are effective for reducing disability and long-term functional decline in people with diabetes. However, further research is needed to determine the impact of preventive care and diabetes management practices, including diabetes treatment and the emergence of new diabetes therapies, on disability risk. Continued surveillance is needed to determine the impact of primary and secondary prevention approaches on disability risk in the coming decades.

Introduction

Diabetes is a serious threat to the health of the American public due to its growing prevalence, its contribution to cardiovascular and microvascular complications, and its direct negative impact on function and quality of life (1,2). As of 2021, 38.4 million people were living with diabetes in the United States, and that number is estimated to increase to more than 60 million by 2060 (1,3). The prevalence of diabetes has steadily increased with the increasing age of the adult population, and nearly one-third of adults age ≥65 years have diabetes (1). The vast majority of diabetes cases are type 2 diabetes, characterized by progressive loss of pancreatic β-cell insulin secretion, typically in the context of insulin resistance (4). Approximately 5%–10% of people with diabetes have type 1 diabetes and complete insulin deficiency, most often due to autoimmune β-cell destruction. Other types of diabetes, including inherited syndromes, diseases of exocrine pancreatic insufficiency, and drug- or chemical-induced diabetes are less prevalent. Type 2 diabetes is generally preceded by prediabetes, a period of mild hyperglycemia and rising insulin resistance that is intermediate between normal glucose levels and diabetes. In 2021, 97.6 million U.S. adults (38.0% of the U.S. adult population) had prediabetes (1). Prediabetes is strongly associated with progression to type 2 diabetes, with higher rates of progression among individuals with higher glucose levels. Indeed, those with glycated hemoglobin (A1C) between 5.5% (37 mmol/mol) and 6.0% (42 mmol/mol) have a 5-year incidence rate of diabetes between 5% and 25%, while those with A1C between 6.0% and 6.5% (48 mmol/mol) have a 25%–50% chance of developing diabetes (5).

Diabetes and its complications frequently lead to functional impairments and disabilities, often through multiple, coexisting mechanisms (6,7,8). Dysglycemia may directly cause adverse changes in musculature, contributing to gait dysfunction and frailty (9,10). Diabetes also causes disability through the effects of its macrovascular complications (heart disease, stroke, peripheral artery disease) and microvascular complications (neuropathy, retinopathy, kidney disease) and their resulting impact on health and function. Diabetes is associated with mood disorders, cognitive impairment, and dementia disorders, which are themselves major causes of disability. Therefore, disability is both a direct and indirect consequence of diabetes and a valuable index of the collective impact of diabetes on health status for both individuals and populations (11).

The importance of physical disability is heightened by several trends in the diabetes epidemic. While the incidence of diabetes in the United States has declined slightly since 2008, the prevalence of diabetes has increased steadily over this time period (1). This is due to the changing age distribution of the population, which increasingly comprises a larger proportion of older adults (12). The increase in diabetes prevalence, combined with movement of the “baby boom” birth stratum (born between 1945 and 1960) into the age range corresponding to particularly high incidence of diabetes and complications (60–78 years as of 2024), is expected to increase the absolute numbers of persons with diabetes-related disability (3). A longer duration of diabetes and older age are both associated with a higher frequency of diabetes-related complications (13). In addition, there has been a recent increase in the incidence of diabetes among children, adolescents, and young adults (1,14,15) that may translate into many years of disability over their lifespan. This combination of factors is expected to lead to an increased burden of disability over the coming decades, with effects on clinical care and public health systems (6).

Understanding the relationship between diabetes and disability is important from several perspectives. For individuals with diabetes, loss of physical functioning may be more concerning and of greater damage to quality of life than the diagnosis of traditional clinical complications, such as retinopathy and neuropathy (7,16,17). For both people with diabetes and the clinicians who care for them, preventing disability—including impairments, activity limitations, and participation restrictions—could be a key goal of preventive care. First, disability alters the life expectancy and, therefore, the likelihood of benefit from long-term treatments (18,19). Second, the presence of disability makes diabetes self-management more difficult because of the physical and cognitive requirements of such tasks as physical activity, food preparation, taking medications, blood glucose monitoring, administering insulin, and using diabetes technology. Disability can also take a profound emotional, physical, and economic toll on family and caregivers. For employers, disability affects work productivity and health insurance costs. Finally, at the population level, rates and trends in disability are important global indicators of the progress of public health programs toward the goal of increasing the number of healthy years of life and reducing the average number of years of morbidity in the population (11,20,21).

