What is Driving Type 2 Diabetes in the US?

Type 2 diabetes (T2D) is a chronic, progressive disease marked by the body's inability to properly use insulin, a hormone essential for regulating blood glucose levels. In this metabolic condition, cells become resistant to insulin’s effects, prompting the pancreas to produce more of the hormone in an attempt to compensate. Over time, this compensatory mechanism fails, resulting in persistent hyperglycemia. Prolonged elevation of blood sugar levels leads to systemic complications, including cardiovascular disease, neuropathy, chronic kidney disease, and vision impairment.¹

The scope of this disease in the US is staggering. As of 2021, approximately 38.4 million Americans (~11.6% of the population) were living with diabetes, with T2D accounting for between 90% and 95% of those cases.² Of these individuals, 29.7 million were diagnosed, while an estimated 8.7 million (nearly 23%) were unaware of their condition.² Prediabetes is even more prevalent: nearly 98 million US adults—over one in three—were identified as having elevated blood glucose levels that place them at increased risk of progressing to type 2 diabetes.³

The US faces a perfect storm of converging systemic, behavioral, environmental, and economic factors that drive its high and rising T2D prevalence.

Overweight and Obesity

Obesity is the most significant modifiable risk factor. More than 40% of American adults meet the clinical criteria for obesity,⁴ a an endocrinologic condition that directly contributes to insulin resistance and metabolic dysfunction. Obesity in childhood is also rising and and poses a growing concern. Currently obesity affects nearly 20% of children and adolescents, a trend that further increases future risk of diabetes and related chronic diseases.¹

Sedentary Lifestyle

The lack of physical activity in the US is widespread with many contributing factors. Despite strong evidence that moderate exercise improves glucose control and reduces insulin resistance, fewer than 1 in 4 US adults meet the CDC’s physical activity guideline of 150 minutes of moderate-intensity exercise per week.² Of interest, there is a growing body of research that supports "weekend warrior" activity, where an individual reaches the weekly exercise target in just 1 or 2 sessions. Evidence has shown that even this irregular exercise pattern is associated with a 33% reduction in cardiovascular mortality and a 21% decrease in all-cause mortality among people with T2D.5,6

Dietary Habits, Ultraprocessed Food

The American diet has also evolved in ways that increase risk for T2D. Consumption of ultraprocessed foods and sugar-sweetened beverages is common, while intake of fiber-rich whole foods remains below national recommendations, according to the Department of Agriculture and Health and Human Services Agency.³ This dietary imbalance is particularly harmful in low-income neighborhoods where access to fresh, healthy food options is limited. Research has consistently shown that this pattern of high-calorie, nutrient-poor intake is a potent contributor to the development of insulin resistance and progression to type 2 diabetes.⁷

Demographics, Genetics

T2D prevalence is unevenly distributed across demographics and has genetic underpinnings as well. The likelihood of developing T2D increases with age, and the disease is more common in individuals with a family history of diabetes. Certain racial and ethnic groups, including Black, Hispanic, American Indian/Alaska Native, and Asian American populations, are at significantly higher risk.⁴ Remarkably, Black adults in the US are nearly 60% more likely to be diagnosed with T2D compared to white adults. Among American Indian and Alaska Native adults, the age-adjusted prevalence is 14.5%, nearly double the 7.4% seen in non-Hispanic white populations.⁴ While genetic predisposition accounts for up to 72% of heritable diabetes risk, individual gene effects are usually modest.⁸

Social Determinants of Health, Health Care Access

Beyond individual behaviors and biological risk factors, the structure of the US health care and social safety net systems contributes to the crisis. Despite high per capita healthcare spending, many Americans lack reliable access to preventive care, nutrition counseling, diabetes education, and ongoing disease management. The economic burden is equally concerning. The average annual cost of diabetes per person is $16,750, and approximately 1 in every 4 US health care dollars is spent on diabetes-related care.9 The US also spends approximately $35 billion annually on insulin, yet cost-related underuse remains a barrier to glycemic control for many people.10

