acknowledge the ongoing effort made by members of the Diabetes Health System in staff of Ambulatory Diabetes Education and Follow-up programs statewide for their …
The Maine 2007 Diabetes Surveillance System
This publication was supported by Cooperative Agreement Number U32/CCU122694 from the Centers for Disease Control and Prevention/ Division of Diabetes Translation Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the CDC
The Maine 2007 Diabetes Surveillance System John E Baldacci, Governor State of Maine Brenda Harvey, Commissioner Department of Health and Human Services Dora Anne Mills, MD,MPH, Director Maine Center for Disease Control and Prevention Barbara Poirier, Acting Division Director Division of Chronic Disease Katie Meyer, ScD, MPH Chronic Disease Epidemiology Consultant James F Leonard, MSW, Program Manager Diabetes Prevention and Control Program Dana Ivers, BS Comprehensive Health Planner The Maine Diabetes Prevention and Control Program April 2007
Acknowledgements
The Maine CDCs Diabetes Prevention and Control Program would like to acknowledge the ongoing effort made by members of the Diabetes Health System in Maine for the work being done to improve diabetes care throughout the state The staff of Ambulatory Diabetes Education and Follow-up programs statewide
for their continued submission of self-management data, and to the many organizations, especially local Healthy Maine Partnerships who have worked tirelessly to make community environments places that support healthy lifestyles Finally we thank the members of the Diabetes Advisory Council for their support and direction in helping the Diabetes Prevention and Control Program reach its vision, Maine enjoys the best diabetes health in the nation as the result of our work in diabetes prevention and management Members of the Diabetes Advisory Council: Claudette Bean Medical Care Development Jo-Anne Bushey Medical Care Development Dona Forke HOT Community Partnership Valli Geiger Maine Primary Care Association Cindy Hale Maine Diabetes Prevention and Control Program James Leonard Maine Diabetes Prevention and Control Program Brenda McCormick MaineCare Leslie A Molleur Northeast Health Care Quality Foundation Mary-Carmela Moreau Anthem Blue Cross and Blue Shield Kristina M Scrutchfield MaineHealth
Maine Diabetes Surveillance System
Table of Contents Introduction 1 Executive Summary 2 Diabetes Surveillance System 3
Introduction 3 Data Sources for the Diabetes Surveillance System 3
Table 1: Data Sources for the Maine Diabetes Surveillance System 4
Prevalence of Diabetes 6
Introduction 6 The Maine Behavioral Risk Factor Surveillance System BRFSS 6 Table 2: Total Number of People Interviewed and Number of People With Diabetes Interviewed Each Year as Part of the Maine Behavioral Risk Factor Surveillance System 8 Figure 2: Year-specific prevalence of non-gestational diabetes in Maine adults, 1994-2005, BRFSS 9 Figure 3: Age-specific prevalence of diabetes of non-gestational diabetes in Maine adults, 2003-2005, BRFSS 10 Figure 4: County-specific, age-adjusted diabetes prevalence estimates, Maine BRFSS, 20032005 10 Figure 5: Gender-specific diabetes prevalence estimates, Maine BRFSS, 2003-2005 11 Figure 6: Age-adjusted prevalence of diabetes according to leisure time physical activity 11 Figure 7: Diabetes prevalence according to BMI 12 Figure 8: Diabetes prevalence according to income 13 Figure 9: Diabetes prevalence according to education 13 Figure 10: Diabetes prevalence in Maine adults with and without high cholesterol 14 Figure 11: Diabetes prevalence in Maine adults with and without high blood pressure 14 References 15
Progress Towards Healthy Maine
2010 and Healthy People 2010 Goals 16
Table 3:Increase the proportion of Maine adults with diabetes who have taken a course or class in managing diabetes to 80 percent 16 Table 4: Increase the proportion of Maine ADEF/DSMT Program participants with diagnosis 5 years to 95 percent This is a Maine-specific goal 16 Table 5:Increase the proportion of people with diabetes who have an annual eye examination to 85 percent 17 Table 6:Increase the proportion of adults with diabetes who have a hemoglobin A1c test at least once a year to 95 percent 17 Table 7:Reduce the rate of lower extremity amputations in adults with diabetes to 18 per 1,000 people with diabetes 17 Table 8:Reduce the diabetes death rate any cause to 65 per 100,000 population 17
Table of Contents
Diabetes-Related Hospitalizations in Maine 18
Hospitalizations from Diabetes In Maine Residents 18 Table 9: Diabetes Related Hospitalizations in Maine 1994-2005 18 Figure 12: Age-adjusted rates of diabetes hospitalization, any listed cause, Maine, 19942005, and US, 1994-2003 19 Figure 13: Age-adjusted rates of diabetes hospitalization among adults with diabetes, any listed cause, Maine, 2001-2005 20 Figure 14: Age-adjusted
rates of diabetes hospitalization, first listed cause, total population, Maine, 1994-2005, and US, 1994-2003 20 Figure 15: Age-adjusted rates of diabetes hospitalization among adults with diabetes, first listed cause, Maine, 2000-2004 21 Figure 16: Age-adjusted rates of hospitalization for non-traumatic lower extremity amputation, any listed cause, Maine, 1994-2005, and US, 1994-2003 21 Figure 17: Age-adjusted rates of hospitalization for keto-acidosis, first listed cause, Maine, 1994-2005, and US, 1994-2003 22 Figure 18: Age-adjusted rates of hospitalization for cardiovascular disease, first listed, and diabetes, any listed cause, Maine, 1994-2005, and US, 1994-2003 22
Diabetes Related Deaths in Maine 23
Introduction 23 Deaths from diabetes In Maine Residents 23 Table 10 24 Figure 19: Age-adjusted and crude rate of death from diabetes as any cause, Maine, 1994 2005 24 Figure 20: Maines Age-Specific Mortality Due to Diabetes 25 Figure 21:Age-Adjusted Gender Mortality Due to Diabetes as Any Listed Cause 26 Figure 22: Age-adjusted Mortality Due to Diabetes as an Underlying Cause of death, Maine, 1994-2005, the US, 1994-2003, and US White, 1994-2003 27 References 27
Diabetes
Treatment, Knowledge and Self-Care Behavior 28
Introduction 28 Treatment and Self-Care Behavior 28 Health Care Visits 28 Table 11: BRFSS Respondents with Diabetes the Number of Health Care Visits for Diabetes in Past Year 28 Eye care2 29 Table 12: Percent of BRFSS Respondents with Diabetes that had an Eye Exam 29 Foot care 29 Table 13: Number of Foot Exams in Past Year for BRFSS Respondents with Diabetes 30 Monitoring Glucose Control 30 Table 14: Frequency of Blood Glucose Monitoring and HbA1c testing 30 Smoking 31 Immunizations 31
Table of Contents
Table 15: Percent with Pneumonia or Influenza 31 Hypertension and Lipids 32 Table 16: Percent of Persons with Diabetes Reported they have High Cholesterol 32 Table 17:Percent of Persons with Diabetes Reported having Hypertension 32 Physical Activity 32 Diabetes Educational Course 32
Diabetes Self-Management Education DSME 33
The Maine ADEF Program 33 Using ADEF Program Data to Estimate Referrals to Diabetes Self-Management Education DSME 33 Table 18: ADADEF/DSME Referrals Per County for 2003-2005 34 Table 19: ADEF Participation 34 Distribution of Diabetes by Type 35 Table 20: Distribution of Types of Diabetes 35 Length
of Time From Diagnosis to Referral 35 Figure 23: Length of Time From Diagnosis to Referral 35 Age Distribution 36 Figure 24: Age Distributions of Persons Referred to ADEF/DSME 36 Weight Distribution 36 Figure 25:Distribution of Body Mass Index BMI of ADEF Participants 36 Gender Distribution 37 Figure 26: Gender Distribution of ADEF Participants 37 Hospitalization and Medical Conditions by Gender 37 Figure 27: Hospitalizations of ADEF Participants In Past Year 37 Table 21:Hospitalizations by Gender of ADEF Participants In Past Year 38 Hypertension and Heart Disease 39 Figure 28: Percent of ADEF Participants with Heart Disease 39 HbA1c Measures 39 Figure 29: ADEF Participants with a HbA1c Test 39 Eye Exams 40 Figure 30: Percent of ADEF Participants with an Eye Exam 40 Monofilament Test 40 Figure 31: Percent of ADEF Participants Reported Having a Monofilament test 40 References 41
Introduction
Introduction
Diabetes is a metabolic disorder characterized by high levels of blood-glucose It is a chronic disease which when mismanaged can result in blindness, digestive problems, leg and foot ulcers, lower-limb amputation, heart disease, kidney disease, kidney failure, coma and
death Recent epidemiological evidence shows an increasing trend of type 2 diabetes in the US population Maine is one of twentytwo states that has seen prevalence double within the past ten years There is no known cure for diabetes It is an expensive disease with yearly costs estimated to be five times greater than for people without diabetes Despite all of this bad news, medical advances have made it possible for people with diabetes to avoid many of the complications that can develop from the disease Medical advances are not miracles however and lifestyle modifications are required to realize the full benefits of these advances Several years have passed since results from two landmark studies demonstrated that many of the complications from diabetes could be avoided through consistent blood-glucose control1 Additional studies have also shown that significant reductions in cardiovascular disease the leading cause of deaths for people with diabetes can be achieved through targeted medical management and lifestyle modification2 Improvements in diabetes management has been a focus of several national quality improvement initiatives Beginning in 1997, a consortium of organizations
