2005, diabetes prevalence among non- Hispanic American Indians and Alaskan prevalence of diabetes among Washington. adults increased as levels of income and …
Diabetes
Definition: Diabetes is a chronic condition characterized by high blood sugar resulting from the bodys inability to use blood glucose for energy In type 1 diabetes, the pancreas no longer makes insulin, and therefore blood glucose cannot enter the cells to be used for energy In type 2 diabetes, either the pancreas does not make enough insulin or the body is unable to use insulin correctly From 5 to 10 of people with diabetes have type 1 diabetes mellitus Ninety to ninety-five percent of people with diabetes have type 2 diabetes mellitus Other types of diabetes might account for 1-5 of diabetes cases Prediabetes is a condition in which blood glucose levels are higher than normal but not high enough to be classified as diabetes Gestational diabetes is a form of glucose intolerance diagnosed in some women during pregnancy Gestational diabetes was not included in the analysis ICD-9 codes 250 ICD-10 codes E10-E15
Summary
More than 300,000 people in Washington State have diagnosed diabetes, nearly 127,000 people have undiagnosed diabetes, and nearly a million people have prediabetes From 1994 to 2006, the age-adjusted percent of Washington adults with diabetes steadily
increased from 4 1 to 7 1 In 2005, diabetes prevalence among nonHispanic American Indians and Alaskan Natives and non-Hispanic blacks was 12 2 and 14 2, respectively The prevalence of diabetes among Washington adults increased as levels of income and education decreased National studies suggest that an individuals socioeconomic position–measured by occupation, education, and income–explains much but not all the disparity in diabetes prevalence Reducing known risk factors such as obesity, tobacco use, physical inactivity, high blood cholesterol, and high blood pressure can prevent diabetes or delay its onset Reducing these risk factors in people with diabetes also prevents or lessens the severity of diabetes complications Intervention approaches should focus on reducing risk factors; increasing screening for diabetes and prediabetes; providing culturally appropriate community-based interventions for those with diabetes and prediabetes; reimbursing providers for improvement in diabetes-related care; improving the quality of care; and strengthening the diabetes public health system
Time Trends
In 2005, 300,000 Washington residents of all ages were estimated to have diagnosed
diabetes Nearly 127,000 people had undiagnosed diabetes, and 987,000 people had prediabetes Thus diabetes affected more than 14 million Washington residents Diabetes prevalence has increased in Washington and nationwide Data from the Behavioral Risk Factor Surveillance System BRFSS showed that among adults responding to the survey, the ageadjusted percent with diabetes increased steadily from 4 1 in 1994 to 7 1 in 2006 Nationwide, diabetes prevalence in adults also increased from 5 in 1994 to 8 in 2005
Diabetes Prevalence WA State and US BRFSS, 1994-2006
Age-Adjusted Percent
8 6 4 2 0 1994 1996
1998
2000
2002
2004
2006
2008
WA
US
HP 2010 Goal
Year 2010 Goals
The national Healthy People 2010, Midcourse Review goal is to decrease the prevalence of diabetes to no more than 25 Given the current trend of increasing diabetes prevalence, neither Washington nor the nation will likely meet this goal
The Health of Washington State, 2007 Washington State Department of Health
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2010
Diabetes Prevalence County Data WA BRFSS 2003-2005 Asotin Wahkiakum Whitman Grays Grant Pierce Okanogan Pend Mason Stevens Douglas Garfield Cowlitz Yakima Lewis
Adams Spokane Pacific Walla Walla Franklin Skagit Kitsap Clark Snohomish Benton WA State Jefferson Chelan Kittitas Thurston Clallam Ferry Klickitat King Columbia Whatcom Island Lincoln Skamania San Juan
0
9 8 8 8 8 8 8 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 6 6 6 6 6 6 6 6 6 6 6 5 5 4 4 3 8 9
diabetes among adults becomes more common as people age, up to age 85 Overall, diabetes prevalence was higher among men 7 1 than women 6 1 The diabetes prevalence for men remained significantly higher than women for ages 55 to 84 The patterns of diabetes prevalence by age and gender remained after taking race, Hispanic origin, income, and education into account