The objectives of this article are to: (1.) summarize the association of diabetes with disability; (2.) identify the key modifiable and nonmodifiable determinants of disability among people with diabetes, along with the key factors explaining the excess disability prevalence among older adults; (3.) describe trends in diabetes-related disability in the United States overall and among key subgroups; and (4.) review evidence that physical disability can be prevented or modified. The estimates presented refer to the combination of persons with type 1 and type 2 diabetes, with most having type 2 diabetes. The content herein is an update of the Diabetes in America, 3rd edition, chapter Diabetes and Disability (22).

Conceptual Frameworks and Measurement of Disability

Several conceptual frameworks have evolved to define disability in ways that are useful to diverse groups, including the individual, family, health care system, employer, researcher, public health, and economic assessors (23,24,25). These frameworks, which have several aspects in common, have been incorporated into the model described by the International Classification of Functioning, Disability and Health, developed by the World Health Organization (26,27). In this model, disability is an umbrella term encompassing impairments, activity limitations, and restrictions in participation (Figure 1) (26). Disability may arise from physical, cognitive, mental, or developmental impairments. Contextual factors (social, economic, physical environment, or structural barriers to healthcare, including structural racism), interact with health conditions or injuries to lead to body impairments. Impairments affect activities and participation and, in turn, disability.

FIGURE 1.

The International Classification of Functioning, Disability and Health Model of Disability. SOURCE: Adapted from reference (26).

Both objective and subjective tools and scales to measure capacity for and performance of functioning have been developed for clinical and epidemiologic settings. Multi-item questionnaires and simple physical tests are often used to assess the impact of chronic diseases on disability. The most common questionnaires used in national studies ask about the respondent’s ability to carry out specific activities (23). In addition, objective physical tests can assess the ability to carry out tasks of mobility or daily functioning (21,28).

Data Sources, Definitions, and Methods

Association of Diabetes With Limitations and Disabilities in Physical Functioning: Review of Prior Studies

Disability is a major contributor to the high costs associated with diabetes in the United States. Most recent estimates suggest that of the $412.9 billion spent on diabetes in 2022, 26% ($106.3 billion) is attributable to indirect costs associated with lost productivity, unemployment, and premature mortality (31). A 2022 meta-analysis found that adults age ≥65 years with diabetes have a 2.28 years (95% CI 0.57–3.99) lower disability-free life expectancy compared to older adults without diabetes (32). Importantly, loss of disability-free life years in people with diabetes was greater than the loss of overall life expectancy, suggesting that diabetes lengthens the period of disability (32). In a Taiwanese longitudinal study, diabetes accelerated disability during aging by 3 years for mobility disability, 7 years for IADL limitations, and 11 years for ADL limitations (33).

Perhaps the earliest population-based estimates of the association of diabetes with disability in the United States were published in 1960, when the National Center for Health Statistics reported prevalences of diagnosed diabetes and disability due to diabetes based on data from the NHIS 1957–1959 (34). Prevalence of diagnosed diabetes among the overall population was only 0.9% at the time (vs. 14.7% in 2017–2020); among the age group 65–74 years, prevalence was 3% in men and 5% in women (in contrast, more than 29% of adults age ≥65 years had diabetes in 2017–2020) (1,34). Among those with diabetes in 1957–1959, fewer than 10% of women and 7% of men reported any limitation in mobility. Among those age ≥65 years, prevalence of any mobility limitation was 18%. About 20% reported at least one day of restricted activity due to diabetes in the previous year, and 9% reported more than one day in bed in the previous year due to diabetes-associated disability.

