Currently, more than 18 million Americans have diabetes and are at risk for related by diabetes, contributed to this document. …

Diabetes: A National Plan for Action

December 2004

MESSAGE FROM THE SECRETARY Currently, more than 18 million Americans have diabetes and are at risk for related complications like heart disease, stroke, blindness, amputations and kidney disease On average, every 25 seconds, someone in the United States is diagnosed with diabetes Diabetes rates are steadily increasing in America, and millions are unaware that they have the disease Yet these facts do not tell the whole story of the true impact that diabetes has on Americans Diabetes touches millions of Americans and their families and friends in ways that are difficult if not impossible to measure Diabetes and its complications seriously diminish the quality of life for individuals suffering from this disease In order to reverse these trends, the US Department of Health and Human Services has increased its efforts to address this health crisis I am proud to present our Diabetes: A National Plan for Action This plan will help mobilize individuals, communities, businesses, and other organizations to address the rising rates of diabetes and its consequences Many key stakeholders, such as government agencies, elected officials, public
health experts, providers, professional organizations, and individuals impacted by diabetes, contributed to this document The document provides up-to-date and accurate prevention, detection and treatment information, and includes simple action steps for individuals, families, health practitioners, policy-makers, government officials, employers, others in the medical community and members of the media to address this growing public health problem It also provides screening tools, information on other federal diabetes programs, and listings of federally funded resources We hope that this document not only will be informative, but also will encourage all interested persons to work together to reduce the burden that diabetes imposes on our nation Only by joining together can we overcome this public health threat and secure a healthier future for our children No effort is too small, and no specialized training is required, to begin to improve your health or the health of your family or community I thank the many public and private health professionals who have pooled their talents to develop this document and for their tireless efforts in diabetes prevention, detection, and
treatment

Tommy G Thompson

Acknowledgements: The Diabetes: A National Plan for Action is the result of the dedication and determination of many groups and individuals The Department would like to thank all those who participated in creating this document Special thanks to the American Diabetes Association, the Juvenile Diabetes Research Foundation International, the American Association of Diabetes Educators, and the American Dietetic Association for their participation at the town hall meetings The Department would like to thank the following individuals for their participation on the expert panels at the town hall meetings: The Honorable Jennette Bradley, Lieutenant Governor and Director of Commerce for Ohio; J Nick Baird, MD, Director, Ohio Department of Health; James Holsinger, PhD, Secretary of the Cabinet for Health Services, Kentucky; Steve Collier, Superintendent, Norwood City Schools; Jerry Mallicoat, Vice President of Midwest Marketing, Anthem Blue Cross/Blue Shield; Francine Kaufman, MD, Past President, American Diabetes Association; Nicole Johnson, Miss America 1999; The Honorable Mike Huckabee, Governor of Arkansas; Fay Boozman, MD, MPH, Director, Arkansas Department
of Health; Virginia Zamudio, RN, MSN, CDE, Past President, American Association of Diabetes Educators; Victor H Gonzalez, MD, National Board Member, American Diabetes Association; Simmie Armstrong, Jr, MD, Pine Bluff Family Medical Center, Arkansas; The Honorable George R Nethercutt, Jr, JD, US House of Representatives, Chairman of the Congressional Diabetes Caucus; Mary Selecky, Secretary, Washington Department of Health; Steven Kahn, MB, ChB, Director of Research and Development, VA Puget Sound Health Care System; Gerald Nepom, MD, PhD, Director, Benaroya Research Institute at Virginia Mason, Juvenile Diabetes Research Foundation International; Joe Finkbonner, RPh, MHA, Director of the Epidemiology Center, Northwest Portland Area Indian Health Board; Bradley J Enegren, Vice President and General Manager, Research and Development, Medtronic, Inc; Angela Bartels, RN, BSN, Diabetes Coordinator, 45th Street Medical Clinic, Seattle, Washington The Department would also like to thank all of the agencies and offices of HHS for their contributions, especially: the Office of the Assistant Secretary for Planning and Evaluation, the Office of the Surgeon General, the Office of
Intergovernmental Affairs, the Office of Minority Health, National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Administration on Aging In addition, the Department would like to thank the Internal Advisory Committee: Kevin Keane, Assistant Secretary for Public Affairs; Howard Zucker, MD, JD, LLM, Acting Deputy Assistant Secretary for Health, Office of Public Health and Science; Garth Graham, MD, MPH, Acting Deputy Assistant Secretary for Minority Health, Office of Minority Health; Nathan Stinson, Jr, PhD, MD, MPH, formerly the Deputy Assistant Secretary for Minority Health, Office of Minority Health; Carolyn Clancy, MD, Director, Agency for Healthcare Research and Quality; John Wren, Director for Planning and Policy Development, Administration on Aging; Frank Vinicor, MD, Director, Division of Diabetes Translation, Centers for Disease Control and Prevention; Sean Tunis, MD, Chief Medical Officer/Director, Office of Clinical Standards and Quality, Centers for Medicare Medicaid Services; Lester Crawford, DVM, PhD, Deputy

Commissioner of Food and Drugs, Food and Drug Administration; Sam Shekar, MD,
MPH, Associate Administrator, Bureau of Primary Health Care, Health Resources and Services Administration; Craig Vanderwagen, MD, Acting Chief Medical Officer, Indian Health Service; and Allen Spiegel, MD, Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health The Department extends additional thanks to Mary Mazanec, MD, JD, Wilma Tilson, MPH, and Ann Albright, PhD, RD, for their hard work in developing this document and acknowledges the work of the Research Triangle Institute International in this endeavor

Michael OGrady, PhD Assistant Secretary of Planning and Evaluation

CONTENTS Section Page

Executive Summary iii Introduction1 What Is Diabetes? 4 Risk Factors for Diabetes5 Health Problems Related to Diabetes 7 Diabetes: A National Plan for Action 10 Prevention 13 Importance of Diabetes Prevention13 Action Steps for Prevention14 Detection 23 The Importance of Early Diabetes Detection 23 Action Steps for Detection25 Treatment 31 The Importance of Diabetes Treatment and Management31 Action Steps for Treatment31 List of Acronyms and Abbreviations43 Appendices Appendix A: Steps to a HealthierUS 45 Appendix B: Medicare and
Diabetes 51 Appendix C: Development of Diabetes: A National Plan for Action55 Appendix D: Current Federal Diabetes Activities/Highlights 63 Appendix E: Are You at Risk for Diabetes?75

FIGURES Number Page

1 Prevalence of Diagnosed and Projected Diagnosed Diabetes Cases in the United States, 1960- 2050 1 2 Age-Adjusted Total Prevalence of Diabetes in People Aged 20 Years or Older, by Race/Ethnicity: United States, 2002 2 3 Body Mass Index 7 4 Prevalence of diabetic retinopathy among adults 40 years and older 2000 7 5 Primary causes for kidney failure 19988 6 Projected increase in total heart disease deaths related to increased diabetes prevalence 8 7 Age-standardized Rate of Hospital Discharge for Non-traumatic Lower Extremity Amputation per 1,000 Diabetic Population, by Race, United States, 1980-20019 8 Vigorous physical activity in adolescents by grade level, 2001 13

TABLES Number Page

1 Risk Factors and Associated Medical Conditions for Diabetes6 2 Signs and Symptoms of Diabetes 24 3 Symptoms of Hypoglycemia and Hyperglycemia 32 4 Diabetes Care Checklist34 5 Examples of Items to Include in Flow Chart for Patients with Diabetes36

EXECUTIVE SUMMARY Currently, more than
18 million Americans have diabetes and projections show that the number of persons with the disease will continue to grow without public health intervention1 Diabetes consists of a group of diseases in which the body is unable to produce insulin type 1 diabetes or makes too little insulin and resists its action type 2 diabetes In addition to diabetes, an estimated 41 million Americans have pre-diabetes, a condition that puts them at high risk for developing type 2 diabetes2 If current trends continue, one in every three children born in the year 2000 will develop diabetes within their lifetime3 Diabetes often causes severe complications that can include heart disease and stroke, blindness, lower extremity amputations, kidney failure, dental disease, and increased susceptibility to infections4 In addition to the personal and social costs resulting from impaired health and quality of life for people affected by diabetes, the disease also carries significant economic costs Estimates suggest the cost of diabetes to be about 132 billion per year5 Diabetes is a serious public health problem, but the good news is that important advances are being made in prevention, detection, and
treatment of diabetes For example, the Diabetes Control and Complications Trial established that intensive control of blood glucose levels greatly reduces complications for people with type 1 diabetes, and the UK Prospective Diabetes Study has shown similar dramatic reductions in complications with control of blood glucose for persons with type 2 diabetes6 In 2002, results from the Diabetes Prevention Program demonstrated that type 2 diabetes can be prevented or delayed by weight loss and increased physical activity for many people at risk for the disease7 These findings provide exciting evidence that the potentially devastating consequences of diabetes can be reduced dramatically

1 Centers for Disease Control and Prevention CDC 2003 Promising practices in chronic disease prevention and

control: A public health framework for action Atlanta, GA: Department of Health and Human Services
2 US Department of Health and Human Services Prevention: A blueprint for action Available at:

http://aspehhsgov/health/blueprint/
3 Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF 2003 Lifetime risk for diabetes mellitus

in the United States Journal of the American Medical
Association, 29014, 1884-1890
4 CDC, opcit 5 American Diabetes Association ADA 2003 Economic costs of diabetes in the US in 2002 Diabetes Care, 26,