developed a set of diabetes-specific performance and outcome measures that would allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers3 This report examines trends on selected diabetes process measures to show how medical care in Maine compares to national standards Medical care is only part of the equation to effective diabetes management Much of the management of diabetes occurs outside of the medical system For this reason we look closely at several indicators of self-management in this report Finally we bring various pieces of data together to highlight where we need to focus our efforts in order to improve outcomes for people with diabetes in Maine
1 Diabetes Control and Complications Trial, 1997 and United Kingdom Prospective Diabetes Study, 1998 2 Goede, P, et al Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes NEJM Volume 348:383-393 January 30, 2003 Number 5 3 McLaughlin, S The Diabetes Quality Improvement Project Diabetes Spectrum Volume 13 Number , 2000, Page 5
Maine Diabetes Surveillance System 1
Executive
Summary
Executive Summary
Diabetes is an insidious disease that can dramatically lower quality of life In the past twelve years the prevalence of diabetes in Maine has more than doubled We have seen rates increase across all age groups, especially in the older segment of our population With more people living longer and with Maine having the oldest population in the United States, an increased rate of diabetes is of particular concern Diabetes is a chronic disease requiring daily self-management and planned medical care to reduce the risks of developing complications There are indications from the data that people are seeing their healthcare provider more often than was reported in our previous study Preventive measures, to detect early signs and symptoms of complications, are also increasing compared to our 2001 report And the data show the beginning signs of a downward trend in cardiovascular related hospitalizations These improvements are encouraging signs and likely the result of the ongoing improvement work being done by many in the Maine healthcare system There are concerns however The rate of smoking among people with diabetes continues to remain high Diabetes and smoking
is an especially risky proposition We need to do more to identify those at risk and encourage treatment There is also suggestion, through the data, of a decline in referrals to diabetes self-management education DSME We have begun a study of barriers to referral and attendance to DSME and plan to release our findings with an action plan this year DSME in Maine continuously shows a positive impact on clinical outcomes Referral slippage is of concern National projections of diabetes trends predict continued increases through 2025 Our health system will experience significant challenges to deliver care to the population, let alone those with a complex disease like diabetes There is hope and evidence that improved selfmanagement can reduce the likelihood of complications that can develop from diabetes As more community resources develop for people with chronic diseases, such as walking trails and nutrition programs, we anticipate greater attention to and participation in selfmanagement programs In summary although the threat of increased diabetes prevalence is a very real one, there is growing evidence of improved diabetes care and greater awareness of the benefits of lifestyle
management on the long-term outcomes of people with diabetes With continued improvement, people in Maine with diabetes can live longer and healthier lives than at any time in the past Respectfully, Jim Leonard, MSW Director Maine CDCs Diabetes Prevention and Control Program
Maine Diabetes Surveillance System 2
Maines Diabetes Surveillance System
Diabetes Surveillance System Introduction
Surveillance is defined as the ongoing, systematic collection, analysis, and interpretation of health dataused for planning, implementing, and evaluating public 1 health interventions and programs Surveillance data are used to identify public health resources needed at multiple levels and to provide baseline measures for gauging the impact and outcome of public health efforts In 1998, the Maine Center for Disease Control And Preventions then known as Maine Bureau of Health Diabetes Control Program DCP developed a surveillance system designed primarily to document the burden of diabetes in Maine, identify trends in diabetes over time, and explore differences in diabetes prevalence and experience with respect to various personal characteristics In 2001 the DCP released its first comprehensive
report using this surveillance system The Maine 2001 Diabetes Surveillance System reported on diabetes prevalence, morbidity, mortality, and preventive practices In this second publication we continue to report on trends in these four critical areas, progress made, and areas to focus on Diabetes is a chronic disease with no known cure Although not curable, the disease is manageable Several studies have shown that complications from diabetes are avoidable or can be diminished through consistent management There has been a large increase in diabetes prevalence in recent years with continued increases predicted through 2020 by the CDC The future health of those with diabetes is largely dependent on consistent management As we read through this report we look for opportunities to improve outcomes of people with diabetes A cardinal area for improvement is within preventive practices We are aiming to increase more people to engage in preventative practices and hope to see lower proportions of complications as a result
Data Sources for the Diabetes Surveillance System
As defined, surveillance requires the ongoing and systematic analysis of health data, and it is therefore essential that
data sources provide valid and reliable data on a consistent basis In the table below, we outline the specific surveillance contribution of the six data sources that form the foundation of the Maine Diabetes Surveillance System
1 Klaucke DN, Thacker SB, Parrish RG, et al Guidelines for evaluating surveillance systems MMWR 1998;37:1-18
Maine Diabetes Surveillance System 3
Maines Diabetes Surveillance System
Table 1: Data Sources for the Maine Diabetes Surveillance System
Data Source Behavioral Risk Factor Surveillance System BRFSS Death certificates Hospital discharge data Vital statistics US Census Bureau Maine Ambulatory Diabetes Education and Follow-up ADEF Program
Data Contributed Diabetes and diabetes risk factor prevalence estimates in adults Mortality rate estimates Estimates of hospitalization rates Maine population estimates Socioeconomic characteristics Clinical data on ADEF program participants
Availability Yearly Yearly Yearly Yearly 10 year surveys Yearly
Figure 1 provides a graphic representation of the roles of various data sources in the surveillance system Each data source contributes to the overall picture of the burden of diabetes in Maine State census
data inform us of the demographic composition of the population in the state Hospital discharge data provide a foundation for tracking and comparing hospitalization rates Mortality data are used to calculate diabetes-related deaths and to compare Maine and national rates BRFSS data are used to estimate the prevalence of diabetes in the adult population and to explore relations between diabetes and variables that are commonly associated with diabetes Finally, the ADEF Program data system, which provides county referral rates for diabetes self-management education DSME, is used to describe the population that was referred to ADEF and that participated in the ADEF Program
Maine Diabetes Surveillance System 4
Maines Diabetes Surveillance System
Figure 1: The Roll of Data Sources in The Maine Diabetes Surveillance System
State Level US/State Census Data Population Demographic Socioeconomic Stratification County Level Population Data Synthetic Estimates National Level State Population Demographics Compared to National
Hospital Discharge Data
DM Related Primary/Secondary
Rate of DM Related Hospitalizations
State DM Hospitalization Rate Compared to National Rate
Mortality Data
DM
as Primary/ Secondary cause
Rate of DM Related Deaths
State DM Related Mortality Rate Compared to National Rate
BRFSS Data
DM Module Behaviors Demographics
State/County DM Rates Behaviors Demographics
State/County DM Rates Compared to National Rates
ADEF/ DSMT Data
Referrals Demographics Clinical Values Education Process Outcomes
State/County Referral and Education/ Clinical Information
County/Town Demographic DM Profile
Existing Resources
Planning Resource Allocation
National Standards