Studies using national data published since that early report have described stronger associations of diabetes with disabilities, including associations with a broad spectrum of specific domains and perspectives of disability, such as mobility and IADL. Among adults age ≥20 years with diabetes, the NHANES 2005–2010 revealed the age-standardized prevalence of mobility disability to be 32.0% in women and 17.7% in men (vs. 13.0% and 8.5% in women and men without diabetes, respectively); prevalence of IADL disability to be 8.0% in women and 6.8% in men (vs. 1.8% and 3.8% in women and men without diabetes, respectively); prevalence of ADL disability to be 0.8% in women and 0.9% in men (vs. <0.2% in women and men without diabetes); and prevalence of work disability to be 29.4% in women and 19.3% in men (vs. 9.4% and 8.6% in women and men without diabetes, respectively) (22). These findings were consistent with the literature from the 1990s and early 2000s, with the prevalence of disability across different domains being approximately three to five times higher among people with diabetes compared to those without (35,36,37,38,39,40). Although the absolute prevalence of disability was lower for all indicators among men with diabetes compared to women, the magnitude of association of diabetes with disability was similar for men and women.

These associations of diabetes with self-reported disability were also present for objective physical performance tests. In a study using NHANES data between 1988 and 1994, men with diabetes were twice as likely as men without diabetes to perform poorly on tests of walking speed, 89% more likely to perform poorly on balance tests, and 36% more likely to perform poorly on chair stands, a test of lower extremity function (41). Subsequent analysis of NHIS data between 1997 and 1999 had similar findings. After adjusting for age, sex, and race and ethnicity, diabetes was associated with three times the odds of self-reported limitations in performing nine physical tasks, including walking a quarter mile, climbing stairs, and carrying groceries (42).

Analysis of NHANES 1999–2006 data found associations between diabetes and six domains of disability in U.S. adults age ≥60 years (43): 74% of persons with diabetes reported difficulty (“some difficulty” or greater) in tasks of general physical mobility (e.g., stooping, crouching, standing up), 52% reported difficulty in lower extremity mobility (walking a quarter mile, climbing stairs), 44% reported difficulty in IADLs (e.g., cooking, cleaning), 37% reported difficulty in ADLs (e.g., eating, dressing), and 34% reported difficulty in leisure and social activities (e.g., going out to movies and shopping; leisure activities at home). The odds ratios of disability associated with diabetes ranged from 1.97 for general mobility to 2.53 for ADL. When disability was defined using more severe thresholds—an inability (as opposed to “a lot of difficulty”) to carry out tasks—the odds ratios of disability associated with diabetes were higher, ranging from 2.64 for general mobility to 3.93 for ADL. An analysis of cross-sectional data from the Health, Aging, and Body Composition (Health ABC) Study showed that diabetes was associated with 40% higher odds of functional decline when defined by objective measures, including chair stands, standing balance, and gait speed, in analyses adjusting for age, sex, BMI, and comorbid conditions (44).

A systematic review quantified the association of diabetes and disability from cross-sectional studies conducted between 1996 and 2010, including the U.S. studies described above (8,41,43). Ten studies were conducted in North America, five in Asia, nine in Europe, and one in Australia (8). For the association of diabetes with mobility disability, odds ratios ranged from 1.10 to 2.20, and the pooled odds ratio was 1.68 (95% CI 1.50–1.86). For IADL, odds ratios ranged from 1.20 to 3.30, and the pooled odds ratio was 1.67 (95% CI 1.57–1.77). There was somewhat more heterogeneity for the association of diabetes with ADL disability, as odds ratios ranged from 1.51 to 4.61, and the pooled odds ratio was 1.87 (95% CI 1.66–2.10).

The age at diabetes diagnosis has an important effect on the risk of disability. Analysis of the 1995 to 2018 waves of the Health and Retirement Study (HRS), a nationally representative, biennial, longitudinal health interview survey of U.S. adults age ≥50 years, examined the incidence of disability, measured using self-reported ADL and IADL dependencies (defined as the first year when participants reported dependency in at least 5 of 11 measured ADL and IADL activities), as a function of age at diabetes diagnosis compared to matched controls without diabetes (45). While the incidence of disability increased with age, the incidence risk ratios (IRRs) for the association of each age group at diabetes diagnosis and disability narrowed with increasing age. The association between diabetes and disability was strongest among individuals diagnosed with diabetes at age 50–59 years (IRR 2.03, 95% CI 1.55–2.66) compared to those diagnosed at age 60–69 years (IRR 1.29, 95% CI 1.07–1.55). Those who were diagnosed with diabetes at age ≥70 years had a similar IRR for incident disability as those without diabetes.