Diabetes Prevalence Age and Gender WA BRFSS 2003-2005 85 75-84 65-74 55-64 45-54 35-44 25-34 18-24 0 1 5 10 15 Percent Female Male 20 25 1 2 3 3 6 7 14 9 19 15 14 14 12 17
Race and Hispanic Origin
1 0 1 5 20
5
Age-Adjusted Percent Value lower than WA State Value similar to WA State Value higher than WA State
Among BRFSS respondents of all races and Hispanic origin, non-Hispanic whites had the lowest prevalence of diabetes Blacks had similar prevalence to American Indians and Alaska Natives
Diabetes Prevalence Race and Hispanic Origin WA
BRFSS 2003-2005 Am Indian/ Alaska Native 12 9 14 9 6 0 Non-Hispanic 5 10 15 20
Geographic Variation
During 20032005, Washingtons age-adjusted rate of diabetes was 7 1 Diabetes rates ranged from 3 1 in San Juan County to 9 2 in Asotin County Asotin, Grant, and Pierce counties had diabetes prevalence higher than the state rate 7 1 King, Lincoln, and San Juan counties had rates lower than the state rate
Asian/Pacfic Islander Black Hispanic White
Age-Adjusted Percent
Age and Gender
Consistent with national data, Washington BRFSS data for 20032005 showed that Diabetes updated: 12/06/2007 5102
Both blacks and American Indians and Alaska Natives had higher prevalence than Hispanics and The Health of Washington State, 2007 Washington State Department of Health
Asian/Pacific Islanders After controlling for gender, income, education, and age only blacks and American Indians and Alaska Natives had significantly higher prevalence than nonHispanic whites The pattern of diabetes prevalence by race and Hispanic origin in Washington is similar to that of the nation 1,2 These patterns probably reflect a combination of differences in genetics, cultural factors, access to health care and to
social and economic opportunities, and experiences of racial discrimination2
educational attainment have been associated with lower rates of blood glucose self-monitoring, lower levels of physical activity, and higher rates of smoking 4 In 20032005, about 68 3 of Washington adults with diabetes said they monitored their blood glucose on a daily basis, greater than the national average of 61 2 Compared to people without diabetes, those with diabetes were more likely to be obese 52 3 versus 20 1, less likely to get enough physical activity 53 5 versus 64 1, and more likely to smoke cigarettes 22 3 versus 19 1 Hospitalizations In 2004, 76,732 Washington hospitalizations included a diagnosis of diabetes at discharge These admissions amounted to 15 billion in charges Among Washington residents, diabetes hospitalization rates nearly doubled from 1988 to 2004, from 687 per 100,000 to 1,232 per 100,000 In 20022004, diabetes hospitalization rates increased with age The hospitalization rate doubled for each subsequent decade between ages 25 and 64 Between ages 5 and 44, females were more likely than males to be hospitalized for diabetes At ages 45 and older, diabetes hospitalization rates
for men were higher than those for women Deaths Diabetes is the seventh leading cause of death in Washington In 2005, 1,549 people in Washington died from diabetes, and diabetes contributed to an additional 3,317 deaths The rate of deaths in which diabetes was either a primary or contributing factor increased from 58 per 100,000 in 1988 to 80 per 100,000 in 2005, mirroring the increase in diabetes prevalence In 20032005, the lowest diabetes death rate was for non-Hispanic whites 75 1 deaths per 100,000 The death rates for blacks, American Indians and Alaska Natives, people of Hispanic origin, and Asians and Pacific Islanders were 176 16, 142 24, 118 14, and 85 8 deaths per 100,000, respectively
Income and Education
Data from the Washington BRFSS for 2003 2005 showed that diabetes prevalence increased with decreasing income Similarly, diabetes prevalence increased with decreasing levels of education The patterns for income remained after accounting for education, gender, race, age, and Hispanic origin The patterns for education remained after accounting for income, gender, race, age, and Hispanic origin These relationships are similar to those found in other studies 3
Diabetes