DPCP ADEF/DSMT Partnership
Information From Data Informs
Process
Maine Diabetes Surveillance System 5
Prevalence of Diabetes
Prevalence of Diabetes Introduction
In this chapter we present data on the number and percentage of people with diabetes in Maine as measured by a statewide survey Raw numbers counts document the absolute burden of disease in the population and can be useful for health care planning The percentage of the population that has diabetes during a particular time period, also called prevalence, controls for changes in the population size and provides an estimate of the per capita burden of diabetes Along with absolute counts and the prevalence of diabetes, we
present data on variables that are commonly associated with diabetes, including obesity, physical activity, and socioeconomic status
The Maine Behavioral Risk Factor Surveillance System BRFSS
We used the Maine Behavioral Risk Factor Surveillance System BRFSS, an annual telephone survey, to estimate the prevalence of diabetes in adults1 The BRFSS collects information from randomly selected participants on their health status, demographic characteristics, and participation in various health behaviors Over the past 12 years, between 1,250 to 4,600 Maine residents have been surveyed annually This sample is used to calculate prevalence estimates that are representative of Maines adult population as a whole The BRFSS operates in all 50 states and 4 territories, allowing comparisons of state and national data A few points about the BRFSS deserve attention As a telephone survey, BRFSS excludes people without individual telephones, including those in nursing homes, prisons, college dormitories, and the homeless Therefore, the BRFSS survey does not completely represent all segments of Maines population In addition, the BRFSS response rate has declined in the past decade, and approximately
fifty 50 percent of sampled individuals complete the BRFSS survey To the extent that those who respond to the survey are more or less likely to have diabetes than the general population, prevalence estimates from the BRFSS will be inaccurate Further, the BRFSS data are only as good as the accuracy of participants self-reported responses With respect to self-reported diabetes, data will be limited by the extent to which people with diabetes have been diagnosed Currently, national data suggest that about sixty-six 66 percent of those with diabetes have been diagnosed 2 If Maine data mirror national data, we would expect that the true diabetes prevalence is about fifty 50 percent higher than that reported on the BRFSS survey
Maine Diabetes Surveillance System 6
Prevalence of Diabetes
The BRFSS diabetes question does not distinguish between type 1 and type 2 diabetes, which are clinically distinct, have different etiologies, and have different preventive and treatment options Type 1 is an autoimmune condition in which pancreatic beta-cells, which produce insulin, are destroyed3 This requires people with type 1 diabetes to supplement their blood with insulin3 Type 2 diabetes is a
condition that develops gradually, starting with insulin insensitivity, in which body cells do not appropriately utilize insulin, and resulting in full diabetes3 Documented risk factors for type 2 diabetes include low physical activity and weight gain3 Type 2 diabetes is the most common form of diabetes, representing about ninety-five 95 percent of all diabetes3 Therefore, we can safely assume that most diabetes reported on the BRFSS will be type 2 The BRFSS survey samples only adults and we are unable to report prevalence estimates for diabetes among those younger than age 18 Generally, diabetes developed before adulthood is assumed to be type 1 diabetes; however, evidence documents that type 2 diabetes is increasing among children and adolescents4 A primary hypothesis for this phenomenon is the dramatic increase in obesity among the young4 Despite these limitations, the BRFSS remains our only source for statewide estimates for many health conditions and behaviors The BRFSS data are sufficiently sensitive to document the increase in diabetes shown in national surveys, including those that include blood glucose testing In addition, the relations between diabetes and risk factors
observed in the BRFSS data also mirror those illustrated in the scientific literature The first two columns of Table 2 show the number of people who were interviewed in each of the past 12 years and the number who reported having been diagnosed with non-gestational diabetes In the next two columns we present the total number of people in the state that are represented by the sampled population and the estimate of how many people would have reported having diabetes if we had interviewed everybody in the state rather than only a sample Again, note that these data assume that BRFSS respondents are representative of Maines population as a whole The final column of Table 2 provides the estimated prevalence of nongestational diabetes in Maine along with its ninety-five 95 percent confidence interval 95 CI Confidence intervals are a measure of the margin of error associated with each estimate due to sampling and random variability For example, an estimate of four 4 percent with a 95 CI of 2-6 percent represents a margin of error of /- 2 percent 4-22 and 426 The number of people in Maine estimated to have diabetes increased from about 34,000 to 77,000 from 1994 through 2005 The increased
burden of diabetes will translate into increases in necessary medical services and corresponding increases in the overall cost of health care in Maine due to diabetes
Maine Diabetes Surveillance System 7
Prevalence of Diabetes
The estimated prevalence of non-gestational diabetes has steadily increased over the 12-year period The prevalence in 2005 represents over a one hundred 100 percent increase from 1994 Table 2, a significant increase with respect to clinical and public health practice, as well as in statistical terms p-value 0001 Table 2 The total number of BRFSS participants, the number of participants who reported having been diagnosed with diabetes, the estimated total number of Maine adults, and the number of Mainers estimated, from BRFSS, to have diabetes The estimated prevalence of diabetes is shown with 95 confidence intervals, Maine BRFSS, 1994-2005
Table 2: Total Number of People Interviewed and Number of People With Diabetes Interviewed Each Year as Part of the Maine Behavioral Risk Factor Surveillance System Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Total number of participants 1,380 1,277 1,699 1,698 1,615 1,671 4,599 2,417 2,435 2,392
3,530 3,960 Participants who reported having diabetes 56 48 84 80 73 98 284 172 188 195 293 337 Maine population represented by those interviewed 928,972 921,401 930,422 932,908 932,982 935,935 944,287 962,803 988,747 1,006,519 1,029,406 1,035,699 Number in Maine with diabetes 34,114 32,331 39,449 45,848 33,495 50,415 56,449 64,931 71,557 74,792 76,683 77,219 Estimated diabetes prevalence 95 CI 37 26-48 35 25-45 42 32-52 49 38-60 36 27-45 54 43-65 60 49-71 67 55-79 72 61-83 74 63-85 75 65-85 75 66-84
Maines age distribution is older than the United States as a whole, a trend that is increasing with time, as demonstrated by the difference between the crude and ageadjusted prevalence rates shown in Figure 2 The crude prevalence is based only on the number of people with diabetes in Maine and the size of Maines population The age-adjusted prevalence is what Maines prevalence would be if Maine had the agedistribution of the United States as a whole in year 2000 For the past five years, the crude prevalence was higher than the age-adjusted prevalence because Maines population was older than the nations population The difference between the crude and age-adjusted prevalence is more
pronounced in recent years, a function of Maines age distribution moving toward older ages faster than the nations in recent years Together, these findings suggest that Maine can expect an increasing burden of diabetes in the future In addition, this increase will likely exceed that expected nationally due to the aging United States population
Maine Diabetes Surveillance System 8
Prevalence of Diabetes
An observed increase in the prevalence of a disease may result from an increase in the development of new cases of disease called incidence or could represent a spurious increase due to improved diagnosis Data from the National Health and Nutrition Examination Survey NHANES support a true increase in diabetes incidence, but studies also show that the percentage of people with undiagnosed diabetes has declined over time Diabetes Care, Dec 2004 article
Figure 2: Year-specific prevalence of non-gestational diabetes in Maine adults, 1994-2005, BRFSS
8 7 Percent with Diabetes 6 5 4 3 2 1 0 1994 1996 1998 2000
37 36 35 35 49 42 47 42 34 36 52 54 58 67 60 64
72 75 67 68
75 70
75
68
Crude Age-Adjusted
2002
2004
Thus far, we have presented single year estimates of diabetes
prevalence However, to increase the reliability of prevalence estimates within population subgroups, we calculated 3-year average prevalence estimates Unless otherwise indicated, subgroup prevalence shown in the following figures represent 3-year averages from years 2003 through 2005
