Confronting a twin epidemic: The urgent need to address inequities in comorbid diabetes and stroke mortality

Abstract

This editorial discusses the critical public health implications of a recent retrospective analysis by Khan et al on mortality trends from comorbid non-insulin-dependent diabetes mellitus and stroke in the United States (1999-2022). The analysis revealed an alarming reversal around 2014, with age-adjusted mortality rates shifting from a period of decline to a sharp and sustained increase, at an annual percentage change of 7.8%. This trend underscores a significant setback after prior gains and exposes profound, persistent disparities across racial, ethnic, geographic, and rural-urban lines. The editorial argues that these disparities are a symptom of systemic healthcare inequities rather than an inevitable outcome. It concludes with an urgent call for a paradigm shift towards precision public health strategies, including culturally tailored interventions, investment in rural telehealth infrastructure, earlier screening for at-risk populations, and policies that address the fundamental social determinants of health to mitigate these inequities.

Key Words: Health disparities; Diabetes mellitus; Non-insulin-dependent diabetes mellitus; Stroke; Mortality; Rural health; Healthcare inequities; Social determinants of health; Precision public health

Core Tip: Recent United States data indicate an alarming reversal in mortality trends from comorbid diabetes and stroke after 2014, ending a period of previous improvement. This rising mortality is not distributed equally; it exposes profound and worsening disparities across race, ethnicity, geography, and rurality. Systemic inequities in healthcare access, driven by factors like linguistic barriers, poverty, and inadequate rural infrastructure, are the root cause of these divergent outcomes. Addressing this crisis requires moving beyond a one-size-fits-all approach to implement targeted, culturally competent interventions and policies. Urgent investment in rural telehealth, expansion of Medicaid, and strategies that address the social determinants of health are essential to curb this twin epidemic.

This editorial refers to “Trends and disparities in mortality from comorbid non-insulin-dependent diabetes mellitus and stroke (1999-2022): A retrospective analysis” by Khan et al, 2025; https://dx.doi.org/10.5316/wjn.v11.i1.110105.

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INTRODUCTION

The comorbidity of multiple chronic non-communicable diseases is one of the most significant challenges to global public health in the 21^st century. Among these, the synergistic comorbidity of non-insulin-dependent diabetes mellitus (NIDDM) and stroke-a “twin epidemic”-results in a particularly devastating synergy, exponentially increasing the risk of disability and death, especially in aging populations. While this editorial focuses on data from the United States, the challenge of managing such complex comorbidites amid systemic inequities is a pressing concern worldwide. In the recent issue of World Journal of Neurology, Khan et al[1] present a critical and sobering longitudinal examination of mortality trends attributed to this comorbid condition in the United States from 1999 to 2022. Their work moves beyond merely documenting overall rates of death from comorbid NIDDM and stroke; it meticulously dissects the profound and persistent disparities that underlie these trends across gender, race, ethnicity, geography, and age. The findings are not just a statistical report; they are a stark indictment of systemic healthcare inequities and an urgent call to action.

INCREASED DEATH FROM COMORBID NIDDM AND STROKE

The central, and most alarming, finding of Khan et al[1] is the dramatic reversal in mortality trends around 2014. After a period of steady decline, the age-adjusted mortality rate (AAMR) for comorbid NIDDM and stroke began a sharp and sustained upward climb, with an annual percentage change (APC) of 7.8% from 2014 to 2022[1]. This inflection point should serve as a wake-up call for the public health community. It suggests that prior gains, likely stemming from improved acute stroke management, better antihypertensive and statin therapies, and enhanced diabetes care, are being systematically eroded by countervailing forces[2,3]. The authors rightly point to the rising global prevalence of diabetes as a key driver, but their stratified analysis reveals that the burden of this reversal is not borne equally.

RACIAL AND ETHNIC DISPARITIES

The study’s detailed disaggregation of data unveils a landscape of entrenched health disparities. The racial and ethnic disparities are particularly striking. While non-hispanic black individuals consistently exhibited among the highest mortality rates, the most precipitous rises were observed in minority groups post-2018, with the Asian/Pacific Islander population experiencing an APC of 17.6%[1]. Khan et al[1] hypothesize that cultural dietary patterns and language barriers contribute to this trend. This is a crucial point that merits greater emphasis. Linguistic isolation, cultural stigma around disease can lead to delayed diagnoses and poor medication adherence. Furthermore, difficulties accessing a complex healthcare system often result in suboptimal management of both diabetes and stroke risk factors[4,5]. Similarly, the high and rising rates among American Indian/Alaska Native populations indicate long-standing issues of poverty, limited access to care, and historical trauma that are embedded in the structural determinants of health[6].