Although the National Diabetes Prevention Program, supported by both NIH and CDC, has demonstrated that modest weight loss and physical activity can reduce the risk of T2D by nearly 60%, the program is underutilized and also underfunded.11 Lack of awareness, poor reimbursement models, and logistical barriers have all hindered broader adoption, particularly in underserved communities.12

The Built Environment Contributes

Research has demonstrated that environmental and urban design factors further exacerbate the issues that contribute to the escalating prevalence of T2D. Many American cities and towns are built in ways that discourage physical activity. Communities often lack sidewalks, bike lanes, or access to safe green spaces.13 This design limits opportunities for routine movement, which is essential for maintaining metabolic health. Additionally, growing evidence suggests that environmental pollutants, including airborne particulate matter, may increase diabetes risk, especially in urban areas with poor air quality.14

When combined, all of these factors create a uniquely challenging public health landscape. While lifestyle-related contributors to T2D are well known, their impact is magnified by systemic inequities in food access, housing, education, and healthcare. These intersecting issues form a web of vulnerability that makes the US particularly susceptible to the epidemic levels of diabetes.

How to Stem the Tide

Yet the trajectory is not irreversible. Evidence-based interventions, including lifestyle modification, early screening, community-based prevention programs, and policy reforms targeting food systems and urban planning, offer powerful tools to reduce new cases and improve outcomes for those already affected. To succeed, these interventions must be accessible, equitable, and supported by systemic changes that address the root causes of diabetes, not just its symptoms.

References

1. Centers for Disease Control and Prevention. About Type 2 Diabetes. Updated May 14, 2024. Accessed July 22, 2025. https://www.cdc.gov/diabetes/about/about-type-2-diabetes.html
2. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2024. Updated May 15, 2024. Accessed July 22, 2025. https://www.cdc.gov/diabetes/data/statistics-report/index.html
3. U.S. Department of Agriculture & U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. Published December 2020. Accessed July 22, 2025. https://www.dietaryguidelines.gov/
4. Office of Minority Health. Diabetes and African Americans. Updated 2023. Accessed July 22, 2025. https://minorityhealth.hhs.gov/statistics/stats-diabetes-aa/
5. Chen LJ et al. Exercising 150 minutes 1–2 times/week may lower death risk 33%—Weekend warrior study. Medical News Today. July 2025. Accessed July 22, 2025. https://www.medicalnewstoday.com/articles/exercising-150-minutes-1-2-times-week-may-lower-death-risk-33-percent-weekend-warrior
6. Weekend warriors with diabetes have a 33% lower cardiovascular mortality risk. EurekAlert!. July 21, 2025. Accessed July 22, 2025. https://www.eurekalert.org/news-releases/1091293
7. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system. Obes Rev. 2013;14(S2):21–28. https://doi.org/10.1111/obr.12107
8. NIDDK. Insulin Resistance & Prediabetes. Updated May 2025. Accessed July 22, 2025. https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/prediabetes-insulin-resistance
9. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2022. Diabetes Care. 2023;46(4):328–340. https://diabetesjournals.org/care/article/46/4/328/148760
10. Kaiser Family Foundation. What Do Americans Pay for Insulin? Published March 1, 2024. Accessed July 22, 2025. https://www.kff.org/health-costs/issue-brief/what-do-americans-pay-for-insulin/
11. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403. https://www.nejm.org/doi/full/10.1056/NEJMoa012512
12. National Council on Aging. The Underuse of Diabetes Prevention Programs. Updated March 2024. Accessed July 22, 2025. https://www.ncoa.org/article/the-underuse-of-diabetes-prevention-programs
13. Frank LD, Engelke PO, Schmid TL. Health and Community Design: The Impact of the Built Environment on Physical Activity. Island Press; 2003. Available via NIH: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448001/
14. Pearson JF, Bachireddy C, Shyamprasad S, Goldfine AB, Brownstein JS. Association between fine particulate matter and diabetes prevalence in the U.S. Lancet Planet Health. 2018;2(7):e301–e312. https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30140-2/fulltext