Maine Diabetes Surveillance System 9
Prevalence of Diabetes
Figure 3 displays age-specific prevalence estimates and 95 confidence intervals for adults in the state On average, 75 percent of Maine adults 18 years of age and older reported ever having been diagnosed with diabetes by a health care provider The prevalence of diagnosed diabetes increases with age, as demonstrated by the chart Approximately 17 percent of residents 65 and older have been diagnosed with diabetes, compared to 92 percent of people ages 45-64 Adults ages 18-44 have the lowest rate of diagnosed diabetes, estimated at about 25 percent
Figure 3: Age-specific prevalence of diabetes of non-gestational diabetes in Maine adults, 2003-2005, BRFSS
20 18 16 14 12 10 8 6 4 2 0
Percent with Diabetes
166 75 25 All Ages 18-44 45-64 65 92
Figure 4: County-specific, age-adjusted diabetes prevalence estimates, Maine BRFSS, 2003-2005
160
140 120 100 80 60 40 20 00
An dr os co Ar ggi n o C ost um oo be k rla Fr n d an H klin an Ke coc nn k eb ec Kn o Li x nc ol On Pe xfo no rd Pi bs s c co t a Sa taq ga uis da So ho mc er se Wt W as ald hi o ng to n Yo rk St at e
Percent with Diabetes
Maine Diabetes Surveillance System 10
Prevalence of Diabetes
We calculated county-specific diabetes prevalence estimates using 5-years of data, from 2003 through 2005 Figure 4 There is much overlap in the 95 percent confidence intervals among the counties and between any one county and the overall state estimate, demonstrating a large amount of variability in the estimates In addition, observed differences among counties may, to some extent, represent differences in how likely an individual is to be diagnosed with diabetes in one county as compared to another The prevalence of diabetes is slighter higher among men 83 percent than among women 67 percent, but this difference is not statistically significant
Figure 5: Gender-specific diabetes prevalence estimates, Maine BRFSS, 2003-2005
Diabetes Prevalence according to Gender
10
Percent with Diabetes
9 8 7 6 5 4 3 2 1 0 Male Female 83 67
Physical activity and body weight are causal
factors in the development of type 2 diabetes3 In the Maine BRFSS, diabetes prevalence was significantly higher among respondents who reported having no leisure time physical activity 132 percent compared to the prevalence among those who reported engaging in any leisure time physical activity 59 percent
Figure 6: Age-adjusted prevalence of diabetes according to leisure time physical activity
Age-adjusted diabetes prevalence according to activity level, Maine adults, BRFSS, 2003-2005
Percent with Diabetes
16 14 12 10 8 6 4 2 0 Leisure time physical activity No leisure time physical activity 59 132
Activity level
Maine Diabetes Surveillance System 11
Prevalence of Diabetes
Similarly, diabetes was strongly associated with weight, as measured by the Body Mass Index BMI Figure 7 The BMI is commonly used to determine healthy weight and is calculated as weight in kilograms divided by height in meters squared A BMI less than or equal to 25 is considered a healthy weight, a BMI between 26 and 30 are overweight, and one greater than 30 is obese We found that only 24 percent of those with BMIs less than 26 reported having diabetes, compared with 71 and 176 percent of BRFSS respondents
who were overweight or obese, respectively Each increase was statistically significant, as represented by the non-overlapping confidence intervals A recent study found that type 2 diabetes is more likely to be diagnosed among obese individuals than among non-obese, which may account for some of the prevalence differences shown in figure 7
Figure 7: Diabetes prevalence according to BMI
Diabetes prevalence according to weight, Maine adults, BRFSS, 2003-2005
25 Percent with Diabetes 20 15 10 5 71 0 24 Healthy weight Overweight Weight status Obese 176
Maine Diabetes Surveillance System 12
Prevalence of Diabetes
Many health outcomes are associated with income, education, and insurance status In the BRFSS data, Mainers who reported an income of less than 15,000 per year were about three times as likely to report having been diagnosed with diabetes than were people who reported incomes of more than 25,000 Figure 8 Similarly, more education was associated with a lower prevalence of diabetes–those with less than high school were about three times as likely to have diabetes as people who graduated from college Figure 9 Insurance status, however, was not associated with diabetes in these
data data not shown This might reflect the availability of insurance for low-income people, as well as the possibility that those without insurance are unlikely to receive a diagnosis of diabetes
Figure 8: Diabetes prevalence according to income
Age-adjusted diabetes prevalence according to income, Maine adults, BRFSS, 2003-2005
20 18 16 14 12 10 8 6 4 2 0
Percent with Diabetes
151 102 51 15,000 15-25,000 25,000
Income
Figure 9: Diabetes prevalence according to education
Age-adjusted diabetes prevalence according to education attainment, Maine adults, BRFSS 2003-2005
Percent with Diabetes
18 16 14 12 10 8 6 4 2 0 High school graduate High school graduate Some college College graduate 140 88 68
48
Education attainment
Maine Diabetes Surveillance System 13
Prevalence of Diabetes
People with diabetes are at greater risk of cardiovascular disease An essential component of managing diabetes is managing cardiovascular disease risk factors, including cholesterol, hypertension, and smoking People with high cholesterol or hypertension were significantly more likely to have diabetes than people without these health conditions The prevalence of diabetes among people with high
cholesterol was about 14 percent, compared to approximately 6 percent among those without high cholesterol Figure 10 The difference in diabetes prevalence was similar, though slightly greater, among those with and without hypertension Figure 11 Smoking was not associated with diabetes data not shown
Figure 10: Diabetes prevalence in Maine adults with and without high cholesterol
Prevalence of diabetes in Maine adults with and without high cholesterol, BRFSS 2003-2005
18
Percent with Diabetes
16 14 12 10 8 6 4 2 0 Told high cholesterol Not told high cholesterol 58 143
Figure 11: Diabetes prevalence in Maine adults with and without high blood pressure
Prevalence of diabetes among Maine adults with and without high blood pressure, BRFSS 2003-2005
25
Percent with Diabetes
20 15 10 5 36 0 High blood pressure No high blood pressure
186
Maine Diabetes Surveillance System 14
Prevalence of Diabetes
References
1 Centers for Disease Control and Prevention CDC Behavioral Risk Factor Surveillance System Survey Data and Questionnaire Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, 1994-2003 2 Harris MI, Flegal KM, Cowie CC, et al
Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults The Third National Health and Nutrition Examination Survey, 1988-1994 Diabetes Care 1998;21:518-524 3 National Diabetes Data Group Diabetes in America, 2nd edition National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases NIH Publication No 95-1468, 1995 4 Bloomarden ZT Type 2 diabetes in the young: the evolving epidemic Diabetes Care 2004;27:998-1010 5 Gregg EW, Cadwell BL, Cheng YJ, et al Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the US Diabetes Care 2004;27:280612
Maine Diabetes Surveillance System 15
Healthy Maine 2010
Progress Towards Healthy Maine 2010 and Healthy People 2010 Goals
In 2002, the Maine CDC formerly Bureau of Health released Healthy Maine 2010: Longer and Healthier Lives, which specifies goals and objectives for ten health priority areas, including chronic disease Outlined in the chronic disease chapter are six diabetes objectives covering diabetes education, eye examinations, HbA1c testing, lower extremity amputations, and the diabetes death rate Healthy Maine 2010 is
available online at wwwmainegov/dhhs/boh/healthy_maine_2010htm Of the six objectives issued in Healthy Maine 2010, five are also referenced in CDCs Healthy People 2010 Healthy People 2010 extends beyond these to additionally include objectives relating to the development of diabetes in the population, foot examinations and sores, gestational diabetes, and other indicators For complete Healthy People 2010 publication, please go to wwwhealthypeoplegov In this chapter, we document how Maine is progressing towards the six Healthy Maine 2010 goals Where an objective is listed in both Healthy Maine 2010 and Healthy People 2010, we include both national and state-level baseline estimates, current status where available, and objectives Because Maines baseline levels were generally different from the baseline levels of the nation as a whole, the goals in Healthy Maine 2010 often differ from those in Healthy People 2010 Current status is assessed using the most recent data, which differs across datasets We report 2003, 2004, and 2005 BRFSS data and 2005 hospitalization and death data