Prevalence Annual Household Income and Education WA BRFSS 2003-2005 Income 15 Education less than 20,000 20,000 to less than 50,000 50,000 or more high school or less some college college graduate or more 0 5 5 10 Age-Adjusted Percent 8 4 9 8 11
Other Measures of Impact and Burden
Diabetes self care Certain personal health care behaviors are critically important to successful disease management for people with diabetes, including daily monitoring of blood glucose and adjusting medications accordingly, following healthy diet and physical activity plans, controlling weight, and not smoking Among people with diabetes, lower income and The Health of Washington State, 2007 Washington State Department of Health 5103
Risk and Protective Factors
There are no known strategies for preventing type 1 diabetes, in which the body is unable to produce insulin Type 2 diabetes, in which the body produces insulin but is unable to utilize it properly, can be delayed or prevented 5,6,7 For example, one study found that weight loss and increased physical activity resulted in a 58 reduction in development
Diabetes updated: 12/06/2007
of diabetes, and medication resulted in a 31 reduction, over three
years 8 Overweight and obesity There is a welldocumented relationship between a body mass index BMI greater than 23 kg/m2 and the development of diabetes 9 According to crosssectional data reported in the 2003 BRFSS, Washington adults who were obese BMI 30 kg/m2 were up to seven times more likely to have diabetes compared to adults in the nonobese category BMI 30 kg/m2 Obesity complicates the management of type 2 diabetes and increases the risk of cardiovascular complications and cardiovascular mortality in people with type 2 diabetes 10 Physical inactivity A large-scale national study found that physical inactivity and obesity were strongly and independently associated with diabetes and diabetes-related complications 11 Smoking Cigarette smoking is an independent risk factor for type 2 diabetes 12 It contributes to significant morbidity and mortality particularly in patients with diabetes 13 Hypertension and high cholesterol Hypertension and high blood cholesterol are risk factors for the development of type 2 diabetes 14 In Washington, blood pressure greater than 130/80 was more prevalent among people with diabetes than among those without the disease 66 3 compared to 21 1, 2003
BRFSS data High cholesterol was also more common among people with diabetes than those without the disease 57 3 compared to 31 1, 2003 BRFSS data2 Prediabetes In one prospective study of a white population, 645 of the participants who had prediabetes at baseline progressed to diabetes during the six-year follow-up 15 Of those with normal glucose levels at baseline, 45 had diabetes at the follow-up examination Another study showed that people at risk for diabetes could be identified before their blood glucose values became diagnostic for diabetes, and those patients who lost weight and increased their physical activity could prevent or delay the development of diabetes 16 Pregnancy Women who have delivered a baby weighing more than nine pounds or have been diagnosed with gestational diabetes are at risk for developing type 2 diabetes after the birth of the baby, both immediately following delivery Diabetes updated: 12/06/2007 5104
and in subsequent years 17 ,18 Women with histories of gestational diabetes are more likely to have modifiable risk factors, such as obesity and lack of regular physical activity, than women without a history of gestational diabetes 19 Preconception care
with the goal of achieving normal blood glucose concentrations prior to pregnancy appears to reduce the risk of congenital malformations among babies born to mothers who have diabetes 20 Family history A family history of diabetes is associated with an increased risk of developing type 2 diabetes 21
Intervention Strategies
Interventions to reduce the incidence of diabetes and to prevent diabetes-related complications and deaths include the following: Screen routinely for diabetes and prediabetes in the health care setting This strategy is based on current American Diabetes Association guidelines 22 Screening high-risk individuals in primary care settings identifies people with prediabetes as well as those with undiagnosed diabetes People found to have prediabetes should receive care to prevent diabetes Washington is one of five states selected by the US Centers for Disease Control and Prevention to conduct diabetes prevention initiatives that are based on established research This research found that a minimum of 7 weight loss or weight maintenance and a minimum of 150 minutes per week of physical activity similar in intensity to brisk 