Studies of the impact of diabetes on work productivity, absenteeism, and early retirement have found significant differences between adults with and without diabetes (46,47,48,49,50,51,52). Persons with diabetes have about twice the absenteeism rate (5–18 days per year across studies) as those without diabetes (3–9 days per year) (46). In the most extensive study of work productivity, defined as time lost from work or impaired at work due to illness, U.S. adults with diabetes without neuropathy lost an average of 12 days per year, while adults with diabetes complicated by neuropathy lost an average of 26 days per year (52).

More recently, the coronavirus disease of 2019 (COVID-19) pandemic may have worsened the disability experienced among people with diabetes. “Long COVID” or post-acute sequelae of SARS-CoV-2 causes a myriad of health effects in multiple body systems that can potentially result in disability (53). People with diabetes are at increased risk for higher severity COVID-19 illness and death (54); however, whether persons with diabetes are more likely to experience long-term morbidity or disability from long COVID is unknown. Robust data are scarce, but several studies showed no independent association between diabetes and risk of long COVID (55,56). Severity of the COVID-19 infection does increase the risk of long COVID (55,56). In addition, COVID-19 infection may increase the risk for developing new-onset diabetes, potentially increasing diabetes prevalence and burden (57).

National Estimates of Disability Prevalence

Table 1 provides national estimates of age-adjusted prevalence of disability among adults age ≥20 years with diagnosed diabetes in the NHANES 2015–2018 by key demographic, socioeconomic, and health factors. Figure 2 provides national estimates of disability in the NHANES 2015–2018 according to glycemic status, leveraging the availability of biochemical measures in the NHANES to identify persons with undiagnosed diabetes (A1C ≥6.5% or FPG ≥126 mg/dL [≥6.99 mmol/L]), prediabetes (A1C 5.7%-<6.5% [39–<48 mmol/mol] or FPG 100–125 mg/dL [5.55–6.94 mmol/L]), and normal glucose levels (A1C <5.7% and FPG <100 mg/dL). The questions used to estimate disability through 2018 were not included in the NHANES January 2019–March 2020 or August 2021–August 2023, the most recent phases of the NHANES at the time of this publication. Figure 3 highlights the challenge in comparing disability prevalence estimates and trends in the NHANES 2015–2018 to the NHIS 2019–2022 due to changes in methodology. Because methodologies to ascertain and define disability differed, absolute rates of disability in the NHANES and NHIS are not directly comparable. Figures 4, 5, 6, and 7 and Tables 2, 3, and 4 describe national estimates of disability among persons with diagnosed diabetes in the NHIS 2019–2022 based on the Washington Group Short Set.

TABLE 1.

Age-Standardized Prevalence of Disability Among Adults Age ≥20 Years With Diagnosed Diabetes, by Demographic, Socioeconomic, and Health Factors, U.S., 2015–2018

FIGURE 2.

Age-Standardized Prevalence of Disability Among Adults Age ≥20 Years, by Glycemic Status, U.S., 2015–2018. Diagnosed diabetes and disability status are based on self-report. Undiagnosed diabetes is defined as A1C ≥6.5% or FPG ≥126 (more...)

FIGURE 3.

Age-Standardized Trends in Prevalence of Disability Among Adults Age ≥20 Years With Diagnosed Diabetes, U.S., NHANES 2015–2018 and NHIS 2019–2022. Diabetes is self-reported. Any disability in the NHANES 2015–2018 includes (more...)

FIGURE 4.

Age-Standardized Prevalence of Disability Among Adults With Diagnosed Diabetes, by Race and Ethnicity, U.S., 2019–2022. Diabetes is self-reported. Any disability was determined using the Washington Group Short Set Composite Disability Indicator, (more...)

FIGURE 5.

Age-Standardized Prevalence of Disability Among Adults With Diagnosed Diabetes, by Education, U.S., 2019–2022. Diabetes is self-reported. Any disability was determined using the Washington Group Short Set Composite Disability Indicator, which (more...)

FIGURE 6.

Age-Standardized Prevalence of Disability Among Adults With Diagnosed Diabetes, by Poverty Income Ratio, U.S., 2019–2022. Diabetes is self-reported. Any disability was determined using the Washington Group Short Set Composite Disability Indicator, (more...)

FIGURE 7.

