{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:55:30Z","timestamp":1790751330249,"version":"4.1.0"},"reference-count":26,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"<jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To examine U.S. trends and underlying-cause patterns among deaths with diabetes recorded as a non-underlying cause (DM-nonUCD).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We used CDC WONDER Multiple Cause of Death data from 1999 to 2024. DM-nonUCD was defined as deaths with ICD-10 codes E10-E14 in multiple-cause fields, excluding deaths with diabetes as the underlying cause. Analyses were performed overall and for type 1 diabetes (E10) and type 2 diabetes (E11). Death counts, age-adjusted mortality rates (AAMRs), and Joinpoint trends were assessed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>DM-nonUCD occurred in 4,794,136 deaths and increased from 141,371 in 1999 to 246,426 in 2024. The leading underlying causes were circulatory diseases (2,294,799; 47.87%), malignant neoplasms (725,592; 15.13%), and respiratory diseases (449,837; 9.38%). Circulatory diseases remained dominant but declined from 60.51% to 44.48%, with decreasing AAMR (average annual percent change [AAPC], -1.01%; 95% CI, -1.21 to -0.88). Shares increased for malignant neoplasms (14.01% to 16.30%), nervous system diseases (2.67% to 7.56%), and mental and behavioral disorders (1.05% to 4.41%). Within circulatory causes, ischemic heart disease AAMR declined (AAPC, -2.04%; 95% CI, -2.23 to -1.92), whereas hypertensive disease AAMR increased (AAPC, 3.21%; 95% CI, 2.94 to 3.56). Subtype analyses showed similar cause-distribution shifts for E10- and E11-nonUCD, with declining circulatory shares and increasing nervous system and mental and behavioral shares.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>DM-nonUCD represents a substantial proportion of deaths in which diabetes was recorded on the death certificate. The underlying-cause profile is shifting from coronary-dominated mortality toward broader multimorbidity, supporting surveillance and health-system planning that consider competing causes beyond ischemic heart disease.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fendo.2026.1957392","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:01:31Z","timestamp":1790748091000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Shifting competing underlying causes of death among U.S. decedents with diabetes recorded as a non-underlying cause, 1999\u20132024"],"prefix":"10.3389","volume":"17","author":[{"given":"Yanhua","family":"Xiao","sequence":"first","affiliation":[{"name":"Department of Dermatology, The First Affiliated Hospital of Gannan Medical University","place":["Ganzhou, China"]},{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qian","family":"Zhou","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xi","family":"Yan","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lihui","family":"Gan","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tong","family":"Chen","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaiyi","family":"Zhang","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]},{"name":"Department of Rheumatology and Immunology, The First Affiliated Hospital of Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Renqing","family":"Zeng","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, The First Affiliated Hospital of Gannan Medical University","place":["Ganzhou, Jiangxi, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dibin","family":"Guo","sequence":"additional","affiliation":[{"name":"Department of Rheumatology and Immunology, The First Affiliated Hospital of Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xuezhi","family":"Hong","sequence":"additional","affiliation":[{"name":"The First Clinical Medical College, Gannan Medical University","place":["Ganzhou, China"]},{"name":"Department of Rheumatology and Immunology, The First Affiliated Hospital of Gannan Medical University","place":["Ganzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2021.109119","article-title":"IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045","volume":"183","author":"Sun","year":"2022","journal-title":"Diabetes Res Clin Pract"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(23)01301-6","article-title":"Global, regional, and national burden of diabetes from 1990 to 2021, with projections of 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