Table 3:Increase the proportion of Maine adults with diabetes who have taken a course or class in managing
diabetes to 80 percent
Years 2003 2005 2010 goal
US Estimate 55 555 2004 60
Maine Estimate 612 604 80
Table 4: Increase the proportion of Maine ADEF/DSMT Program participants with diagnosis 5 years to 95 percent This is a Maine-specific goal
Years 2003 2005 2010 goal
US Estimate Not applicable Not applicable Not applicable
Maine Estimate 77 79 95
Maine Diabetes Surveillance System 16
Healthy Maine 2010
Table 5:Increase the proportion of people with diabetes who have an annual eye examination to 85 percent
Years 2003 2005 2010
US Estimate 509 Not available 76
Maine Estimate 729 754 85
Table 6:Increase the proportion of adults with d 
iabetes who have a hemoglobin A1c test at least once a year to 95 percent
Years 2003 2005 2010 goal
US Estimate 24 Not available 50
Maine Estimate 86 913 95
Table 7:Reduce the rate of lower extremity amputations in adults with diabetes to 18 per 1,000 people with diabetes
Years 2003 2005 2010 goal
US Estimate 48 Not available 29
Maine Estimate 27 18 18
These estimates are for people age 18 and older as reported to the BRFSS
Table 8:Reduce the diabetes death rate any cause to 65 per 100,000 population
Years 2003 2005 2010 goal
US
Estimate 78 2002 Not Available 45
Maine Estimate 808 per 100,000 population 775 65
Maine Diabetes Surveillance System 17
Hospitalizations
Diabetes-Related Hospitalizations in Maine Hospitalizations from Diabetes In Maine Residents
We show the number of hospitalizations for diabetes as the first listed cause or as any listed cause of hospitalization, and the number of hospitalizations with a first listed cause of cardiovascular disease and secondary cause of diabetes Table 9 To allow comparisons with national data, we included only individuals whose diabetes diagnosis was listed in fields 1 through 7 of the hospitalization database, where field 1 provides the first-listed, or principle, diagnosis, the reason for hospitalization, and fields 2-7 are secondary, or contributing, causes of hospitalization Comparing 1994 and 2005, the absolute number of hospitalizations for diabetes as any cause increased by about 25-30 percent People with diabetes are at higher risk for cardiovascular disease morbidity and death There were approximately 5,500 hospitalizations in 2005 for cardiovascular disease as first listed with any mention of diabetes
Table 9: Diabetes Related Hospitalizations in
Maine 1994-2005
Year Diabetes as the first-listed cause of hospitalization Diabetes as any cause of hospitalization Cardiovascular disease as first-listed, diabetes as second-listed
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
1,489 1,475 1,422 1,540 1,541 1,719 1,746 1,774 1,644 1,695 1,592 1,513
16,352 16,674 17,608 18,188 19,086 19,420 20,543 20,777 20,770 21,354 21,679 20,863
5,666 5,804 6,300 6,737 6,784 6,451 6,718 6,446 6,174 6,095 5,838 5,529
Maine Diabetes Surveillance System 18
Hospitalizations
Figure 12 presents age-adjusted hospitalization rates for diabetes as any listed cause in Maine residents from 1994 through 2005 and in US residents from 1994 through 2003 From 1994 to 2005, the age-adjusted hospitalization rate in Maine increased from 126 to 135 per 10,000 population Maines rate appears to have leveled off in 2000, with a decline in the final year of observation It is unclear whether the reduced rates will remain or continue to decline or whether they represent random variability Like Maine, the US rates have increased over the past decade, from a rate of 138 in 1994 to a rate of 176 per 10,000 in 2005 Ageadjusted rates of the US remained
higher than those for Maine throughout the time period, which may be accounted for, in part, by differences in racial/ethnic composition
Figure 12: Age-adjusted rates of diabetes hospitalization, any listed cause, Maine, 1994-2005, and US, 1994-2003
200 180 Rate per 10,000 population 160 140 120 100 80 60 40 20 0 1993 1995 1997 1999 2001 2003 2005 Maine US
Maine Diabetes Surveillance System 19
Hospitalizations
Diabetes hospitalization rates for Maine adults with diabetes are shown in Figure 13 We were unable to compare Maines rates to the US rates because the US rates reflect the total population with diabetes, while Maine has data on the number of adults with diabetes only We restricted the analysis to the past 5 years in order to limit the effect of bias due to improved diabetes diagnosis over time Between 2001 and 2005, rates have declined from 273 to 223 per 1,000 people with diabetes, though the change has not been incremental over time
Figure 13: Age-adjusted rates of diabetes hospitalization among adults with diabetes, any listed cause, Maine, 2001-2005
300
250 Rater per 1,000 population
200
150
100
50
0 2000
2001
2002
2003
2004
2005
2006
Between 1994 and
2005, there was minimal variability in the rates of hospitalization for diabetes as the first listed cause shown in Figure 14 In Maine, those rates varied between 107 and 132 per 10,000 population The US had higher rates, with 189 and 204 hospitalizations per 10,000 population
Figure 14: Age-adjusted rates of diabetes hospitalization, first listed cause, total population, Maine, 1994-2005, and US, 1994-2003
25 Rate per 10,000 population 20 15 10 5 0 1993
Maine US
1995
1997
1999
2001
2003
2005
Maine Diabetes Surveillance System 20
Hospitalizations
Among Mainers with diabetes, the age-adjusted rates of hospitalization for diabetes as the first listed cause declined from 372 to 236 per 1,000 between 2001 and 2005 as shown in Figure 15 However, these declines were inconsistent, with drop to just under 30 per 1,000 in 2002 followed by an increase nearly as high as that in 2001
Figure 15: Age-adjusted rates of diabetes hospitalization among adults with diabetes, first listed cause, Maine, 2000-2004
40 35 R ate per 1,000 population 30 25 20 15 10 5 0 2000
2001
2002
2003
2004
2005
2006
The Maine rates of hospitalization for non-traumatic lower extremity amputations have
been variable over the past decade, with an apparent trend downwards, especially in the last year of observation 2005 as shown in Figure 16 Approximately 20 to 25 people per 10,000 total population have been hospitalized per year US rates were slightly higher, with about 25 to 30 per 10,000
Figure 16: Age-adjusted rates of hospitalization for non-traumatic lower extremity amputation, any listed cause, Maine, 1994-2005, and US, 1994-2003
35 30 R te pe 1 ,0 0 popula a r00 tin 25 20 15 10 05 00 1993 Maine US
1995
1997
1999
2001
2003
2005
Maine Diabetes Surveillance System 21
Hospitalizations
Hospitalization rates for keto-acidosis appear to have increased in both Maine and the US over the observation period as shown in Figure 17 In 1994 there were 23 hospitalizations for keto-acidosis first listed cause per 10,000 Mainers and 29 per 10,000 in 2005 In the US, hospitalization rates increased from 34 per 10,000 to 40 from 1994 to 2003
Figure 17: Age-adjusted rates of hospitalization for keto-acidosis, first listed cause, Maine, 19942005, and US, 1994-2003
45 4 R te p r 1 ,0 0 p p la n a e 0 0 o u tio 35 3 25 2 15 1 05 0 1993 1995 1997 1999 2001 2003 2005 Maine
US
Cardiovascular disease is a major cause of morbidity among people with diabetes In Figure 18 we present hospitalization rates of cardiovascular disease as first listed cause with any mention of diabetes as a contributing cause Between 1994 and 2005, age-adjusted rates in Maine have declined from 436 to 351 per 10,000 Over the same time period through 2003, US rates have increased In 1994, rates for Maine and the US were about the same, with 44 hospitalizations per 10,000; By 2003, the US rate had increased to 506 hospitalizations per 10,000, while the Maine rate was slightly lower at 403 per 10,000
Figure 18: Age-adjusted rates of hospitalization for cardiovascular disease, first listed, and diabetes, any listed cause, Maine, 1994-2005, and US, 1994-2003
60 R tep r 1 ,0 0p p la n a e 0 0 o u tio 50 40 30 20 10 0 1993 Maine US
1995
1997
1999
2001
2003
2005
Maine Diabetes Surveillance System 22
Diabetes Related Mortality in Maine
Diabetes Related Deaths in Maine Introduction
Maines Office of Data, Research and Vital Statistics collects mortality data in accordance with the National Center for Health Statistics guidelines Mortality data provide a source of demographic,
geographic, and cause of death information for all deaths in Maine State-level mortality data are processed following a standard protocol created by the National Center for Health Statistics, making mortality data comparable to other state data Mortality data have limitations, especially where diabetes is concerned Diabetes is co-morbid to many conditions causing death and is believed to be under-reported as a cause of death on death certificates 1-2 Despite this, mortality data are uniformly reported and may offer valuable information on trends over time and state-to-nation comparisons
Deaths from diabetes In Maine Residents