Age-Standardized Prevalence of Disability Among Adults With Diagnosed Diabetes, by Health Insurance Status, U.S., 2019–2022. Diabetes and health insurance status are self-reported. Any disability was determined using the Washington Group Short (more...)

TABLE 2.

Prevalence of Disability and Some Functional Difficulty Among Women Age ≥20 Years, by Diabetes Status and Age, U.S., 2019–2022

TABLE 3.

Prevalence of Disability and Some Functional Difficulty Among Men Age ≥20 Years, by Diabetes Status and Age, U.S., 2019–2022

TABLE 4.

Age-Standardized Prevalence of Disability Among Adults Age ≥20 Years With Diagnosed Diabetes, by Sociodemographic and Health Factors, U.S., 2019–2022

Factors Explaining the Association of Diabetes With Disability

Several studies have attempted to determine the mechanisms whereby diabetes mediates increased disability risk. This research has been conducted using two primary approaches: (1.) adding potential mediators to statistical models of the effect of diabetes on disability and examining for attenuation of the diabetes to disability association (41,58,59,60,61,62); and (2.) examining the effect of diabetes on pathophysiologic processes known to mediate disability (9,10,60,63,64,65). There is also a large body of research modeling the contribution of diabetes to the population burden of associated chronic conditions and diabetes complications, which helps clarify the total magnitude of disability resulting from diabetes. These conditions include cardiovascular disease (66,67), peripheral neuropathy and amputation (68,69,70), diabetic retinopathy (71,72), chronic kidney disease (73,74,75,76), stroke and neurovascular conditions (60,77), and psychiatric disorders (78,79). These conditions may lead to disability through disease-specific mechanisms or, as in the case of vision impairment due to diabetic retinopathy, are themselves disability subtypes. Overall, these various approaches to explaining how diabetes contributes to disability examine different facets of a complex relationship between direct effects of glycemia on organ dysfunction, indirect effects on chronic health conditions, and disability (80).

Analyses of mediators of the relationship between diabetes and disability have primarily used older, cross-sectional data from large cohort studies or national surveys. A mediation analysis using data from the NHANES III (1988–1994) found that coronary heart disease (CHD) and obesity together explained more than one-half of the excess disability risk associated with diabetes among women. Among men, CHD and stroke were the two most dominant factors (41,80). Several other factors, including stroke, visual impairment, and arthritis, played significant roles in both men and women. Subsequent analyses using the Women’s Health and Aging Study found peripheral arterial disease, peripheral nerve dysfunction, and depression were important mediators of disability in diabetes (59).

A growing body of literature is evaluating the direct effect of chronic hyperglycemia on pathophysiologic processes underlying disability. Sarcopenia, or the natural loss of muscle mass that occurs with aging, may be a central mechanism in this process. Hyperinsulinemia, insulin resistance, hyperglycemia, and a longer duration of diabetes have each been associated with sarcopenia (63,81). The association of diabetes with sarcopenia may be multifactorial, as behavioral factors (physical inactivity and reduced energy expenditure), central adiposity and resulting inflammatory factors, hormonal changes (e.g., hypogonadism, vitamin D deficiency), and comorbid conditions (e.g., kidney disease, peripheral artery disease) could connect diabetes to sarcopenia (81). A study using data from the NHANES 2011–2014 found that muscle quality is impaired even among individuals with prediabetes, and this relationship is mediated in large part by insulin resistance (82).

A number of other studies have examined the association between diabetes and frailty, a condition that often overlaps with sarcopenia, which is characterized by physical decline with fatigue, weight loss, muscle weakness, and gait dysfunction (25). A systematic review found that having diabetes increases the odds of incident frailty by 50%, and frailty among those with diabetes is associated with a higher risk of complications and mortality (10). It is important to note that the relationship between glycemia and frailty is not linear, and both higher and lower A1C levels are found to be associated with frailty in people with diabetes (9). It is likely that there are multiple distinct phenotypes of frailty in people with diabetes, including individuals with high A1C and resultant sarcopenia, and individuals who become ill or malnourished, leading to both frailty and low A1C levels (9). The relationship between diabetes and frailty is likely bidirectional, as there is evidence that physical and cognitive disabilities in people with diabetes causes these individuals to engage in less physical activity, which can lead to worsening strength and mobility (62). Hypoglycemia caused by diabetes treatment has also been associated with frailty in several studies, although the direction of this effect is unclear (9,83). The impact of diabetes pharmacotherapy on sarcopenia and frailty requires further study.