walking decreased new cases of type 2
diabetes by 58 23 Connect health systems to culturally appropriate community-based interventions for people with diabetes to self-manage their condition These interventions should also target weight reduction and increasing physical activity to prevent and control type 2 diabetes The use of lay leaders and outreach workers to teach self-management strategies in community and workplace settings has been effective in changing behavior 24 One example is the Chronic Disease Self Management Program 25 in Washington, supported by the Department of Health, the Washington Health Foundation, and numerous local health organizations A randomized controlled trial showed that this program improved health status, health behavior, and self-efficacy and reduced emergency room visits 26 Improve quality of care and outcomes for people with diabetes and prediabetes by implementing the Chronic Care Model Washington is one of several states adopting the Chronic Care Model 27 as The Health of Washington State, 2007 Washington State Department of Health
a basis for improving the effectiveness of primary care practices with patients and communities The Washington State Collaborative is a 13-month
evidence-based approach to improving outcomes for people with chronic illness by providing clinical practice teams with proven tools to assist them in making changes to improve care Practice teams participating in one or more of the collaboratives increased the number of foot and retinal examinations and LDL cholesterol testing 28 conducted More than 120 health organizations have participated in one or more of the five Washington State Collaboratives offered to date Reimburse providers for improvement to diabetes-related processes of care This strategy changes the system of payment from one based solely on fee-for-service to payment for high quality physician performance, with the expectation of improved health status for people with diabetes Care must be taken in this approach, however, to insure that patients whose disease may be more difficult to manage 29 are not excluded from clinical practices More than 50 Washington physicians are among the nearly 2,300 physicians nationwide who currently hold National Committee for Quality Assurance recognition for high quality care of patients with diabetes With this certification, physicians can participate in evidence-based
pay-for-quality programs Prevent and control diabetes-related health disparities Social conditions are major determinants of individual health and risk behaviors as well as access to resources that protect good health In Washington, individual risk behaviors and social inequities collide to result in poor diabetes-related health for many In addition to increasing access to and cultural appropriateness of health care, experts recommend promoting policies that equalize life opportunities through investment in basic education, affordable housing, income security, and other anti-poverty measures 30 Strengthen the diabetes public health system to improve coordination, communication, and collaboration between organizations States with strong statewide diabetes coalitions have demonstrated a political presence that can bring about changes in legislation and policy For example, the Minnesota Diabetes Steering Committee provided a communication network The Health of Washington State, 2007 Washington State Department of Health 5105
and forum for key organizations to learn about cuts to diabetes coverage in a state-subsidized insurance plan for low-income workers In conjunction with other