917-932
6 The Diabetes Control and Complications Trial Research Group 1993 The effect of intensive treatment of

diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus The New England Journal of Medicine, 32914, 977-986; and Turner, RC 1998 The UK prospective diabetes study: A review Diabetes Care, 21Suppl 3, C35-C38 7 Diabetes Prevention Program Research Group 2002 Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin New England Journal of Medicine, 3466, 393-403

iii

However, without significant action, the prevalence of diabetes, together with diabetes-related complications, will continue to increase To help ensure that Americans take the steps needed to quell the growing diabetes problem, Secretary of Health and Human Services Tommy G Thompson has identified diabetes prevention, detection, and treatment as one of the central components of his health agenda for the nation Activities supporting the Secretarys focus on diabetes include Steps to a
HealthierUS: Putting Prevention First, the Diabetes Detection Initiative, and the Small Steps, Big Rewards, Prevent Type 2 Diabetes campaign In addition, the Medicare Prescription Drug, Improvement, and Modernization Act MMA of 2003, establishes coverage of a one-time Welcome to Medicare Physical Examination within 6 months of a beneficiarys first coverage under Part B to encourage health promotion and disease detection The MMA also adds coverage for cardiovascular and diabetes screening for Medicare beneficiaries Both benefits take effect January 1, 2005 More information on MMA and Medicare benefits in general can be found at http://wwwmedicaregov/ or 1-800-Medicare 1-800-633-4227 Appendix B provides additional information on diabetes benefits offered through Medicare The Diabetes: A National Plan for Action is the latest initiative sponsored by the US Department of Health and Human Services to address diabetes prevention, detection, and treatment Prompted by the Secretarys commitment to disease prevention and health promotion, together with efforts of individuals and organizations–including the American Diabetes Association, Juvenile Diabetes Research Foundation International,
American Association of Diabetes Educators, and other professional associations–the national action plan utilizes a comprehensive action-oriented approach to identify activities among relevant stakeholders to improve diabetes prevention, detection, and care This document is designed to: 1 Reduce the prevalence of diabetes and factors that increase the risk of diabetes; 2 Promote improved diabetes detection, monitoring, and treatment; and 3 Reduce the complications of diabetes The plan seeks to raise national awareness of existing resources, facilitate and coordinate efforts, and leverage resources for the prevention, detection, and treatment of diabetes In addition, the plan outlines steps individual Americans can take to help prevent or delay type 2 diabetes, together with recommendations persons already diagnosed with diabetes can use to prevent or

delay complications from the disease However, individual action alone is not sufficient for addressing diabetes Thus, the plan also recommends and outlines action steps for families, friends, health care providers, schools, the media, communities, health insurance providers, employers, researchers and professional educators, and
tribal and other government agencies, to help mitigate the increase in the prevalence of diabetes and its complications Additional information and resources about diabetes prevention, detection, and treatment are also provided

INTRODUCTION Diabetes is approaching epidemic proportions in the United States More than 18 million Americans today have diabetes Approximately 41 million Americans have pre-diabetes,8 which means they are at high risk for developing type 2 diabetes9 For people with diabetes, blood glucose sugar levels are elevated either because the body cannot make adequate amounts of the hormone insulin and/or its cells do not respond to insulin10 Over the past half century, there has been a four- to eight-fold increase in the prevalence of diagnosed cases of diabetes in the US11 In 2002, the prevalence of diagnosed diabetes among people aged 20 years or older was 87 percent and among 60 years or older was 183 percent12 From 1997 through 2002, the number of new cases of diagnosed diabetes per year increased from 878,000 to 1,291,000 a 47 percent increase13 Projections of diabetes for future years are not encouraging Figure 1 A 165 percent increase in the number of
persons with diabetes in the US is Figure 1 Prevalence of Diagnosed and Projected Diagnosed Diabetes Cases in the United States, 19602050

SOURCE: Data for 19601998 from the National Health Interview Survey, National Center for Health Statistics NCHS Centers for Disease Control and Prevention CDC projected data for 20002050 from the Behavioral Risk Factor Surveillance System, Division of Diabetes Translation, CDC Note: The Diagnosed cases arrow refers to the section of the figure that includes diagnosed cases of diabetes versus the section that includes projected cases The line graph and not the line arrow indicate the number of diagnosed cases

8 Pre-diabetes is a condition defined by impaired fasting glucose IFG or impaired glucose tolerance IGT or both 9 CDC, opcit 10 ibid 11 Centers for Disease Control and Prevention CDC Diabetes Surveillance System Atlanta, GA, US Department

of Health and Human Services Available at: http:wwwcdcgov/diabetes/statistics/indexhtm; and Kenny SJ, Aubert RE, Geiss LS Prevalence and incidence of non-insulin-dependent diabetes, in Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennette Ph eds 1995 Diabetes in America, 2nd ed Bethesda, MD:
National Institutes of Health 12 Centers for Disease Control and Prevention CDC Diabetes Surveillance System Atlanta, GA, US Department of Health and Human Services Available at: http:wwwcdcgov/diabetes/statistics/indexhtm 13 Centers for Disease Control and Prevention CDC Diabetes Surveillance System Incidence of diabetes Available at: http://wwwcdcgov/diabetes/statistics/incidence/fig1htm Accessed September 15, 2004

projected through 2050, with a rise from 11 million to 29 million diagnosed persons of all ages14 Without preventive action, one in every three children born in the year 2000 will develop diabetes in their lifetime15 Figure 2 Age-Adjusted Total Prevalence of Diabetes in People Aged 20 Years or Older, by Race/Ethnicity: United States, 2002

SOURCE: 1999-2001 National Health Interview Survey and 1999-2000 National Health and Nutrition Examination Survey estimates projected to year 2002 2002 outpatient database of the Indian Note: Whites refers to non-Hispanic Whites, and Blacks refers to non-Hispanic Blacks AI/AN who receive care from the IHS

In addition, minority populations are disproportionately affected by diabetes Figure 2 On average Blacks, Hispanics, and
American Indians and Alaska Natives are more likely 16 to 23 times as likely to have diabetes than non-Hispanic Whites16 Rates of diabetes-related deaths
14 Boyle JP, Honeycutt AA, Narayan KM, Hoerger TJ, Geiss LS, Chen H, Thompson TJ 2001 Projection of

diabetes burden through 2050: Impact of changing demography and disease prevalence in the US Diabetes Care, 2411, 1936-1940 15 Narayan, opcit 16 Centers for Disease Control and Prevention CDC 2003 National diabetes fact sheet: General information and national estimates on diabetes in the United States Atlanta, GA: US Department of Health and Human

are higher among Blacks, American Indians, and Hispanics than for Whites,17 and diabetes is the 5th leading cause of death for Asian and Pacific Islanders18 Certain minority groups also have much higher rates of diabetes-related complications, in some cases as much as 50 percent more than the diabetes population For example, Blacks are more likely to have serious complications from diabetes, such as end-stage renal disease and lower extremity amputations19 Costs of diabetes are high in both human and economic terms While estimating the national costs for diabetes over time is
difficult because of changes in the US population and changes in the cost of health care services, evidence suggests that these costs are high and rising The American Diabetes Association ADA estimated the national cost of diabetes for 2002 to be approximately 132 billion: 92 billion for direct medical expenditures and 40 billion for indirect costs, such as lost work days, restricted activity days, and mortality and permanent disability due to diabetes20 Research from the Centers for Disease Control and Prevention CDC indicates that people with diabetes miss 83 days per year from work, compared to 17 days for people without diabetes21 In the same ADA study, it is projected that the annual costs of diabetes in 2002 dollars could rise to 156 billion by 2010 and to 192 billion in 2020 By 2020, direct medical costs are estimated to increase to 138 billion and indirect costs from lost productivity could increase to 54 billion22

Services, Centers for Disease Control and Prevention Available at: http://wwwcdcgov/diabetes/pubs/pdf/ndfs_2003pdf 17 ibid 18 National Center for Health Statistics 2003 15 Leading causes of death for Asian and Pacific Islanders, 2001 Chart, Health, United
States, 2003 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention Available at http://wwwomhrcgov/healthgap/datastats_aapi1pdf 19 World Health Organization Global strategy on diet, physical activity and health Available at: http://wwwwhoint/gb/ebwha/pdf_files/WHA57/A57_R17-enpdf Accessed May 28, 2004; Centers for Disease Control and Prevention CDC 2003 Diabetes surveillance, 2003 [Statistics 2003 surveillance report] Atlanta: National Center for Chronic Disease and Prevention and Health Promotion, Centers for Disease Control and Prevention Available at: http://wwwcdcgov/diabetes/statistics/esrd/Fig5htm; Agency for Healthcare Research and Quality AHRQ 2001 Diabetes disparities among racial and ethnic minorities AHRQ Pub NO 02-P007 Rockville, MD: AHRQ Available at http://wwwahrqgov/research/diabdisphtm; and Gornic, ME, Eggers PW, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC 1996 Effects of race and income on mortality and use of services among Medicare beneficiaries New England Journal of Medicine, 33511, 791-799 20American Diabetes Association ADA Direct and indirect costs of Diabetes in the United States 2003 Available
at: http://wwwdiabetesorg/diabetes-statistics/cost-of-diabetes-in-usjsp Accessed September 15, 2004; and ADA, opcit, Economic costs of diabetes 21 Centers for Disease Control and Prevention CDC Fact sheet,Diabetesatworkorg Available at: http://wwwcdcgov/diabetes/pubs/factsheets/atworkhtm 2004 22 ADA, opcit, Economic costs of diabetes

What Is Diabetes? Diabetes is typically classified according to three main types–type 1 diabetes, type 2 diabetes including a related condition called pre-diabetes, and gestational diabetes Type 1 diabetes previously called juvenile diabetes is an autoimmune disorder in which the insulin producing beta cells are destroyed by the bodys immune system As a result the body is unable to produce insulin Without insulin, the body is unable to use glucose sugar as energy for everyday activities Individuals with type 1 diabetes must take insulin by injection or pump every day to survive This type of diabetes occurs in 5 percent to 10 percent of Americans who are diagnosed with diabetes Children and adolescents are most often diagnosed with type 1 diabetes although a significant portion of those with type 1 diabetes are diagnosed as adults Type 2 diabetes
previously called adult onset diabetes is the most common form of diabetes, accounting for about 90 percent to 95 percent of all diabetes cases In this type of diabetes, the body does not produce enough insulin and/or the bodys cells become resistant to insulin Insulin resistance occurs when the bodys muscle, fat, and liver cells do not respond to insulin The pancreas tries to keep up with the demand for insulin by producing more Since insulin helps to mobilize glucose from the blood stream into cells, excess glucose builds up in the blood stream Many people with insulin resistance have high levels of blood glucose and high levels of insulin circulating in their blood at the same time indicating that the cells are not responding properly to insulin A related condition, called pre-diabetes, occurs when a persons blood sugar levels are higher than normal, but not high enough for a diagnosis of diabetes People with prediabetes have impaired fasting glucose fasting blood sugar level is 100 to 125 milligrams per deciliter [mg/dl] or impaired glucose tolerance blood sugar level is 140 to 199 mg/dl after a 2-hour oral glucose tolerance test23 People with pre-diabetes and type 2 diabetes
often do not show symptoms and they do not know that they have the conditions The Diabetes Prevention Program–a major clinical trial in 3,234 people with impaired glucose tolerance–showed that in some individuals the loss of 5 percent to 7 percent of body weight reduced their risk of