GEOGRAPHIC DISPARITIES

The geographic disparities uncovered are equally convincing. The highest AAMRs were concentrated in the West and Midwest, with states like West Virginia (AAMR 18.7/100000) and Oregon (18.1/100000) recording rates nearly five times that of Nevada (3.8/100000)[1]. It is not merely a North-South divide, as often seen in studies of cardiovascular disease. Instead, it suggests a complex interplay of factors including state-level health policies (e.g., Medicaid expansion), the distribution of specialist care (especially in neurology and endocrinology), rurality, and the unique demographic composition of each state[7,8]. The West’s high AAMR rate, for instance, may be heavily influenced by states with large populations of high-risk ethnic groups, as the authors note with California’s Asian American community.

RURAL HEALTH

Perhaps the most profound disparity highlighted is the urban-rural divide. The study confirms that non-metropolitan areas face a higher baseline mortality burden from this comorbid condition. The coronavirus disease 2019 (COVID-19) pandemic brutally exposed the fragility of the rural health infrastructure, but Khan et al[1] reshow that this crisis was brewing long before 2020[9]. Rural populations contend with a perfect storm of risk factors: Higher rates of poverty and food insecurity, poorer access to primary and specialist care, longer pre-hospital delay to stroke centers, and greater challenges in accessing digital health technologies due to broadband deserts[10,11]. The concurrent rise in AAMR in both urban and rural areas after 2014 indicates a systemic failure in healthcare, but the baseline inequity ensures that rural communities start from a position of greater vulnerability and have fewer resources to respond.

AGE-RELATED TRENDS AND PANDEMIC IMPACT

The age-stratified analysis adds another layer of concern. The marked rise in crude mortality rates among adults aged 55-64 (APC 14.3%) signifies a distressing trend of premature mortality[1]. This demographic is often in the peak of their productive years, and their increasing vulnerability to fatal complications of diabetes and stroke has profound implications for families, the workforce, and the economy. This trend aligns with other reports of increasing stroke incidence in younger adults and underscores the failure of current preventive strategies to adequately reach this population[2]. It suggests that screening for diabetes and its vascular complications may be starting too late and that more aggressive management of risk factors in middle age is urgently needed.

The period from 2018 to 2020 showed sharp increases in mortality across nearly all subgroups. While the COVID-19 pandemic undoubtedly played a significant role-either as a direct cause of death in vulnerable individuals or by disrupting chronic disease management and emergency care-it likely acted as an accelerant on pre-existing kindling[12]. The pandemic did not create these health inequities; it exploited and amplified them. The staggering 22.2% APC in the Northeast during this period is a testament to this effect[1].

TOWARD PRECISION PUBLIC HEALTH AND POLICY

The study by Khan et al[1] is powerful because it diagnoses the problem with great clarity. The imperative now is to treat it. Their findings demand a paradigm shift from a one-size-fits-all approach to a targeted, precision public health strategy that addresses the specific barriers faced by different populations. (1) For Racial and Ethnic Minorities: Implement culturally and linguistically tailored interventions. This includes investing in community health workers from within these communities, providing translated materials and interpreter services, and developing dietary recommendations that are culturally appropriate and feasible[4,5]; (2) For Rural America: Bridge the geographic gap through innovation. This requires sustained investment in telehealth infrastructure, including broadband expansion. Models such as mobile stroke units, telestroke networks, and hub-and-spoke systems for endocrinology can bring specialist expertise to remote areas[10,11]. Supporting and expanding the rural primary care workforce is fundamental; (3) For younger at-risk adults: Target public health campaigns at earlier age groups to promote lifestyle changes and emphasize the importance of regular screening for blood pressure, cholesterol, and blood glucose. Employers and workplace healthcare programs can be key partners in this effort; and (4) At the policy level: Advocate for policies that address the root causes. Expanding Medicaid in all states would immediately improve access to care for low-income populations. Long-term investments are needed in the social determinants of health-such as increasing access to affordable healthy food, funding affordable housing, and supporting education-as these are crucial for breaking the cycle of health disparity[13].

CONCLUSION

In conclusion, the research by Khan et al[1] is an essential contribution to the literature. It provides the detailed, disaggregated data needed to move from awareness to action. The rising mortality from comorbid NIDDM and stroke is not an inevitable outcome; it is a symptom of systemic inequity. Addressing it will require courage, collaboration, and commitment across all sectors of society-from clinicians and researchers to policymakers and community leaders. We must heed this call to action and work tirelessly to ensure that where a person lives, their race, their ethnicity, or their income does not determine their odds of surviving a preventable and treatable condition.