efforts, this statewide coalitions involvement led to restored MinnesotaCare coverage for diabetes supplies and equipment and a doubling in the 31 annual outpatient care cap to 10,000 The Washington State Diabetes Network, formed in 2005, is a broad coalition of organizations and people working in public, private, tribal, community, and academic training settings to prevent and control diabetes See Related Chapters: Physical Activity, Obesity and Overweight, Social and Economic Determinants of Health Data Sources For additional detail, see Appendix B Washington Hospitalization Data: Dataset compiled by the Washington State Department of Health, Center for Health Statistics from the Washington Comprehensive Hospitalization Abstract Reporting System, Oregon Hospital Discharge data, and Veterans Hospital Administration datasets, December 2006 Washington State Behavioral Risk Factor Surveillance System BRFSS data: 19872006 The data for 20032006 were also weighted to reflect the county population estimates from the Washington State Office of Financial Management OFM Data release for 20032005: November 2006; data release for 2006: June 2007 US Behavioral Risk Factor Surveillance System
data: 1994 2005, downloaded from http://wwwcdcgov/brfss/technical_infodata/surveydatahtm, August 2006 Washington State Death Certificate Data: Washington State Department of Health, Vital Registration System Annual Statistical Files, Deaths 19802005, released December 2006 For More Information Healthy People 2010 Chapter 5 on Diabetes available at http://webhealthgov/healthypeople/Document/HTML/Volume1/ 05Diabeteshtm Washington State Diabetes Collaborative http://wwwdohwagov/cfh/wsc/defaulthtm Collaborative methodology http://improvingchroniccareorg and http://wwwhealthdisparitiesnet Technical Notes Number of people known to have diabetes in Washington State was calculated through estimation of adult diabetes prevalence from the Washington State Behavioral Risk Factor Surveillance System survey combined 2003 2005 data and youth diabetes prevalence from the National Health Interview Survey NHIS–a 32 national prevalence estimate applied to Washington These prevalence figures were then applied to the 2004 Washington intercensal population estimates by age groups 0-17, 18-44, 45-64, 65-74, and 75 Diabetes updated: 12/06/2007
Estimates of undiagnosed diabetes were calculated based on
a national prevalence estimate for undiagnosed diabetes, applied to the Washington State diabetes population The national prevalence estimate for undiagnosed diabetes was used in the 2005 CDC National Diabetes Fact Sheet for methods, see http://wwwcenterforamericannursesorg/wellness/health/cd cfactsheetpdf Estimate of prediabetes was calculated by applying the 19881994 National Health and Nutrition Examination Survey NHANES III prevalence estimate of prediabetes among adults, ages 40-74 years 401, as reported in the 2005 CDC National Diabetes Fact Sheet to the 2004 Washington State resident population estimates for this age group 2,401,964 obtained from OFM Endnotes
1 US Centers for Disease Control and Prevention 2005 National diabetes fact sheet Retrieved November 17, 2006, from http://wwwcdcgov/diabetes/pubs/figuretext05htmfig3 2 Washington State Department of Health Diabetes Disparity Report In print 3 Robbins, J M, Vaccarino, V, Zhang, H, Kasl, S V 2005 Socioeconomic status and diagnosed diabetes incidence Diabetes Research and Clinical Practice, 68, 230-236 4 Brown, A F, Ettner, S L, Piette, J, Weinberger, M, Gregg, E, Shapiro, M F, et al 2004 Socioeconomic position and
health among people with diabetes mellitus: A conceptual framework and review of the literature Epidemiologic Reviews, 26, 63-77 5 US Centers for Disease Control and Prevention Primary Prevention Working Group 2004 Primary prevention of type 2 diabetes mellitus by lifestyle intervention: Implications for health policy Annals of Internal Medicine, 140, 951-957 6 Tuomilehto, J, Lindstrom, J, Eriksson, J G, Valle, T T, Hamalainen, H, Ilanne-Parikka, P, et al 2001 Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance New England Journal of Medicine, 344, 1343-1350 7 Pan, X R, Li, G W, Hu, Y H, Wang, J X, Yang, W Y, An, Z X, et al 1997 Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study Diabetes Care, 20, 537544 8 Diabetes Prevention Program Research Group 2002 Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin New England Journal of Medicine, 346, 393-403 9 Haslam, D W, James, W P 2005 Obesity The Lancet, 366, 1197-1209 10 Weight management using lifestyle modification in the prevention and management of type 2 diabetes:
rationale and strategies [Position Statement] 2005, Summer Clinical Diabetes, 23, 130-136 11 Sullivan, P W, Morrato, E H, Ghushchyan, V, Wyatt, H R, Hill, J O 2005 Obesity, inactivity, and the prevalence of
diabetes and diabetes-related cardiovascular comorbidities in the US, 2000-2002 Diabetes Care, 28, 1599-1604 12 Wannamethee, S G, Shaper, A G, Perry, I J 2001 Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men Diabetes Care, 24, 1590-1595 13 Ford, S K, Shilliday, B B 2006 Smoking and diabetes: helping patients quit Clinical Diabetes, 243, 133-137 14 DAgostino, R B, Jr, Hamman, R F, Karter, A J, Mykkanen, L, Wagenknecht, L E, Haffner S M 2004 Cardiovascular disease risk factors predict the development of type 2 diabetes: The Insulin Resistance Atherosclerosis Study Diabetes Care, 27, 2234-2240 15 De Vegt, F, Dekker, J M, Jager, A, Hienkens, E, Kostense, P J, Stehouwer, C D A, et al 2001 Relation of impaired fasting and postload glucose with incident type 2 diabetes in a Dutch population: The Hoorn Study Journal of the American Medical Association, 285, 2109-2113 16 Herman, W H, Hoerger, T J, Brandle, M, Hicks, K, Sorensen, S, Zhang, P, et al 2005 The
cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance Annals of Internal Medicine, 142, 323-332 17 Case, J, Willoughby, D, Haley-Zitlin, V, Maybee, P 2006 Preventing type 2 diabetes after gestational diabetes The Diabetes Educator, 32, 877-886 18 Fletcher, B, Gulanick, M, Lamendola, C 2002 Risk factors for type 2 diabetes mellitus Journal of Cardiovascular Nursing, 16, 17-24 19 Yun, S, Kabeer, N H, Zhu, B-P, Brownson, R C 2007 Modifiable risk factors for developing diabetes among women with previous gestational diabetes Preventing Chronic Disease Retrieved May 16, 2007 from http://wwwcdcgov/pcd/issues/2007/ jan/06_0028htm 20 American Diabetes Association 2006 Standards of medical care in diabetes-2006 [Position Statement] Diabetes Care, 29Suppl 1, S4S42 21 Murff, H J, Rothman, R L, Byrne, D W, Syngal, S 2004 The impact of family history of diabetes on glucose testing and counseling behavior in primary care Brief Report Diabetes Care, 27, 2247-2248 22 American Diabetes Association 2006 Standards of medical care in diabetes-2006 [Position Statement] Diabetes Care, 29Suppl 1, S4S42 23 The Diabetes
Prevention Program Research Group 2002 The Diabetes Prevention Program DPP: Description of lifestyle intervention Diabetes Care, 25, 2165-2171 24 Glazier, R H, Bajcar, J, Kennie, N R, Willson, K 2006 A systematic review of interventions to improve diabetes care in socially disadvantaged populations Diabetes Care, 29, 1675-1688 25 Chodosh, J, Morton, S C, Mojica, W, Maglione, M, Suttorp, M J, Hilton, L, et al 2005 Meta-analysis: Chronic disease selfmanagement programs for older adults [Improving Patient Care][Author Abstract] Annals of Internal Medicine, 143, 427-439 26 Lorig, K R, Ritter, P L, Jacquez, A 2005 Outcomes of border health Spanish/English Chronic Disease Self-Management Programs Diabetes Educator, 313, 401-409 27 Wagner, E H, Glasgow, R E, Davis, C, Bonomi, A E, Provost, L, McCulloch, D K, et al 2001 Quality improvement in chronic illness care: A collaborative approach The Joint Commissions Journal on Quality Improvement, 27, 63-80
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Daniel, D M, Norman, J, Davis, C, Lee, H, Hindmarsh, M F, McCulloch, D K, et al 2004 A state-level application of the Chronic
Illness Breakthrough Series: Results from two collaboratives on diabetes in Washington State The Joint Commissions Journal on Quality and Safety, 302, 69-79 29 Leichter, SB 2006 Pay-for-Performance contracts in diabetes care Clinical Diabetes, 242:56-59 30 Daniels, N, Kennedy, B, Kawchi, I 2000 Justice is good for our health Boston Review Retrieved March 6, 2006 from http://wwwbostonreviewnet/BR251/danielshtml 31 National Association of Chronic Disease Directors nd Improving diabetes care coverage for low-income workers Retrieved May 13, 2007 from http://wwwchronicdiseaseorg/files/public/SSS_MN_ diabetes_uninsured_WEBpdf 32 Kenny S J, Aubert, R E, Geiss, L S 1995 Prevalence and incidence of non-insulin-dependent-diabetes In M I Harris Ed, Diabetes in America 2nd ed, Chapter 4, p 50 Washington, DC: US Government Printing Office Retrieved May 17, 2007 from http://diabetesniddknihgov/dm/pubs/america/pdf/chapter4pdf
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Source:doh.wa.gov