23 National Institute of Diabetes and Digestive and Kidney Diseases NIDDK Insulin resistance and pre-diabetes

NIH Publication No 04-4893 Available at: http://diabetesniddknihgov/dm/pubs/insulinresistance/indexhtm 2004

developing type 2 diabetes by 58 percent24 This study also suggested that people with pre-diabetes can prevent or delay the development of type 2 diabetes through lifestyle changes that include eating a low-calorie, low-fat diet to lose weight and getting 150 minutes of physical activity a week25 Gestational diabetes is a form of diabetes that occurs in some women who have high blood glucose levels during pregnancy but have never had diabetes before This type of diabetes may disappear after the pregnancy ends, but women who have had gestational diabetes have a 20 percent to 50 percent chance of developing type 2 diabetes in the next 5 to 10 years26 Risk Factors for Diabetes
Diabetes occurs in people of all ages and racial and ethnic groups Researchers do not fully understand the cause of type 1 diabetes or what can be done to prevent it Research suggests that type 1 diabetes has a strong genetic basis that is modified by environmental factors Certain viruses are among the factors that have been suggested, but the definitive factors have yet to be determined27 Having a family member with type 1 diabetes puts one at higher risk for developing the disease28 However, most type 1 diabetes patients do not have a family history of the disease Research is currently being done to learn more about the genetic and environmental factors important in type 1 diabetes

24 Diabetes Prevention Program Research Group, opcit 25 ibid 26 National Institute of Diabetes and Digestive and Kidney Diseases NIDDK What I need to know about

gestational diabetes NIH Pub No 04-5129 Available at: http://diabetesniddknihgov/dm/pubs/gestational/3 Accessed May 28, 2004 27 Graves PM, Norris JM, Pallansch MA, Gerling IC, Rewers M 1997 The role of enterviral infections in the development of IDDM: Limitations of current approaches Diabetes, 46: 161-168; and Salminen KK, Vuorinen T,
Oikarinen S, Helminen M, Simell S, Knip M, Ilonen J, Simell O, and Hyöty H 2004 Isolation of enterovirus strains from children with preclinical type 1 diabetes Diabetes Medicine, 21:156-164 28 Diabetes Research Working Group Conquering Diabetes: Highlights of program efforts, research advances and opportunities Available at: http://wwwniddknihgov/federal/dwg/2002/3summarypdf 2002

Table 1 Risk Factors and Associated Medical Conditions for Diabetes
Risk Factor Family History Family member with diabetes Lifestyle Overweight or obesity Sedentary lifestyle exercise fewer than three times per week Associated Medical Conditions or Events Impaired glucose tolerance or impaired fasting glucose High blood pressure Low HDL cholesterol and/or high triglycerides History of gestational diabetes Delivered baby 9 lbs or heavier Race/Ethnicity Black Hispanic/Latino American Native American Asian American Native Hawaiian or Pacific Islander ancestry Type 1 Diabetes X Type 2 Diabetes X X X X X X X X X X X X X Pre-diabetes X X X X X X X X X X X X X Gestational Diabetes X X X X

X X X X X X X

SOURCES: National Institute of Diabetes and Digestive and Kidney Diseases NIDDK Am I at risk for type 2
diabetes? NIH Publication No 044805 Available at: http://diabetesniddknihgov/dm/pubs/riskfortype2/ Insulin resistance and pre-diabetes Available at: http://diabetesniddknihgov/dm/pubs/insulinresistance/ What I need to know about gestational diabetes NIH Pub No 04-5129 Available at: http://diabetesniddknihgov/dm/pubs/gestational/3 Accessed May 28, 2004

Research conducted to date has identified specific risk factors related to the development of type 2 diabetes, pre-diabetes, and gestational diabetes, including family history, a sedentary lifestyle, and overweight or obesity Table 1 Maintaining a healthy weight as measured by body mass index BMI reduces ones risk for developing type 2 diabetes, pre-diabetes, or gestational diabetes29 BMI is a measure of weight in relation to height see Figure 3 Studies have shown that BMI is significantly correlated with body fat content for most adults For adults, a BMI less than 25 is considered a healthy weight Regular physical activity and eating a healthy diet can help attain and maintain a healthy weight

29National Institute of Diabetes and Digestive and Kidney Diseases NIDDK National diabetes statistics NIH

Publication No 04-3892 Available
at: http://diabetesniddknihgov/dm/pubs/statistics/indexhtm 2004; and Diabetes Prevention Program Research Group, opcit

Figure 3 Body Mass Index

SOURCE: The Surgeon Generals Call to Action to Prevent and Decrease Overweight and Obesity 2001

Health Problems Related to Diabetes Diabetes can have a significant impact on quality of life by increasing risk for a variety of complications These include: Blindness–Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years, with the greatest number in adults 65 years and older Figure 4 Retinopathy causes 12,000 to 24,000 new cases of blindness each year in people with diabetes30 Figure 4 Prevalence of diabetic retinopathy among adults 40 years and older 2000

SOURCE: National Institutes of Health, National Eye Institute data from Prevalence and Causes of Visual Impairment and Blindness Among Adults 40 Years and Older in the United States, http://wwwneinihgov/eyedata/

30 CDC, National diabetes fact sheet, opcit

Kidney Disease–Diabetes is the leading cause of endstage kidney disease, accounting for 43 percent of new cases each year Figure 531 In 2001, nearly 43,000 people with diabetes began treatment
for end-stage kidney disease and approximately 143,000 people with end-

Figure 5 Primary causes for kidney failure 1998

stage kidney disease were Glomerulonephritis is a variety of kidney disease characterized by living on chronic dialysis inflammation of the capillaries or with a kidney transplant due to diabetes32 The rate of diabetic end-stage kidney disease is 26 times higher among Blacks than among Whites33

SOURCE: National Institute of Diabetes and Digestive Kidney Diseases 1998 Accessed at http://kidneyniddknihgov/kudiseases/pubs/kdd/indexhtm

High Blood Pressure–About 73 percent of adults with diabetes have blood pressure greater than or equal to 140/90 mm Hg or use prescription medications for hypertension34 Heart Disease and Stroke–About 65 percent of deaths among people with diabetes are due to heart disease and stroke35 Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes It is projected that in the year 2025, twenty-nine percent of all heart disease deaths will be due Figure 6 Projected increase in total heart disease deaths related to increased diabetes prevalence

SOURCE: Unpublished estimates from the
National Heart, Lung and Blood Institute, October 18, 2002

31 ibid 32 ibid 33 AHRQ, opcit 34 CDC, National diabetes fact sheet, opcit 35 ibid

to diabetes Figure 6 The risk for stroke is two to four times higher among people with diabetes Nervous System Disease–About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage including impaired sensation or pain in the feet or hands, carpal tunnel syndrome, slowed digestion of food in the stomach, and other nerve problems36 Severe forms of nerve disease are a major contributing cause of lower-extremity amputations for people with diabetes Dental Disease–Gum disease is more common among people with diabetes Among young adults, those with diabetes have about twice the risk of developing gum disease as those without diabetes Almost one third of people with diabetes have severe gum diseases Amputations–More than 60 percent of nontraumatic lowerlimb amputations occur among people with diabetes37 In 2000 2001, about 82,000 nontraumatic lowerlimb amputations were performed annually among people with diabetes38 Blacks have higher rates of lower extremity amputations than Whites see Figure 739 Figure 7
Age-standardized Rate of Hospital Discharge for Non-traumatic Lower Extremity Amputation per 1,000 Diabetic Population, by Race, United States, 1980-2001

Pregnancy Complications–Poorly controlled diabetes before conception and during the first
36 ibid 37 ibid 38 ibid 39 AHRQ, opcit

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics, data from the National Hospital Discharge Survey and Division of Health Interview Statistics, data from the National Health Interview Survey US Bureau of the Census, census of the population and population estimates and Centers for Disease Control and Prevention, National Center for Health Statistics, bridged-race population estimates

trimester of pregnancy can cause major birth defects in 5 percent to 10 percent of pregnancies and spontaneous abortions in 15 percent to 20 percent of pregnancies40 Poorly controlled diabetes during the second and third trimesters of pregnancy can result in very large babies, posing a risk to the mother and the child during delivery Other Complications–People with diabetes are more susceptible to many other illnesses and often have worse
outcomes For example, people with diabetes are more likely to die from pneumonia or the flu than people who do not have diabetes41 Early and optimal treatment is key to prevent or delay such complications Diabetes: A National Plan for Action Secretary of Health and Human Services HHS Tommy G Thompson has identified diabetes prevention, detection, and treatment as important components of his health agenda Activities supporting the Secretarys focus on diabetes include Steps to a HealthierUS: Putting Prevention First Appendix A, the Diabetes Detection Initiative, and the Small Steps, Big Rewards, Prevent Type 2 Diabetes campaign In addition, the Medicare Prescription Drug, Improvement, and Modernization Act MMA of 2003, establishes coverage of a one-time Welcome to Medicare Physical Examination within 6 months of a beneficiarys first coverage under Part B to encourage health promotion and disease detection The MMA also adds coverage for cardiovascular and diabetes screening for Medicare beneficiaries Both benefits take effect January 1, 2005 More information on MMA and Medicare benefits in general can be found at http://wwwmedicaregov/ or 1-800-Medicare 1-800-633-4227 Appendix B
provides additional information on diabetes benefits offered through Medicare Diabetes: A National Plan for Action hereby referred to as the National Diabetes Action Plan–NDAP is the latest initiative to address diabetes This action plan was prompted by the Secretarys commitment to disease prevention and health promotion It utilizes a comprehensive action-oriented approach to identify activities to improve diabetes prevention, detection, and care The goals of the NDAP are to: Increase national awareness of diabetes, its impact, and what various stakeholders can do to prevent or manage the disease;