In summary, these studies found the relationship between diabetes and disability to be multifactorial with complex, and sometimes bidirectional, mechanisms. Obesity, CHD, lower extremity complications, stroke, and depression appear to be prominent factors explaining the difference in disability risk between people with and without diabetes. Factors early in the pathogenesis of diabetes, including inflammation and insulin resistance, may cause sarcopenia and frailty that may mediate the higher disability risk in people with diabetes. Volpato and Maraldi organized explanatory factors into a conceptual model wherein diabetes interacts in a bidirectional manner with obesity, CHD, hypertension, stroke, and depression to influence several primary impairments, including visual acuity, peripheral neuropathy, cognitive function, and strength, which combined with underlying comorbidities, lead to functional limitations and disabilities (84).

Disability and Diabetes Risk

Epidemiologic studies of diabetes and disability have primarily been conducted to examine the potential for diabetes to cause disability. However, the association could act in the reverse direction, with disability increasing the risk of diabetes, particularly among high-risk adults. In a longitudinal analysis of data from 22,878 middle-aged and older adults, prevalent mild disability was associated with a 28% increased risk of diabetes incidence, while incident mild disability was associated with a 40% increased diabetes risk (85). More severe disability was associated with an even higher magnitude of diabetes risk (63% for prevalent disability and 81% for incident disability). The authors speculated that disability could contribute to diabetes risk through increases in sedentary behavior and change in the ratio of lean to fat mass, affecting insulin sensitivity in vulnerable adults. Supportive of this hypothesis are data from individuals with chronic spinal cord injury, who often develop increased insulin resistance and have higher rates of incident diabetes compared to the general population (86). Further, a large cohort study of adults age ≥55 years in Canada found that adults with lower extremity osteoarthritis, especially hip osteoarthritis, had a modestly increased risk for incident diabetes (25% higher hazard ratio comparing two vs. no affected hips), which was in part explained by mobility limitations (87).

Effectiveness of Interventions to Reduce Disability Risk

Only a few controlled intervention trials have examined the effectiveness of approaches to reduce disability among adults with diabetes or at risk for diabetes. Studies conducted among adults (with and without diabetes) with arthritis-mediated functional impairment found that lifestyle-based weight loss of 5%–6% over 18 months resulted in significant improvements in functional status (88,89). Similar effects have been reported in adults with CHD and preexisting functional limitations (90,91). The Look AHEAD (Action for Health in Diabetes) study is the largest intervention trial to date to examine the effects of lifestyle change on disability and the first large study of its kind among adults with diabetes. Look AHEAD randomized adults with type 2 diabetes and overweight or obesity to an intensive lifestyle intervention aimed at achieving weight loss through calorie restriction and increased physical activity or diabetes support and education. Look AHEAD had several key findings related to disability. At 4 years of follow-up, persons in the intensive lifestyle intervention arm had a 48% lower odds of mobility-related disability (92). The prevalence of severe mobility disability at 4 years follow-up was 21% in the intensive lifestyle intervention and 26% in the control arm. Over 10 years of follow-up, the intensive lifestyle intervention resulted in a 0.8–0.9-year delay in the onset of moderate to severe physical disability (93). A subset of Look AHEAD participants underwent objective performance testing using the Short Physical Performance Battery that demonstrated benefits of the intensive lifestyle intervention on physical function at 8- and 11-years follow-up (94,95).

In addition to lifestyle intervention, achieving evidence-based goals for glucose lowering and management of cardiovascular risk factors is likely to prevent disability among people with diabetes by preventing complications (43). Further, the risk and/or impact of disability among people with diabetes may be mitigated by addressing social isolation (96,97,98,99), supporting physical activity (97,100) and other healthy behaviors (98), and addressing depressive symptoms (101). For example, a large observational cohort study in Sweden found that a healthy lifestyle profile characterized by physically active leisure activities, avoidance of tobacco or heavy alcohol use, and being in the middle or upper tertile of a social connectivity index was associated with a 3-year longer disability-free survival among adults with diabetes (98).