The following table shows the number of deaths of all causes in Maine residents, the number of deaths due to diabetes as any cause or as the underlying cause of death, and the percentage of total deaths that had diabetes listed as a cause of death During the 12-year period, 1994 to 2005, the absolute number of deaths from diabetes as any cause increased by 26 percent, and the number of deaths due to diabetes as the underlying cause of death increased by 24 percent Diabetes also grew to account for a greater percentage of all deaths over the 12-year period The
percentage of total deaths that were due to diabetes as any cause increased from 84 percent in 1994 to 95 percent in 2005, an increase of 13 percent Similarly, the percentage of total deaths due to diabetes as the underlying cause increased from 27 percent in 1994 to 30 percent in 2005, an increase of 11 percent These data are consistent with other evidence of a growing burden of diabetes in Maine and the nation However, the possibility that these numbers may, to some degree, reflect improved coding of diabetes, as a cause of death should not be discounted
Maine Diabetes Surveillance System 23
Diabetes Related Mortality in Maine
Table 10
Year 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Total deaths in Maine 11,292 11,375 11,333 11,607 11,739 12,233 12,337 12,403 12,670 12,525 12,441 12,769
Diabetes as any cause of death percentage of total deaths 951 84 1,016 89 945 83 1,067 92 1,073 91 1,108 91 1,187 96 1,199 97 1,249 99 1,225 98 1,154 93 1,218 95
Diabetes as underlying cause of death percentage of total deaths 307 27 307 27 296 26 288 25 328 28 348 28 356 29 398 32 405 32 397 32 382 31 382 30
Figure 19 tracks crude and age-adjusted death rates for diabetes
as any listed cause in Maine residents from 1994 through 2005 Over this period, the crude death rate increased from 77 to 92 per 10,000 population, or about 20 percent A large part of Maines increase appears due to the aging of Maines population, based on comparison to the age-adjusted death rate The age-adjusted death rate is the rate that would be observed in Maine if Maine had, the same age distribution as the United States had in year 2000 The crude death rate is only slightly higher than the age-adjusted rate in 1994, but these rates diverge over time With a stable age distribution equal to that of the nation in year 2000, Maines diabetes death rate would have increased from 73 to 77 per 10,000 population
Figure 19: Age-adjusted and crude rate of death from diabetes as any cause, Maine, 1994 - 2005
120 Death rate per 10,000 population 100 80 60 40 20 00 1993 Crude rate Age-adjusted rate
1995
1997
1999 Year
2001
2003
2005
Maine Diabetes Surveillance System 24
Diabetes Related Mortality in Maine
Figure 20 illustrates age-specific death rates per 10,000 in Maine due to diabetes as any listed cause, 1994-2005 As expected, the largest number of diabetes deaths occurred in
those aged 75 years and older, with rates per 10,000 people between 66 in 1994 and 84 in 2000
Figure 20: Maines Age-Specific Mortality Due to Diabetes
90 80
76 69 67 75 75 84 78
82 77 73 72
Death rate per 10,000 population
70 60 50 40 30 20 10 0 1993
66
0 to 44 45 to 64 65 to 74
34 28 28 31 33 29 29 28 30 28 29 26
75 plus
58 50 02 02 44 02 45 02 50 03
54 02
52 03
56 03
57 03
60 53 04 03
55 03
1995
1997
1999
2001
2003
2005
Year
Maine Diabetes Surveillance System 25
Diabetes Related Mortality in Maine
Figure 21 displays age-adjusted, gender- and year-specific rates of death from diabetes as any listed cause, for years 1994 through 2005 Based on these data, it appears that greater increases in the age-adjusted diabetes death rate may have occurred in men than in women over this 12-year period, although death rates for men increase about 2 per 10,000 over this time-frame, the trend does not appear to increase consistently over time
Figure 21:Age-Adjusted Gender Mortality Due to Diabetes as Any Listed Cause
12 102 10 Death rate per 10,000 population 88 81 8 67 6 67 63 69 67 80 75 71 73 70 70 92 91 87 92 96 95 87 96
65
64
Female Male
4
2
0
1993
1995
1997
1999 Year
2001
2003
2005
Maine Diabetes Surveillance System 26
Diabetes Related Mortality in Maine
The age-adjusted death rate of diabetes as an underlying cause of death does not increase consistently over time during the 12-year period, 1994-2005 Starting and ending at 24 per 10,000 population Figure 22 Upon closer examination we see a decrease from 24 in 1994 to 21 in 1997 per 10,000 population, then an increase to 27 in 2001 and 2002 followed by a decrease to 24 in 2005 Across the 1994 2003 time period, national diabetes death rates increased, but the national yearspecific estimates and the national data specific to whites display greater stability due to the larger sample
Figure 22: Age-adjusted Mortality Due to Diabetes as an Underlying Cause of death, Maine, 19942005, the US, 1994-2003, and US White, 1994-2003
3 27
Age-Adjusted Death rate per 10,000 population
27 25
26 25
25
24 23 23 23 23 22 22 22 21 21 21
25 25
25
25
24
2
22
23
23
23
23
23
Maine 15 US US white 1
05
0 1992
1994
1996
1998 Year
2000
2002
2004
2006
References
1 Andresen EM, Lee JA, Pecoraro RE, Koepsell TD, Hallstrom AP, Siscovick DS Underreporting of diabetes
on death certificates, King County, Washington Am J Public Health 1993;83:1021-1024 2 Bild DE, Stevenson JM Frequency of recording diabetes on US death certificates: analysis of the 1986 National Mortality Followback Survey J Clin Epidemiol 1992;45:275-281 Maine Diabetes Surveillance System 27
Diabetes Treatment, Knowledge, and Self-Care Behavior
Diabetes Treatment, Knowledge and Self-Care Behavior Introduction
Here we assess several treatment practices by comparing BRFSS responses to national standards of care These data provide information on the medical care and self-care of Mainers with diabetes The American Diabetes Association ADA publishes annual clinical practice recommendations for the care of people with diabetes The treatment and self-care indicators presented here are discussed in the ADA Clinical Practice Recommendations: 20071 Although BRFSS cannot be used to examine all ADA recommendations, data are available on many topics described in the recommendations Unless otherwise indicated, all analyses represent the combined population of BRFSS respondents from 2003-2005
Treatment and Self-Care Behavior
Health Care Visits
We considered the number of visits with a health
care provider per year as an indication of medical management This treatment indicator provides a measure of the number of visits with a health provider, but does not capture appointments that were recommended but not made or those made but not kept Among respondents with diabetes: 12 percent reported not having had a visit with a healthcare provider in the past year Approximately 9 percent had one visit with a health care provider, 24 percent had 2-3 visits, 28 percent had 4 visits, 27 percent had 5 or more visits with a healthcare provider in the past 12 months
Table 11: BRFSS Respondents with Diabetes the Number of Health Care Visits for Diabetes in Past Year
Number of visits with health care provider for Percent with response 95 CI diabetes in past 12 months
5 or more 4 2 or 3 1 None 270 282 241 86 121 235 308 248 319 208 278 65 113 97-151
Maine Diabetes Surveillance System 28
Diabetes Treatment, Knowledge, and Self-Care Behavior
Eye care2
Diabetic retinopathy is the most common cause of blindness in adults2 People with diabetes need regular eye examinations In people living with diabetes for two decades, more than 60 percent of people with type 2 diabetes and most
people with type 1 diabetes will have developed retinopathy2 ADA recommendations state that people with type 2 diabetes should receive annual eye examinations, with the option of less frequent exams 2-3 years under advice of an eye care professional2 People with type 1 diabetes should also receive annual eye exams, although their first exam is not needed until 3-5 years after diagnosis2 We report the time since last dilated eye exam and whether told by a physician that diabetes is affecting eyes Approximately 73 percent of people with diabetes had had a dilated eye exam within the past year, 12 percent had a dilated eye exam between 1 and 2 years ago, and approximately 7 percent reported never having had a dilated eye exam Nearly a quarter reported having been told by a physician that diabetes is affecting their eyes
Table 12: Percent of BRFSS Respondents with Diabetes that had an Eye Exam
Time since last dilated eye exam Within one year Within 2 years More than two years ago Never Told by physician that diabetes is affecting eyes
727 689 763 123 99 152 83 63 108 66 46 94 235 203 271
Foot care
People with diabetes should have an annual foot examination to identify foot
conditions prior to the development of more serious complications3 People with high-risk foot conditions should be evaluated more frequently than once a year3 This is especially important in populations at highest risk for foot ulcers or amputations including men, those with poor glucose control or vascular complications, and those having had diabetes for ten years plus3 We present data on the number of foot exams BRFSS participants reported having in the past year and whether they have ever had a foot sore that took at least 4 weeks to heal Among people with diabetes: about 70 percent reported having at least one foot exam during a visit to a health provider in the past year,