40 CDC, National diabetes fact sheet, opcit 41 ibid

Reduce the prevalence of diabetes and factors that increase the risk of diabetes; Promote improved detection, monitoring, and treatment of the disease; and Identify existing public and private efforts to facilitate coordination and to leverage existing resources for detection, prevention, and treatment of diabetes An advisory committee composed of senior officials within the US Department of Health and Human Services HHS was named to direct the development of the NDAP This committee provided recommendations to reduce the
prevalence and burden of diabetes In addition, the Secretary and his senior staff hosted several town hall listening sessions in different parts of the country to highlight the important steps that individuals, health care practitioners and providers, businesses, and communities can and are taking to prevent, detect, and treat diabetes and educate patients, their families, and other Americans The first town hall meeting focused on prevention of diabetes and was held in Cincinnati, Ohio, on March 29, 2004 The second town hall focused on diabetes detection and education and was held in Little Rock, Arkansas, on June 18, 2004 The third town hall focused on diabetes treatment and was held in Seattle, Washington, on July 26, 2004 In all, more than 1,200 people attended the three town halls During the public comment period at these town hall meetings, individuals and those representing organizations were able to ask questions, express their views, and provide input to the national diabetes action plan Hundreds of people shared their thoughts about the burden of diabetes and solutions for preventing or delaying the disease and its complications The public comment period identified issues
of concern to the diabetes community These included: The key role that schools and teachers can play in educating students and parents about the importance of healthy behaviors ie physical activity, nutrition to reduce their risk for diabetes; The important role health insurance plays in the ability of people with diabetes to manage their diabetes and the need for policymakers to continue to strive to improve the health insurance system for people with diabetes and other chronic conditions; The need to educate and train healthcare providers in state-of-the art diabetes prevention, detection, and management strategies; The importance of continued research into effective and innovative prevention strategies and treatments for diabetes; and

The need for focused prevention, detection, and treatment efforts targeted specifically to individuals at higher risk for diabetes, including Blacks, Hispanics, American Indians, Alaskan Natives, Asians and Pacific Islanders using culturally sensitive materials and messages emphasizing the importance of early detection and optimal treatment See Appendix C for more information on the development of the NDAP The remainder of this document is
organized around three key components: prevention, detection, and treatment of diabetes Within each component, action steps are provided for individuals, friends and family, health care providers, schools, the media, community organizations, health insurance providers, employers, and government agencies to improve the quality of life for people living with diabetes and reduce the burden of diabetes on the nation

PREVENTION Importance of Diabetes Prevention The causes of type 1 diabetes are under investigation, and researchers are working to learn how to prevent the disease While the causes of type 2 diabetes are not well understood, recent research has demonstrated that it often can be prevented or delayed through lifestyle changes in at risk persons42 This section focuses on the prevention of type 2 diabetes The Treatment section within this document addresses the prevention of medical complications caused by diabetes The prevalence of diagnosed type 2 diabetes increased sixfold in the latter half of the past century43 Figure 8 Vigorous physical activity in adolescents by grade level, 2001

Obesity and physical inactivity have played a major role in this dramatic increase in
rates of type 2 diabetes44 For example, until recently type 2 diabetes was not frequently seen in school-aged children and SOURCE: Kann L, et al 2000 Youth Risk Behavior Surveillance Survey US 1999, in CDC Surveillance Survey MMWR, 49SS-5, 1-96 adolescents Now the prevalence of type 2 diabetes for persons 20 and under appears to be rising considerably, and this rise can be attributed to increases in physical inactivity and excess weight gain45 More than one-third of young people in grades 9-12 do not regularly engage in vigorous activity Figure 846

42 Diabetes Prevention Program Research Group, opcit 43 Centers for Disease Control and Prevention CDC 2001 Diabetes: A serious public health problem Atlanta,

GA: Department of Health and Human Services
44 CDC, opcit, Promising practices in Chronic Disease 45 ibid 46 Kann L, et al 2000 Youth Risk Behavior Surveillance Survey US 1999, in CDC surveillance survey

MMWR, 49SS-5, 1-96

Vigorous activity is defined as sustained activity that results in a significant increase in heart and breathing rate47 The Diabetes Prevention Program DPP–a major clinical trial involving 3,234 people with impaired glucose tolerance, a condition that
often precedes diabetes–demonstrated that some people at high risk for type 2 diabetes can prevent or delay the onset of the disease by losing 5 percent to 7 percent of their body weight and getting 30 minutes or more of physical activity at least 5 days per week48 In this study, the development of type 2 diabetes was reduced by 58 percent over a three-year period This benefit was seen in participants of all ages and racial and ethnic backgrounds The very encouraging results of this trial show that it is possible to prevent or delay type 2 diabetes in high-risk persons It is not easy for many people to lose weight and increase their physical activity However, it is imperative to build upon the results of the DPP and encourage people to take the necessary steps to prevent type 2 diabetes This not only will help many Americans live healthier, more productive lives, but it also has the potential to save billions of dollars in health care costs associated with hospitalizations for diabetes and its complications Friends, families, schools, health care providers, work sites and communities all can contribute in important ways to support healthier lifestyles Action Steps for Prevention
Individuals Americans at risk for type 2 diabetes please see Appendix D–Are You At Risk For Diabetes? can take important steps to prevent or delay the disease by losing a small amount of weight by eating a reduced fat, low-calorie diet and increasing their physical activity The goal is to eat fewer calories and increase physical activity to lose a small amount of weight49 The following action steps help people lower their risk for type 2 diabetes and other chronic diseases Other helpful tips can be found at http://wwwsmallstepgov/ and http://wwwnalusdagov/fnic/dga/dguide95html Eat a variety of foods within the basic food groups fruits, vegetables, grains, milk, and meat and beans

47 Centers for Disease Control and Prevention CDC Physical Activity Terms Available at:

http://wwwcdcgov/nccdphp/dnpa/physical/terms/indexhtmVigorous Accessed September 15, 2004
48 Diabetes Prevention Program Research Group, opcit 49 US Department of Agriculture and US Department of Health and Human Services 1995 4th ed Nutrition for

your health: dietary guidelines for Americans Available at: http://wwwnalusdagov/fnic/dga/dguide95html

Choose a diet low in fats not recommended for children 2 years
old and under, saturated fats, and cholesterol; and use sugar and alcohol in moderation50 Order healthier food choices or split a meal with a friend or ask the server to put half of it in a take home box when dining out Use a salad plate for meals, rather than a full-size dinner plate, to make the meal appear larger Learn to use the food label to determine the size or amount of a portion or serving of foods and beverages Consume appropriate portions of foods and beverages Drink a big glass of water or low-calorie beverage before a meal to help curb your hunger Drink plenty of water throughout the day Bake or broil foods rather than fry Drink 2 percent or 1 percent milk rather than whole milk Request a low-fat dressing for your salad Keep a daily record of eating habits, noting type of food, amount, and time of day Determine times where overeating occurs and develop a plan to help avoid these situations in the future Find ways other than eating to deal with stress Take a walk, stretch or take slow deep breaths Be snackwise Have a piece of fruit or some reduced-fat popcorn instead of reaching for a piece of cake Make small nutritional changes Some people find they are able to lose
weight by simply eliminating sugary drinks Try some new recipes for healthier foods, such as those suggested by the American Diabetes Association http://wwwdiabetesorg or the American Heart Association http://wwwamericanheartorg Make regular physical activity an essential part of daily activities Exercise while watching TV by running or marching in place to avoid being a couch potato Put away the remote and get up to change the channel on the TV Find an enjoyable exercise or physical activity and get active For example, for those who enjoy dancing, put on some music and dance each day Take the stairs instead of elevators and escalators Park farther away from stores, or ride a bicycle or walk to stores Walk inside a mall as an inexpensive way to exercise in a sheltered space Volunteer to walk dogs at the local animal shelter or for an elderly neighbor

50 ibid

Ask friends or use the Internet to find out about local parks or other facilities where you can exercise Set personal goals for exercise and track progress For example, if a goal is to walk at least 30 minutes five times a week, keep a record of how many times the goal was met If a day is missed, record it and indicate
why it was missed At the end of the week, consider what changes to make so that the goals for the following week will be met Some people find it helpful to begin with smaller, easier-to-reach goals Families and Friends One of the best ways to build exercise and healthy eating into daily activities is to do it with others, including family and friends Here are some suggestions: Parents can exercise with their children Be a role model for them Walking together has the added benefit of providing a regular opportunity to talk with them Parents can model good eating habits for their children by eating a diet that includes plenty of whole grain products, vegetables, and fruits, and is low in fats, saturated fats, and cholesterol, and limiting portion sizes Caregivers should promote physical activity and good eating habits for older family members Walk the dog Make walking the dog a regular family activity The dog will appreciate it Give pedometers to family or friends to help make exercise fun Support the exercise habits of family members, including older adults Look for ways to help them fit exercise into their schedules Offer to bring fresh fruit as a dessert rather than cake or
cookies when going to a friend or familys house for a meal Schools The increase in type 2 diabetes among children makes schools essential partners in preventing the disease Some specific activities for schools and teachers to consider include: Educate and share health promotion messages about sound nutrition and regular physical activity with teachers, school nurses, students, and parents Educate children about the importance of balanced nutrition and regular exercise in preventing diabetes Encourage children to develop plans for better nutrition and exercise and ways to measure their progress Engage parents to increase their understanding of the importance of healthier diets and the benefits of exercise Offer regular physical education/gym classes