It is also important to note the large potential benefits of diabetes prevention on reducing the burden of disability. Interventional studies, including the Diabetes Prevention Program, established that lifestyle intervention and, to a lesser extent, metformin therapy are effective at reducing diabetes incidence over 15 years or longer (102,103). A modeling analysis using data from England and Wales found that decreasing the incidence of diabetes over the next four decades could result in dramatic reductions in moderate to severe disability, dementia, and mortality (104).

Finally, disability risk may be modifiable by treatment with newer diabetes medications, especially glucagon-like peptide-1 (GLP-1) receptor agonists that induce weight loss and have cardiovascular and kidney benefits and sodium-glucose cotransporter-2 (SGLT2) inhibitors that have cardiovascular and kidney benefits, including on symptomatic heart failure (105). The GLP-1 receptor agonist semaglutide was found to improve symptoms and decrease physical limitations among people with type 2 diabetes and obesity-related heart failure (106). More research is needed to evaluate the changing landscape of diabetes pharmacotherapy and its effects on disability.

Given the high prevalence of disability among people with diabetes and the potential for mitigating disability through intervention, it is important for clinicians to understand how disability impacts the activities or function of the people with diabetes they care for. Diabetes guidelines recommend that an assessment of disability should be conducted at every clinic visit for people with diabetes (107).

Conclusions

Diabetes is associated with a twofold to threefold increased risk of functional disability, including disability related to mobility, IADL, ADL, and work. Longitudinal studies indicate that diabetes precedes the onset of disability in many cases, but that the diabetes and disability association is also bidirectional. Among persons with diabetes, disability is most common among women and persons of lower education and socioeconomic status (PIR <1.0) and increases rapidly with age. The relative associations of diabetes (vs. no diabetes) with disability are highest among middle-aged adults. The age-standardized prevalence of any disability in persons with diabetes is ~20% in both men and women. This prevalence estimate was unchanged across the individual survey cycles between 2019 to 2022.

The association of diabetes with disability is explained by multiple factors, including some that precede diabetes diagnosis as part of the pathogenesis of diabetes (e.g., obesity, insulin resistance, systemic inflammation), hyperglycemia itself, diabetes-related complications (e.g., CHD, lower extremity arterial disease, stroke, visual impairment), and other comorbidities that may or may not be caused by diabetes (notably, depression and arthritis). Intensive lifestyle interventions that involve regular physical activity and weight loss appear to be effective in reducing risk for disability among adults with diabetes and overweight or obesity. Interventions to prevent diabetes and primary care-based management of depression and cardiovascular disease risk could also plausibly affect disability risk, but this hypothesis has not been examined in randomized controlled trials.

Continued surveillance of disability levels is important to determine whether clinical and public health approaches are reducing the collective impact of diabetes on morbidity. Inclusion of older adults and mobility and disability outcomes in future clinical trials will be important to improve the evidence base about which interventions reduce disability.

List of Abbreviations

A1C

glycated hemoglobin

ADL

activities of daily living

BMI

body mass index

CHD

coronary heart disease

CI

confidence interval

COPD

chronic obstructive pulmonary disease

COVID-19

coronavirus disease of 2019

FPG

fasting plasma glucose

IADL

instrumental activities of daily living

IRR

incidence risk ratio

Look AHEAD

Action for Health in Diabetes

NHANES

National Health and Nutrition Examination Survey

NHIS

National Health Interview Survey

PIR

poverty income ratio

Conversions

A1C: (% x 10.93) - 23.50 = mmol/mol

Glucose: mg/dL x 0.0555 = mmol/L

Acknowledgment

This is an update of: Gregg EW, Menke A. Diabetes and Disability. Chapter 34 in Diabetes in America, 3rd ed. Cowie CC, Casagrande SS, Menke A, Cissell MA, Eberhardt MS, Meigs JB, Gregg EW, Knowler WC, Barrett-Connor E, Becker DJ, Brancati FL, Boyko EJ, Herman WH, Howard BV, Narayan KMV, Rewers M, Fradkin JE, Eds. Bethesda, MD, National Institutes of Health, NIH Pub No. 17-1468, 2018, p. 34.1–34.15.

Article History

Received in final form on September 9, 2024.

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Drs. Pilla, Rooney, and McCoy reported no conflicts of interest.