Maine Diabetes Surveillance System 29
Diabetes Treatment, Knowledge, and Self-Care Behavior
18 percent reported having visited a health care provider but not having received a foot exam, 12 percent reported not having visited a health care provider, 11 percent of respondents with diabetes had a foot sore that took at least 4 weeks to heal
Table 13: Number of Foot Exams in Past Year for BRFSS Respondents with Diabetes
Number of foot exams by health care provider in past year Visited health provider
in past year and had at least one foot exam Visited health provider in past year but did not have a foot exam No visits with a health provider in past year Ever had a foot sore that took at least four weeks to heal
698 659 - 733 178 149 - 212 124 99 - 154 111 88 137
Monitoring Glucose Control
Glycemic control is a key element in preventing major complications from diabetes4, 5 and is associated with decreased microvascular and cardiovascular disease6 Among people with type 2 diabetes, the recommended frequency of self-monitoring of blood glucose will vary according to the specific needs of the individual; however, monitoring frequency should be sufficient to maintain glucose control6 Hemoglobin A1c which reflects mean blood glucose levels over the preceding 2 to 3 months, should be measured at least twice a year6 BRFSS respondents with diabetes reported they monitored their own blood glucose: 64 percent monitored at least once per day, 25 percent monitored less than daily, 10 percent never monitored their own glucose 91 percent of BRFSS respondents reported having had an HbA1c test in the past year
Table 14: Frequency of Blood Glucose Monitoring and HbA1c testing
Frequency
of blood glucose monitoring At least daily Less than daily Never Frequency of hemoglobin A1c monitoring in past 12 months Any test No test in past 12 months
641 601 679 255 222 291 104 81 134 913 886 934 87 66 114
Maine Diabetes Surveillance System 30
Diabetes Treatment, Knowledge, and Self-Care Behavior
Smoking
People with diabetes are at higher risk for cardiovascular disease, as are people who smoke7 Smoking is also associated with the development of complications and the rate at which complications progress7 Smoking cessation counseling is effective in people with diabetes7 However, it is believed that the risks associated with smoking have not been sufficiently communicated to people with diabetes or to providers7 In 2004, 23 percent of the people in Maine with diabetes reported they currently smoke
Age Adjusted Rates Population with Diabetes Population without Diabetes 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 225 250 249 253 211 227 193 224 191 233 232 238 260 239 272 236 245 236 230 210
Immunizations
People with diabetes: have abnormalities in immune function and increased risk of morbidity and mortality due to infection are at high risk for
complications, hospitalization, and death from influenza and pneumococcal disease generally have appropriate immune response to vaccination8 The ADA recommends a pneumococcal and annual influenza vaccinations for people with diabetes8 According to BRFSS data, nearly 56 percent of people with diabetes reported having received a pneumonia vaccine and about 63 percent reported having had a flu shot in the past 12 months
Table 15: Percent with Pneumonia or Influenza
Had pneumonia vaccine Had flu shot in past 12 months
557 516-598 627 588-666
Maine Diabetes Surveillance System 31
Diabetes Treatment, Knowledge, and Self-Care Behavior
Hypertension and Lipids
Because of the increased risk for cardiovascular disease among people with diabetes, lipid levels should be evaluated annually in adults9 In clinical trials, treatment of LDL low-density lipoprotein or bad cholesterol in people with diabetes decreased the occurrence of cardiovascular events9 Nearly 94 percent of adults with diabetes surveyed reported having had their cholesterol tested Of those about 57 percent were told that they have high cholesterol
Table 16: Percent of Persons with Diabetes Reported they have High
Cholesterol
Cholesterol tested Told have high cholesterol
937 908 957 571 519 6219
Hypertension increases the risk of micro- and macrovascular complications in people with diabetes and is a common comorbid condition in both type 1 and 2 diabetes10 Blood pressure should be measured at every office visit10 In BRFSS, about 64 percent of adults with diabetes reported having high blood pressure, of those, 93 percent reported being treated
Table 17:Percent of Persons with Diabetes Reported having Hypertension
Told have high blood pressure Treated for high blood pressure if told have high blood pressure
624 573-675 925 894 956
Physical Activity
Physical activity has been associated with improved carbohydrate metabolism, decreased obesity, and decreased risk of cardiovascular disease11 Among people who reported having diabetes on the BRFSS survey, 38 percent reported no leisure time physical activity
Diabetes Educational Course
Only 577 percent 95 CI: 522-619 of respondents who reported having been diagnosed with diabetes reported having taken a diabetes educational course
Maine Diabetes Surveillance System 32
Diabetes Self-Management Education
Diabetes Self-Management
Education DSME
Diabetes Self-Management Education DSME is the cornerstone of care for all individuals with diabetes who want to achieve successful health related outcomes12 Referral for DSME is recommended for all people with diabetes12 The benefits to the person with diabetes and health-care cost-savings are well documented in the literature12, 13,14,15 DSME is a covered medical service in Maine when it is provided through a state and/or national certified program16
The Maine ADEF Program
The Ambulatory Diabetes Education and Follow-up ADEF Program is a comprehensive DSME program anchored to the National Standards for Diabetes Self-Management Education The program was developed in 1979 by the Maine CDCs Diabetes Control Program DCP, now know as the Diabetes Prevention and Control Program DPCP with the assistance of a Statewide Task Force of Diabetes Educators and is periodically renewed and updated to reflect the current national standards and ADA Clinical Practice Recommendations for care of people with diabetes1 The ADEF Program is delivered through state-certified sites by healthcare professionals educated on the delivery of the program and data reporting responsibilities
Uniform ADEF Program reporting is accomplished using a data form packet nine-pages to document DSME services There are currently 35 ADEF Program sites throughout Maine
Using ADEF Program Data to Estimate Referrals to Diabetes Self-Management Education DSME
ADEF Program data are routinely collected at assessment The data are a combination of clinical measurements taken by health care professionals and information self-reported by program participants It should be noted that these data represent people who have both been referred to the ADEF Program and participated in at least part of the program Individuals who were referred, but for whatever reason did not participate in the program are not represented in the following data We also do not distinguish between people who completed the yearlong ADEF Program from those who completed only some of the program Finally, in certain portions of the analysis we compare ADEF participants to BRFSS respondents who reported having ever been diagnosed with diabetes While it is interesting to note similarities and differences, one must remember that BRFSS assesses the lifetime prevalence of diabetes while in what follows, we are studying only
3-years of ADEF participation
Maine Diabetes Surveillance System 33
Diabetes Self-Management Education
Data collected by the DPCP from ADEF program sites throughout the state are tabulated on a regular basis For years 2003-2005, statewide participation in the ADEF Program decreased each year Table 18 ADEF Program participation also decreased annually for many of the counties with ADEF sites Table 18 This trend, if accurate is of significant concern Given that diabetes prevalence is increasing, we would expect to see year to year growth, not decline, in the DSME referrals Table 19 shows the number of ADEF participants for the years 1997 through 2005
County Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York County total County not reported Totals
2003 164 359 288 24 68 302 188 60 104 220 31 68 107 96 32 351 2462 67 2529
Ave 2004 2005 Number 139 98 134 338 362 353 202 126 205 16 10 17 64 66 66 247 226 258 172 121 160 38 37 45 55 39 66 198 114 177 35 10 25 45 29 47 108 111 109 34 19 50 11 9 17 277 191 273 1979 1568 135 339 2114 1907 2003
2183
Table 18: ADEF/DSME Referrals Per County for
20032005 Table 19: ADEF Participation
3500 3000 2500 2000 1500 1000 500 0 1997 1998 1999 2000 2001 2002 2003 2004 2005
2884 1989 2270 1915 2529 2114 1907
1694
1786
Maine Diabetes Surveillance System 34
Diabetes Self-Management Education
Distribution of Diabetes by Type