Provide opportunities for unstructured activities for all ages at lunch and during breaks For elementary school children, this might include actively participating in physical activities on the playground For older students, sports equipment can be provided eg, basketballs, tennis rackets, etc, with coaches encouraging participation in activities Provide opportunities for nontraditional sports and alternatives to team sports for
students who may not have the same physical talents as their peers Provide after-school activities through the school or in partnership with other organizations, such as city parks and recreation leagues, religious organizations, community YMCAs, or Boys and Girls Clubs Provide tasty food options that are low in saturated fats and include fruits, vegetables, nuts, and whole grains for cafeteria and food cart choices Provide healthy alternatives, such as milk, low-calorie beverages, or water in vending machines and in the cafeteria Solicit help from school staff in setting examples for healthier eating and increased exercise Foster the benefits of exercise through fun competitions and activities For example, sponsor contests among teacher and student groups to register the most steps on their pedometers Encourage all students to participate in exercise and support each other regardless of different abilities Partner with State Diabetes Prevention and Control Programs run by the State Health Department Health Care Providers Health care providers play a key role in the prevention of type 2 diabetes Research shows that medical providers are among the most important health messengers
and that patients are more likely to adopt new behaviors when instructed to do so by their health practitioners51 Providers can take the following steps to encourage healthy behaviors among their patients: Counsel patients with pre-diabetes about their risk of developing diabetes and develop a concrete plan for patients to help them decrease the likelihood of developing the disease Refer high-risk individuals to appropriate resources for nutrition counseling and prediabetes education Screen for overweight and obesity Counsel patients who are overweight to lose weight Set reasonable weight loss goals to avoid failure and frustration
51 Logsdon DN, Lazaro CM, Meier RV 1998 The feasibility of behavioral risk reduction in primary medical care

Am J Prev Med, 55, 249-256; and Inui TS, Yourtee EL, Williamson JW 1976 Improved outcomes in hypertension after physician tutorials: A controlled trial Ann Intern Med, 846, 646-651

Refer patients to local resources or services that offer weight loss and physical activity programs and/or provide tools to help patients make lifestyle changes, activity logs, or meal plan guides52 Provide information eg, handouts on safe approaches to weight
loss Ready-to-use materials are available free of charge for providers through resources such as Your Game Plan for Preventing Type 2 Diabetes: Health Care Providers Toolkit http://wwwndepnihgov/diabetes/pubs/GP_Toolkitpdf Encourage patients whose health permits to begin an exercise plan Emphasize that even small steps can produce big rewards Help patients set reasonable and realistic long-term and short-term exercise goals that can be measured over time so that they can see their successes Build in accountability for patients For example, after delivering the initial prevention messages and working with patients to set realistic goals, set up a reminder or follow-up system with patients who have been counseled to lose weight to assess progress and offer motivational messages Acknowledge patients efforts to adopt healthier behaviors, even if the initial changes reflect only part of the change needed Encourage lifestyle changes for youth and counsel their parents on the importance of exercise and healthy eating to help prevent type 2 diabetes53 Work with State Diabetes Prevention and Control Programs run by the State Health Department Employers Healthy employees are more productive
and can be cost beneficial to companies For example, a research study conducted on the return on investment ROI for worksite health promotion and disease prevention programs in nine companies, found significant ROI with the benefit to cost ratio ranging from 149 to 491 in benefits per dollar spent on the program54 The following are some suggested worksite actions for employers that can encourage healthy behaviors in their employees: Be creative about developing exercise options For example, think outside the conference room box by encouraging employees to hold discussions while walking with their colleagues rather than sitting in a conference room

52 The National Diabetes Education Program has developed tools to support providers in their efforts to encourage

healthier lifestyle choices among their patients These tools are available free of charge at http://wwwndepnihgov/resources/healthhtm 53 Sinha R, Fisch G, Teague B, et al 2002 Prevalence of impaired glucose tolerance among children and adolescents with marked obesity New England Journal of Medicine, 34611, 802-810 54 US Department of Health and Human Services Prevention makes common cents 2003 Available at:
http://aspehhsgov/health/prevention/

Provide exercise space For example, a conference room with a VCR player, a couple of low-impact aerobics tapes, and some low-cost mats made available at lunch time can serve as an exercise space for employees as well as a valuable networking activity that can improve morale and productivity Provide healthy food options in cafeterias and vending machines to employees Encourage employees to adopt healthy behaviors For example, offer contests with prizes to encourage exercise for employees Consider providing health promotion or wellness programs and disease management programs for employees as part of their health benefits Provide on-site education about diabetes prevention to employees Utilize resources that are readily available at no cost to employers, such as Diabetes at Work http://wwwdiabetesatworkorg/ Consider partnering with the local YMCA or community health club to offer discounted memberships to employees and their families Partner with community organizations to develop and implement community health promotion and disease prevention initiatives Request health insurers to provide appropriate information for employees to educate them
on their health and diabetes prevention Provide employees information about local parks and walking trails Health Insurance Providers Successful prevention initiatives can reduce the need for some costly medical services and treatment Therefore, health insurance providers can also assist prevention efforts as follows: Educate patients and purchasers on the importance of prevention to reduce the risk for diabetes Review preventive health benefits offered to purchasers Partner with others working in diabetes prevention such as State Diabetes Prevention and Control Programs in State Health Departments Develop creative prevention messages and programs that encourage patients to adopt healthy behaviors ie, eating healthy, regular exercise Participate in research into effective preventive services and practices Communities Local communities also play an important role in preventing or delaying type 2 diabetes by providing environments that promote healthier lifestyles through improved nutrition and increased physical activity Civic and community organizations can partner with business groups, government agencies and others to encourage healthier eating and increased
physical

activity for the community Some actions communities can take to help prevent type 2 diabetes for their citizens include: Promote environments that foster fitness, such as walking trails Marking sidewalks with distance markers and messages can help encourage exercise Encourage a community culture that promotes healthier eating habits For example, community groups can sponsor cook-offs to create healthy culinary options among local chefs Create community vegetable gardens Organize community activities, such as community block parties with dancing and healthy food choices Media The media serve as important partners in promoting diabetes prevention messages The following are steps that members of the media can take to help spread the word about how to prevent type 2 diabetes: Promote public awareness about the importance of diabetes prevention and the benefits of maintaining a healthy weight with regular physical activity and a healthy diet Disseminate credible and accurate messages that encourage healthy habits and discourage risky behaviors Media staff can help tailor messages to target specific audiences Partner with medical professionals, federal, state, and local
governments, and privatesector community entities to help the public understand the importance of preventing diabetes Publicize providers who are doing a particularly good job in facilitating behavior change or a hospital that has opened its doors to run a no-cost exercise program in a low-income area Conduct or participate in research to study the effectiveness of media messages promoting healthy lifestyles Use public access networks to broadcast local conferences or training videos on diabetes prevention Researchers and Professional Educators Researchers and professional educators also play important roles in diabetes prevention The following are some general diabetes prevention steps these groups can take: Continue research into the causes of type 1 and type 2 diabetes Continue applied research into the prevention of diabetes and other relevant issues such as cost benefit analysis and evidence-based prevention strategies for combating the disease 20

Continue to conduct clinical trials like the DPP to prevent the onset of type 2 diabetes in individuals at high risk for developing the disease, such as minority populations Continue to develop effective methods to translate
research findings into clinical practice to prevent diabetes Develop useful outcome measures for health promotion and diabetes prevention activities, services, and practices to assess progress in these areas, and provide information to inform program improvement Develop and evaluate innovative methods to inform people about the importance of diabetes prevention and the link between the risk for diabetes and personal behaviors and choices, such as physical activity and dietary choices Develop partnerships with community organizations to promote research and educational initiatives regarding diabetes prevention State and Local, Federal, and Tribal Governments The public sector plays an important role in a supporting healthy lifestyles among Americans that may prevent type 2 diabetes, b advancing research on how to prevent diabetes, and c supporting efforts to translate research to practice Action steps that can be taken by state, federal, and tribal governments include the following: Review and design policies that optimize strategies to address diabetes at all stages Partner with communities and other entities to create environments that encourage healthy lifestyles and habits eg,
collaborate with communities to develop walking trails and parks where people can exercise safely and implement initiatives Disseminate information about the importance of healthy lifestyles to prevent diabetes Tailor these messages to be meaningful to people of all ages, and cultural, socio-economic, ethnic, and racial backgrounds Support research on the effectiveness of different interventions to prevent diabetes Conduct surveillance activities to measure progress toward achieving public health goals Create an evidence base of effective strategies for preventing diabetes Intensify prevention efforts among Blacks, Hispanics, American Indians and Alaskan Natives, and other population groups who disproportionately suffer diabetes and its complications55 Motivate government employees to adopt healthy lifestyles, thereby serving as a model to other employers Foster interagency collaboration at federal, state, and tribal levels to promote healthy lifestyles in order to reduce the risks for diabetes
55 Centers for Disease Control and Prevention 1991 Diabetes surveillance system Atlanta: US Department of

Health and Human Services Available at:
http://wwwcdcgov/diabetes/statistics/survl99/chap1/conclusionhtm

DETECTION The Importance of Early Diabetes Detection Approximately 5 million of the 18 million people with diabetes in the US do not know they have it56 Early detection and treatment of diabetes is an important step toward keeping people with diabetes healthy It can help to reduce the risk of serious complications such as premature heart disease and stroke, blindness, limb amputations, and kidney failure57 Some of the important signs and symptoms of diabetes are shown in Table 2 Many people with type 2 diabetes have no signs or symptoms, but do have risk factors see Table 1 For persons at increased risk or those experiencing these signs and symptoms, several tests are used to diagnose diabetes: A fasting plasma glucose test measures blood glucose after not eating for at least 8 hours This test is used to detect diabetes 126 mg/dl and above or pre-diabetes between 100 mg/dl and 125 mg/dl58 An oral glucose tolerance test measures blood glucose after not eating for at least 8 hours and 2 hours after drinking a glucose-containing beverage This test is used to diagnose diabetes 200 mg/dl and above or pre-diabetes
between 140 mg/dl and 199 mg/dl59 In a random plasma glucose test, blood glucose is checked without regard to when food is consumed Values of 200 mg/dl or greater in the presence of specific symptoms, such as increased urination or thirst and unexplained weight loss, indicate a diagnosis of diabetes60 Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day Type 1 diabetes is typically detected much sooner after onset than type 2 disease because the symptoms are dramatic and the need for medical care is immediate and obvious In contrast, the signs and symptoms of type 2 diabetes can be absent or so mild that the disease may not be

56 Williamson DF, Vinicor F, Bowman BA 2004 Centers For Disease Control and Prevention Primary

Prevention Working Group: Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications for health policy Ann Int Med, 14011, 951-957 57 US Department of Health and Human Services DHHS Diabetes detection initiative: Finding the undiagnosed Available at: http://wwwndepnihgov/ddi/about/indexhtm 58 National Institute of Diabetes and Digestive and Kidney
Diseases NIDDK 2003 Diagnosis of diabetes NIH Pub No 04-4642 Available at: http://diabetesniddknihgov/dm/pubs/diagnosis/indexhtm 59 ibid 60 ibid

diagnosed for 7 to 10 years after the onset resulting in increased risk for complications, such as nerve, eye, and kidney disease, when the disease is finally detected61 Table 2 Signs and Symptoms of Diabetes
Symptoms Type 1 Diabetes Type 2 Diabetes

Frequent urination Unusual thirst Extreme hunger Unusual weight loss Extreme fatigue Sudden vision changes Fruity, sweet, or wine-like odor on breath Heavy, labored breathing Stupor, unconsciousness Irritability Frequent infections Blurred vision Cuts/bruises that are slow to heal Recurring skin, gum, or bladder infections

X X X X X X X X X X X X X

X X X X X

SOURCES: National Institute of Diabetes and Digestive and Kidney Diseases NIDDK 2004 Am I at risk for type 2 diabetes? NIH Publication No 04-4805 Available at http://diabetesniddknihgov/dm/pubs/riskfortype2/ Accessed May 28, 2004 Juvenile Diabetes Research Foundation Knowing the warning signs for type 1 diabetes could save a childs life Available at
http://wwwjdrforg/indexcfm?fuseactionhomeviewPageandpage_id117E31FB-001E-A85D-3C71EBB8B19732AC Accessed May 28, 2004

In the past, type 2 diabetes was a disease seen primarily in adults over age 45 with the highest percentage occurring in adults 60 years and older62 It is now being seen at increasingly younger ages, including children and adolescents63 As with adults, identifying type 2 diabetes in children is challenging because children may not have any symptoms or show only very mild symptoms Diagnosis of type 2 diabetes in young people means that they may have the disease for a longer period time than if they developed diabetes as adults The longer duration of the

61 DHHS, opcit 62 ibid 63 Centers for Disease Control and Prevention CDC 2000 CDC funds registries for childhood diabetes Press

release, November 21 Available at http://wwwcdcgov/od/oc/media/pressrel/r2k1226htm

disease increases the rate of severe complications such as blindness, renal failure, and amputations64 Early diagnosis of diabetes and pre-diabetes is important so that patients can begin to manage the disease early and potentially prevent or delay the serious disease complications that can decrease
quality of life Recognizing the importance of identifying the more than 5 million Americans with undiagnosed diabetes, Secretary Tommy G Thompson launched the Diabetes Detection Initiative DDI in November 2003 The DDI is a new community-based effort to identify persons with undiagnosed type 2 diabetes and refer them for follow-up blood testing and treatment, if appropriate The pilot program was evaluated in 10 locations throughout the US see Appendix C for more information on the DDI Action Steps for Detection Knowledge of the risk factors, and signs and symptoms of diabetes and pre-diabetes may help increase awareness about the need to be tested for diabetes Individuals, family members, friends, health care providers, schools, the media, community organizations, health insurance providers, employers, as well as local, state, and federal governments all play important roles in helping to ensure that at-risk or asymptomatic individuals are screened for diabetes65 Individuals and Family and Friends People at risk for diabetes and their family and friends can be actively involved in ensuring that diabetes is diagnosed early Individuals may be able to recognize diabetes symptoms for
themselves, or a friend or family member may recognize these symptoms in a loved one and encourage that person to get tested for diabetes The following are some steps that can help to identify people at risk for diabetes: Take a self-administered type 2 diabetes risk assessment test see Appendix D to determine individual risk for diabetes and important next steps Discuss the results with a health care provider Pregnant women should ask their health care provider if a diabetes test is needed Individuals with pre-diabetes should work with their health care provider to develop a plan to help delay or prevent the onset of type 2 diabetes Even if blood glucose levels do not indicate diabetes, pre-diabetes is a risk factor for developing diabetes Losing a
64 ibid 65The USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening

asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose The USPSTF does recommend screening for type 2 diabetes in adults with hypertension or hyperlipidemia see http://wwwahrqgov/clinic/uspstf/uspsdiabhtm for more information The generally accepted standards of care for diabetes
screening can be found at: http://carediabetesjournalsorg/cgi/content/full/27/suppl_1/s11SEC3

small amount of weight by eating a healthier diet and getting regular exercise may prevent or delay the onset of type 2 diabetes Encourage family members and friends with diabetes symptoms to seek medical help Talk with a health care provider or local office of the American Diabetes Association to learn how to support someone who may be at risk for diabetes Schools School personnel play an important role in identifying children with type 1 and type 2 diabetes Specific actions schools can take to help in diabetes detection include: Educate teachers and school nurses about the signs, symptoms, and risk factors of diabetes and encourage them to report concerns about students to parents or the appropriate school officials Diabetes education information can be found at http://wwwndepnihgov Educate parents and children about diabetes, for example, by sending information home with report cards about how the number of children with type 2 diabetes is increasing, and providing information about diabetes risk factors and signs and symptoms to look for in children or by providing diabetes and
health education information during parent teacher meetings Partner with local and state health departments and/or organizations, such as the American Diabetes Association, to support diabetes awareness activities in schools Health Care Providers Different types of medical providers, such as doctors, physicians assistants, nurse practitioners, nurses, diabetes educators, registered dietitians, and pharmacists can play critical roles in helping to detect diabetes Here are some things providers can do: Gain and maintain state-of-the-art knowledge about the risk factors for diabetes and pre-diabetes and effective strategies related to testing for and diagnosing the disease For example, the diagnostic glucose numbers for diabetes and pre-diabetes have been revised in the past few years See The Importance of Early Diabetes Detection in this section for current diagnostic glucose numbers Create opportunities within the health care setting to identify persons at high risk for diabetes, such as asking patients to provide information about diabetes symptoms and risk factors on a pre-visit questionnaire Knowing a patient has symptoms or risk factors for diabetes can serve as an important
prompt for diagnostic testing Assess risk for gestational diabetes The American College of Obstetricians and Gynecologists ACOG advises that it is appropriate to screen all pregnant women for gestational diabetes, whether by patient history, clinical risk factors for gestational diabetes, or a laboratory test to determine blood glucose levels However, ACOG acknowledges that more research is needed before it can be determined what

screening method is best and when it should occur66 The US Preventive Services Task Force concludes that evidence is insufficient for or against routine screening for gestational diabetes67 Establish and implement protocols to ensure that newly diagnosed patients with diabetes are 1 promptly educated about lifestyle changes and diabetes selfmanagement techniques that can delay or prevent complications of diabetes; 2 tested when appropriate for comorbid conditions, such as eye or cardiovascular disease; and 3 involved in developing a plan to control HbA1c, blood pressure, and cholesterol, the ABCs of diabetes68 Refer patients and provide contact information as needed to additional health care providers to address specific or urgent problems Be a
diabetes messenger and help to educate patients and community members about the risk factors and signs and symptoms of diabetes and encourage behavior change Share information about diabetes detection with community leaders Become involved in research aimed at identifying effective approaches to detect diabetes in various populations, such as children, older persons, and members of specific racial/ethnic groups Employers Employers can play a key role in educating their employees about the risk for diabetes and encouraging them to be screened and/or tested for the disease By working with the National Diabetes Education Program,69 some employers have become the central nexus for improved detection: Distribute information about diabetes and its risk factors and signs and symptoms to employees and their families Partner with the health department or other local organizations to provide work-site diabetes screening and strongly encourage individuals who indicate a high risk for diabetes to be tested for the disease

66 American College of Gynecologists 2001 Pregnant women should be screened for gestational diabetes:

Though no one test is ideal Press release, August 31 Available at:
http://wwwacogorg/from_home/publications/press_releases/nr08-31-01cfm August 31, 2001 67 US Preventive Services Task Force Screening for gestational diabetes mellitus: Recommendations and rationale February 2003 Agency for Healthcare Research and Quality, Rockville, MD Available at http://wwwahrqgov/clinic/3rduspstf/gdm/gdmrrhtm 68 National Diabetes Education Program Guiding principles for diabetes care: For health care providers NIH Publication No 99-4343 Available at: http://wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf 69 The National Diabetes Education Program is a jointly funded program by the National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce morbidity and mortality associated with diabetes