The table below Table 20 shows the distribution of type of diabetes from 20032005 ADEF data Type 1 made up 2 percent of the total while type 2 comprised 98 percent of participants The gender distribution was similar for both types of diabetes In addition, Table 20 illustrates the breakdown of treatment methods used by people with type 2 diabetes Among people with type 2 diabetes, about 46 percent were treated with an oral agent, 41 percent were using diet alone to control their diabetes, about 5 percent were using insulin, and 6 percent were using a combination of insulin and an oral agent Again, these results were similar for men and women
Table 20: Distribution of Types of Diabetes
Type Type 1 Type 2 Total Type 2 Diet Type 2 - Oral Agent Type 2 Insulin Type 2 - Insulin Oral
Total 21 979 411 461 47 61
Male 54 2,308 871 1,183 119 135
23 977 369 501 50 57
Female 57 2,983 1,349 1,307 134 193
19 981
444 430 44 64
Length of Time From Diagnosis to Referral
Figure 23: Length of Time From Diagnosis to Referral
21 1 2-5 5
13
66
Between 2003 and 2005, about 66 percent of people referred to the ADEF Program reported they were diagnosed with diabetes within the past year This is up from 63 percent from the previous 3-year period 2000-2002, suggesting the possibility that as the program continued, a greater proportion of ADEF participants were being referred earlier than in the past In the 20032005 time period, 13 percent reported being diagnosed 2-5 years before referral to the ADEF Program, and the remaining 21 percent reported having been diagnosed more than five years before referral
Maine Diabetes Surveillance System 35
Diabetes Self-Management Education
Age Distribution
Figure 24: Age Distributions of Persons Referred to ADEF/DSME
Percentage of ADEF participants
200 150 100 50 00 50 37 64 106 131
149 138 130 94 65 35
35 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79
80 Plus
Between 2003 and 2005, the proportion of total ADEF participants increased with age up to age 60 and then declined Each of the 6 five-year age groups between 45 and 74 years old
represented between 9 and 15 percent of ADEF participants People less than 45 and greater than 74 combined represented a quarter of the ADEF population
Weight Distribution
According to data reported 67 percent of the ADEF population were obese BMI30, 24 percent were overweight, and about eight percent were neither overweight nor obese
Figure 25:Distribution of Body Mass Index BMI of ADEF Participants
Percentage of ADEF participants
80 60 40 20 0 25 25-299 82 243
675
30
Maine Diabetes Surveillance System 36
Diabetes Self-Management Education
Gender Distribution
The majority of ADEF participants were women: 558 percent were female and 442 were male A similar distribution was observed in the previous 3-year period, 20002003
Figure 26: Gender Distribution of ADEF Participants
Percentage of ADEF participants
60 50 40 30 20 10 0
442
558
Male
Female
Hospitalization and Medical Conditions by Gender
For the years 2003 thru 2005, prior to attending ADEF Program 1,226 226 percent ADEF participants reported having been hospitalized at least once for any cause in the year prior to attending ADEF Approximately 9 percent of participants reported being hospitalized for diabetes Thus,
about 40 percent of those hospitalized were for a diabetes-related cause Less than 1 percent reported having been hospitalized for a lower extremity amputation LEA
Figure 27: Hospitalizations of ADEF Participants In year prior to attending ADEF
25 Percent of ADEF participants
226
20
15
10
9
5
062
0 Any hospitalization Diabetes-related hospitalization Type of hospitalization LEA hospitalization
Maine Diabetes Surveillance System 37
Diabetes Self-Management Education
The proportions match the overall gender breakdown in the ADEF population between 2003 and 2005, 54 percent female and 46 percent male Therefore, gender does not appear to be associated with all-cause hospitalization When we examine diabetes-related hospitalizations, we note that males make up the about one half of hospitalizations, 49 percent of diabetes-related hospitalizations were male compared to 51 percent female, this is a decline in percentage from the previous data period 2000 2003 when males made up the majority at 55 percent However, when we examine LEA hospitalizations, 70 percent are male In this ADEF population from 2003-2005, males appear to have experienced a disproportionate burden of LEA
related hospitalizations, these percentages are similar to the 2 pervious data periods 2000 2003 and 1997 1999 males made up about 70 percent in each data period This could suggest that females are referred to ADEF at earlier and less severe stages of diabetes Alternatively, males and females could be referred to ADEF equally, but males at a later stage of disease are more likely to participate Distribution of all-cause, diabetes-related, and lower extremity amputation LEA hospitalization by gender
Table 21:Hospitalizations rates by Gender of ADEF Participants prior to attending ADEF
All-cause hospitalization Diabetes-related hospitalization LEA hospitalization
Male 46 49 70
Female 54 51 30
Maine Diabetes Surveillance System 38
Diabetes Self-Management Education
Hypertension and Heart Disease
Between the years 2003 and 2005, 642 percent of ADEF Program participants reported having hypertension Of those, 44 percent were male and 56 percent were female, mirroring the overall distribution of the ADEF population in this time frame Heart disease was reported by 27 percent of ADEF participants More males 31 percent reported having heart disease than females 24 percent as shown in
Figure 28
Figure 28: Percent of ADEF Participants with Heart Disease
35 Percentage with heart disease 30 25 20 15 10 5 0 Male Female
31 24
HbA1c Measures
For the years 2003 to 2005, 80 percent 5,185 ADEF participants reported that they had received an HbA1c test in the year prior to attending the program Of those, 442 percent were male and 558 percent were female, mirroring the overall distribution of the ADEF population in this time frame
Figure 29: ADEF Participants with an HbA1c Test
HbA1c Testing of Participants in the Year Prior to Attending ADEF Program
20
Test No test
80
Maine Diabetes Surveillance System 39
Diabetes Self-Management Education
Eye Exams
Nearly 63 percent of 5,158 participants reported having an eye exam in the year prior to referral to the ADEF Program Of those, 425 percent were male and 578 percent were female, showing little difference between men and women in eye exams
Figure 30: Percent of ADEF Participants with an Eye Exam
Proportion of ADEF Participants with Eye Exam in the Year Prior to Attending ADEF Program
37
Exam No exa m
63
Monofilament Test
Only approximately a third of ADEF participants received a monofilament sensory test prior to
their enrollment in the ADEF Program in the years from 2003 through 2005
Figure 31: Percent of ADEF Participants Reported Having a Monofilament test
Proportion of ADE F Participants Who Received a Monofilament Test in the Year Prior to Attending ADEF P rogram
32
Test No test
68
Maine Diabetes Surveillance System 40
Diabetes Self-Management Education
References
1 Diabetes Care 2007; 30 Suppl 1 2 Fong DS, Aiello L, Gardner TW, et al Retinopathy in diabetes Diabetes Care 2004; 27 Suppl 1:S84-S87 3 American Diabetes Association Preventive foot care in diabetes Diabetes Care 2004; 27 Suppl 1:S63-S64 4 The Diabetes Control and Complications Trial Group The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus N Engl J Med 1993;329:977-986 5 UK Prospective Diabetes Study Group Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes Lancet 1998;352:837-853 6 American Diabetes Association Tests of glycemia in diabetes Diabetes Care 2004; 27 Suppl 1:S91-S93 7 American Diabetes Association Smoking
and diabetes Diabetes Care 2004; 27 Suppl 1:S74-S75 8 American Diabetes Association Influenza and pneumococcal immunization in diabetes Diabetes Care 2004; 27 Suppl 1:S111-S113 9 American Diabetes Association Dyslipidemia management in adults with diabetes Diabetes Care 2004; 27 Suppl 1:S68-S71 10 American Diabetes Association Hypertension management in adults with diabetes Diabetes Care 2004; 27 Suppl 1:S65-S67 11 American Diabetes Association Physical activity/exercise and diabetes Diabetes Care 2004; 27 Suppl 1:S58-S62 12 Mensing C, Boucher J, Cypress M, et al National standards for diabetes selfmanagement education Diabetes Care 2004;27:S143-S150 13 Schwartz R, Zaremba M, Knut R Third party coverage for diabetes education programs Quality Review Bulletin: Journal of Quality Assurance 1985;11:213-217 14 Mazzuca SA, Moorman NH, Wheeler ML, et al The diabetes education study: a controlled trial of the effects of diabetes patient education Diabetes Care 1986;9:1-10 15 Brown SA Effects of educational interventions in diabetes care: a meta-analysis of findings Nursing Research 1988;37:223-230 16 Public Law 592 An act to require that diabetes supplies and self-management training be
covered by health insurance policies HP 1242-LD 1702
Maine Diabetes Surveillance System 41
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