Health Insurance Providers Health insurance organizations can also support early detection of diabetes through education and outreach efforts to their members Early identification of diabetes can help improve quality of life and avoid costly complications Health plans may also consider giving diabetes screening and testing guidelines to providers Potential
steps health insurance providers can take include: Educate members about the risk factors and signs and symptoms for diabetes and offer incentives to at-risk patients to be tested for diabetes Inform pregnant women about the potential value of screening for gestational diabetes Consider offering incentives to health care providers to follow evidence-based diabetes diagnostic guidelines Provide information to assist providers in reaching racial and ethnic groups that are disproportionately affected by diabetes Provide culturally sensitive messages that are targeted to racial and ethnic populations at higher risk for diabetes Communities and Local Health Departments Community organizations and local health departments can play an important role in diabetes education and detection Various local organizations eg, federally supported health centers, the local chapter of the American Diabetes Association, faith-based organizations, etc along with the local health department may be valuable resources to help develop and/or distribute information on the importance of early diabetes detection and the risk factors for and signs and symptoms of diabetes Some action steps for community
organizations include: Encourage local organizations to disseminate information, such as copies of diabetes risk assessment tests, through their various communication channels Examples of potential partnerships include vendors placing diabetes information on shopping bags; local utility companies including inserts into mailings; and churches, synagogues, and other faith-based organizations placing diabetes risk assessment tests in their newsletters, bulletins, or other mailings Organize outreach sessions at community venues such as libraries that can provide space, equipment, and other resources for community-wide presentations on diabetes detection, including risk factors, signs and symptoms, and action steps for individuals who think they might have the disease Develop a directory of community resources for diabetes screening, testing, and treatment that can be distributed to people at high risk for diabetes

Media The media can make an important contribution to early detection of diabetes by helping to educate the public about the risk factors and signs and symptoms of diabetes and encouraging those with risk factors and signs and symptoms to discuss testing with their
health care providers Specific functions the media can perform to enhance diabetes detection include: Increase diabetes awareness through responsible reporting about the risk factors and signs and symptoms of diabetes Provide information about the risk factors for diabetes and make people aware that many people with diabetes may not have signs or symptoms Promote health messages that emphasize the importance of early diabetes detection to improve health outcomes and avoid diabetes complications Promote National Diabetes Alert Day the fourth Thursday in March on national, state, and local levels Utilize resources that are readily available at no cost, such as information about the Diabetes Detection Initiative http://wwwndepnihgov/ddi/indexhtm Partner with medical professionals, federal, state, and local governments, and privatesector community entities to develop effective health messages that will generate public interest and increase public understanding of the importance of detecting diabetes Participate with public health researchers to develop appropriate, targeted, and effective media messages to reach people at risk for diabetes, particularly older adults and at-risk racial
and ethnic populations Provide tailored messages targeting specific racial and ethnic populations at higher risk for diabetes Work with officials to encourage public access networks to broadcast local conferences or training videos on diabetes detection Work with local professional organizations to identify and acknowledge health care providers who have excelled in diabetes detection efforts Recognize local, state, and national programs that have been successful in detecting diabetes and decreasing the proportion of Americans with undiagnosed diabetes State, Tribal, and Federal Governments At the state and national levels, government organizations and others are working to improve diabetes detection Appendix C describes several important ongoing governmental activities for diabetes detection Other examples of specific action steps include: Review and design policies that optimize strategies to address diabetes detection

Create an evidence base of best strategies for detecting diabetes that includes screening protocols for both diabetes and pre-diabetes Acknowledge community efforts that have effectively increased the percentage of persons diagnosed with diabetes Educate
elected officials about how early detection can help improve overall quality of life for constituencies and the implications for reducing health care costs Provide important information about population groups, such as older adults and atrisk racial and ethnic populations, and people with certain risk factors, including obesity, that make them more likely to have diabetes and thus have a greater need for screening Identify trends in new cases of type 1 diabetes, type 2 diabetes, gestational diabetes, and pre-diabetes to inform diabetes detection activities Create culturally sensitive diabetes awareness messages targeted to underserved populations that are at high risk for diabetes Examine health insurance coverage policy for public employees with respect to diabetes testing

TREATMENT The Importance of Diabetes Treatment and Management If left untreated or undertreated, diabetes can cause severe complications that can damage many vital organs in the body and lead to premature death70 Possible complications from diabetes can include heart disease, blindness, lower extremity amputations, kidney failure, dental disease, and increased susceptibility to infections Estimates suggest
that in many states, half of all people with diabetes do not receive recommended preventive care services that are known to reduce the risk of diabetes complications71 The good news is that the complications from diabetes can often be prevented or delayed with quality medical care and by adopting healthy behaviors to manage diabetes For example, the Diabetes Control and Complications Trial DCCT demonstrated that careful control of blood glucose levels resulted in delaying the onset and slowing the progression of retinopathy eye disease, nephropathy kidney disease, and neuropathy nerve disorders for people with type 1 diabetes72 Other studies such as the UK Prospective Diabetes Study UKPDS73 have shown similar dramatic reductions in complications with control of blood glucose for people with type 2 diabetes Empowering people with diabetes with knowledge and resources to proactively manage their disease and prevent or control diabetes complications is an important step in successful disease management Friends and family members, health care professionals, schools, employers, health insurance providers, community organi zations, the public media, and government agencies can all help
persons with diabetes to live healthy and productive lives This section suggests action steps to improve diabetes management and decrease risks for diabetes complications Action Steps for Treatment Individuals The possible complications from diabetes can be extremely serious There is strong evidence from clinical trials that many of these complications may be delayed or prevented by

70 CDC, National Diabetes Fact Sheet, opcit 71 Centers for Disease Control and Prevention CDC Levels of Diabetes-related preventive-care practices-United

States, 1997-1999 MMWR Morbidity Mortality Weekly Report 2000; 4942, 954-958
72 The Diabetes Control and Complications Trial Research Group, opcit; and Diabetes Complications, National

Diabetes Information Clearing House Available at http://diabetesniddknihgov/complications/ Accessed on September 7, 2004 73 Turner, RC, opcit

carefully controlling blood glucose levels, blood pressure, and LDL cholesterol levels74 To help manage diabetes, individuals should discuss, create, and follow a diabetes management plan with a health care provider and set goals for a treatment plan The following are some specific suggestions to consider: Ask health care
providers about the ABCs of diabetes A is HbA1c, a measure of average blood glucose; B is blood pressure; and C is LDL-cholesterol Patients should determine what their levels are, what they should be, and what steps they can take to reach those goals75 Work with health care providers to establish and maintain individualized target blood glucose levels Ask how often and when to measure blood glucose levels Individuals should keep a record of blood glucose readings to show their health care provider so they can better regulate their blood glucose Be aware of the symptoms for hypoglycemia low blood sugar and hyperglycemia high blood sugar Individuals who experience these symptoms, should adjust their treatment plan and seek medical advice on how to maintain healthy blood glucose levels Table 3 presents symptoms of hypoglycemia and hyperglycemia Table 3 Symptoms of Hypoglycemia and Hyperglycemia Symptoms of hypoglycemia Feel weak, confused, irritable, hungry, or tired Sweat a lot or get a headache Feel shaky Symptoms of hyperglycemia Feel very thirsty and tired Have blurry vision Have to go to the bathroom often Nausea
SOURCE: National Institute of Diabetes and Digestive and Kidney
Diseases NIDDK Your guide to diabetes–type 1 and type 2 Available at: http://diabetesniddknihgov/dm/pubs/type1and2/lowglucosehtm Hypoglycemia is a low blood sugar Hyperglycemia is a high blood sugar

74 The Diabetes Control and Complications Trial Research Group, opcit; and Turner, RC, optcit 75 The ABCs of Diabetes refers to knowing the patients blood glucose level through the HbA1c test and making

sure blood pressure and cholesterol are at recommended levels Information on Knowing your ABCs can be found at: http://wwwndepnihgov/diabetes/control/4StepshtmStep2

Follow a meal plan developed with a health care provider This can be an important step for maintaining desirable blood glucose levels and avoiding complications Work with a health care provider to develop an appropriate exercise program and follow this plan Appropriate exercise can be important for people with diabetes because it can help insulin work better to lower blood glucose levels and improve cardiovascular health Follow a health care providers recommendations for how and when to take diabetes medications Discuss with a health care provider if medications do not seem to be working properly Individuals should
ask their primary care provider about a dilated eye exam at least once a year as people with diabetes are at higher risk for vision problems and blindness Early detection and treatment of diabetic eye disease can prevent or delay vision loss Request regular blood pressure checks at every medical visit and cholesterol checks at least once per year because people with diabetes are at higher risk for heart disease and stroke Lowering blood pressure and cholesterol can reduce the risk of heart attack and stroke, the major cause of death in people with diabetes Individuals, who smoke cigarettes, should seek help from a health care provider to quit smoking to further reduce their risk for heart disease Brush teeth regularly and visit a dentist at least once every six months because people with diabetes are at higher risk for gum disease Check feet for sores and calluses every day, wear shoes that fit properly, and get a comprehensive foot exam at least once per year with a health care professional since people with diabetes are at a higher risk for foot problems that can be caused by neuropathy nerve damage or poor blood flow to the feet Ask for a urine test by a health professional at
least once a year to monitor the level of protein in urine, a measure of kidney function If planning a pregnancy, consult a health care provider to make a care plan that focuses on good blood glucose control before and during the pregnancy Maintain records of daily self-management activities and medical visits The checklist in Table 4 can help individuals and healthcare providers keep track of diabetes care Other materials for managing diabetes can be found at http://wwwndepnihgov/diabetes/control/controlhtm or by calling 1-800-860-8747 Ask a health care provider about new medicines and medical devices, such as blood glucose meters and insulin pens and pumps that could help manage diabetes Seek the help of qualified health care professionals–such as a primary care provider, an endocrinologist, a certified diabetes educator or a registered dietician–to help with diabetes management Seek help and encouragement through a diabetes support group

Continue to obtain information on diabetes The National Diabetes Education Program http://wwwndepnihgov/ or 1-800-438-5383 and organizations such as the American Diabetes Association http://wwwdiabetesorg/homejsp or 1-800DIABETES, the
American Association of Diabetes Educators and the Juvenile Diabetes Research Foundation International http://wwwjdrforg/ or 1-800-533CURE can be excellent resources to help in learning more about caring for diabetes Get information about clinical trials in progress that may identify new and more effective medicines and treatment regimens to treat diabetes Available at: http://wwwclinicaltrialsgov Talk about diabetes with family and friends to make them aware of ways they can help with diabetes management Table 4 Diabetes Care Checklist Daily diabetes care activities
G Exercise G Follow meal plan G Take diabetes medicine G Check blood glucose as recommended by a health care provider G Check feet for sores that are not healing properly G Brush teeth and floss

At doctor visits
G Get feet checked G Check blood pressure

At least twice per year
G Get an HbA1c test G Get a dental check-up and have teeth cleaned by a dental professional

At least once per year
G Get a dilated eye exam G Get a complete foot exam–checking circulation and for changes in foot shape G Get a urine test for kidney function G Get a flu shot G Get blood lipid levels cholesterol checked
SOURCE: National Diabetes
Education Program 2001 7 principles for controlling your diabetes for life NIH Publication No 99-4343L Available at: http://wwwndepnihgov/diabetes/pubs/7Principles_Engpdf

Families and Friends People with diabetes need their family members and friends to help them manage their disease and keep track of their diabetes care Here are some things families and friends can do to support people with diabetes: Plan walks or other activities with friends and family with diabetes to help them get regular exercise Help them follow the advice of their health care provider about ways to exercise safely Prepare healthy meals that fit into meal plans for people with diabetes and prediabetes Offer to help friends or family members check their feet for sores or calluses Provide transportation to the heath care providers office so that friends or family members do not miss important medical visits Become aware of the signs and symptoms of hypoglycemia and hyperglycemia and how to appropriately treat them If friends or family members do not understand English, help translate patient education materials into a language he/she knows or help identify resources that are language appropriate Provide
assistance to a friend or family member with diabetes that is sick with a cold, the flu, or another type of infection or illness Being sick can raise blood glucose and may make it difficult to eat properly or monitor blood glucose as needed If a child in your family has been diagnosed with diabetes, work closely with health care providers to develop a care plan that addresses diabetes and fits in with the childs schedule Revisit the plan on an ongoing basis to make sure that changes in the childs condition or lifestyle are considered Seek advice from health care providers about ways to teach children to be proactive in taking care of their diabetes Schools Because diabetes must be managed on a daily basis, school staff teachers, nurses, principals, and office staff can play an important role in helping students manage their diabetes Specific action steps for schools to take to help students manage diabetes include: Provide training for school staff that work with students with diabetes This training should include basic information about diabetes and the students needs, how to recognize medical emergencies, and steps to take in the event of an emergency Work with children with
diabetes and their parents or caregivers to follow the personalized diabetes care plan devised by the family and the health care team The National Diabetes Education Program has compiled a comprehensive booklet called

Helping the Student with Diabetes Succeed: A Guide for School Personnel, which can be can be found at http://wwwndepnihgov/diabetes/pubs/Youth_NDEPSchoolGuidepdf or by calling 1-800-860-8747 Table 5 Examples of Items to Include in Flow Chart for Patients with Diabetes
Each visit Weight check Blood pressure check Foot exam Diabetes education and self-management Twice per year HbA1c test quarterly if not within recommended range Dental exam Annual Lipid profile Dilated eye exam Physical exam for detecting nerve damage Serum creatinine and urinalysis for protein, microalbumin to creatinine ratio to detect kidney disease Vaccines Influenza annual Pneumoccal usually only once, repeat if over age 64 or immunocompromised and the last vaccice was longer than 5 years ago
SOURCE: National Diabetes Education Program NDEP Guiding principles for diabetes care: for health care providers HHS Publication No 99-4343 Available at:
http://wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf Accessed August 24, 2004

Health Care Providers Primary care providers, such as family physicians, internists, physicians assistants, and nurse practitioners, play an important role in providing routine high-quality diabetes care as well as referrals to other practitioners for specialty care As new research and drugs become available and practice guidelines for diabetes evolve, it is critical for health care providers to stay abreast of standards of care and new evidence-based treatments and devices to support diabetes management Important information for providers about diabetes care can be found at http://wwwndepnihgov/resources/healthhtm, http://wwwbetterdiabetescareorg, http://carediabetesjournalsorg/content/vol28/suppl_1/ Possible action steps for the primary care provider include:

Help patients control blood glucose levels The DCCT and the UKPDS demonstrated that intensive therapy in blood glucose management is effective in delaying the onset of complications and slowing the progression of diabetes76 Educate patients on the ABCs of Diabetes77 HbA1c, blood pressure, and cholesterol to lower overall risks for heart
disease Goal ranges are HbA1c of less than 7 percent, blood pressure of less than 130/80, and cholesterol LDL of less than 100 mg/dl78 Develop flowcharts that ensure patients with diabetes receive preventive and diagnostic services Table 5 contains examples of care practices to include in flow charts for patients with diabetes79 Advise women with diabetes considering pregnancy about the risks that diabetes poses for pregnancy and the importance of good blood glucose control before and during pregnancy Incorporate information management systems, such as patient registries, to track patient health status and receipt of preventive care services and provide information about the patients status to the entire care team Use office prompts eg, posters asking patients to remove their shoes and socks prior to the exam to facilitate care Work with patients and their families to develop comprehensive care plans that include lifestyle changes and medical services needed to control blood glucose, blood pressure, and LDL cholesterol and prevent and manage complications from diabetes Care plans should include the following: a meal plan, an exercise program to help patients maintain a healthy
weight and good cardiovascular health, diabetes education to guide self-management, and a schedule to ensure that patients receive preventive and diagnostic care services, such as HbA1C tests, dilated eye exams, and foot exams in a timely manner Prescribe medications angiotensin converting enzyme inhibitors or angiotensin receptor blockers that can slow progression of diabetic kidney disease in patients found to have hypertension and/or elevated urinary microalbumin Ask if patients with diabetes smoke, and help those who smoke to stop smoking Help educate patients family members and friends about ways they can help loved ones with diabetes to manage the condition Refer patients with diabetes to various health care specialists and educators as appropriate

76 The Diabetes Control and Complications Trial Research Group, opcit; and Turner, RC, opcit 77 The ABCs of Diabetes, opcit 78 National Diabetes Education Program NDEP Guiding principles for diabetes care: For health care providers

HHS Publication No 99-4343 Available at: http://wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
79 ibid

Refer people with diabetes to community resources that can help them manage their diabetes
Facilitate community support groups for people with diabetes and their friends and family to help educate them about the health problems that can be caused by diabetes and the ways they can manage the disease and live healthy and productive lives Talk with community leaders about diabetes and the importance of supporting people with diabetes Translate patient materials into other languages for people in the community when feasible Participate in clinical trials to evaluate new technologies for treating diabetes Become involved in research studies to determine effective approaches for educating and treating patients with diabetes in various populations, such as children, elderly persons, and members of specific racial/ethnic groups Employers Potentially, any one of your employees could have diabetes now or develop the disease in the future Diabetes does not discriminate; it can affect anyone, regardless of age, race/ethnicity, or gender Since the prevalence of diabetes is increasing, no matter how large or small your workforce, your company may be increasingly affected by diabetes Employees need your support and assistance to continue to be productive and effective workers Specific
actions aimed to control diabetes and prevent its complications may help increase overall employee productivity and company profitability80 Specific action steps employers can take to support employees with diabetes include: Review the health plans offered to employees to determine benefits for health care services and supplies associated with diabetes management eg, physician visits, diabetes education, dietitian visits, blood glucose testing supplies Encourage public reporting of health plan and provider performance in meeting diabetes care objectives Seek out information about diabetes to better understand the needs of employees with diabetes Information is available at http://wwwdiabetesatworkorg/

Health Insurance Providers Health insurance providers can also support management of diabetes through education and outreach efforts to their members Bringing individuals into high-quality diabetes care early

80 National Diabetes Education Program NDEP Making a difference, the business community takes on diabetes

Available at: http://wwwndepnihgov/resources/business/indexhtm

can help improve quality of life and may avoid complications Some action steps for health insurance
include: Distribute educational materials to health plan members with diabetes via direct mail or to health care providers for distribution Inform women with diabetes about the importance of blood glucose control before and during pregnancy Acknowledge providers that effectively use care guidelines to provide high-quality diabetes care Consider offering health care providers incentives to follow evidence-based practice guidelines for care to optimize treatment outcomes Educate patients about the importance of healthy lifestyle behaviors and self-blood glucose monitoring and management Create patient education materials targeting groups that are particularly vulnerable to diabetes, such as children, people of various racial and ethnic groups, and elderly persons Consider designing insurance benefits that cover evidence based services needed to treat diabetes, including diabetes self-management education Communities Community organizations can play a vital role in educating people with diabetes and their family members about the importance of managing diabetes to prevent complications Various national organizations eg, the American Diabetes Association, American Association of
Diabetes Educators may have a local chapter in your area that is working to help your friends and neighbors with diabetes Some action steps for community organizations to consider include: Develop a directory of community resources for diabetes care and supplies that can be distributed to people with diabetes and their caregivers Support efforts to raise awareness for diabetes by participating in local and national walk, run, or bike rides for diabetes Coordinate efforts with groups that address chronic conditions related to diabetes, such as obesity and heart disease Partner with local media outlets to develop and distribute messages about the importance of managing diabetes Distribute information about diabetes treatment and management within the community eg, at stores, shopping malls, senior citizen centers, etc Organize support groups where people with diabetes and their caregivers can meet with health professionals and their peers to discuss ways to manage diabetes Coordinate with local members of various racial/ethnic groups to develop patient education materials in different languages and formats

Encourage local restaurants and food chains to flag menu items that are
appropriate for people with diabetes and/or provide nutritional information content of menu items Join with local Chambers of Commerce to recognize employers for providing working conditions that support people with diabetes eg, Health Friendly Workplace awards Partner with State Diabetes Prevention and Control Programs run by the State Health Department Media Different kinds of popular media eg, television, radio, newspapers can be used to inform people with diabetes and their caregivers about the importance of quality diabetes treatment and self-management Specific action steps for working with the media include: Promote messages about managing diabetes by distributing information provided in health communication campaigns developed by the National Diabetes Education Program available at http://wwwndepnihgov/campaigns/campaigns_indexhtm; http://wwwndepnihgov/campaigns/toolshtmpsa Promote National Diabetes Awareness Month November of each year on national, state, and local levels Distribute messages in multiple languages so the information reaches people who do not speak English Tools in various languages are available at:
http://wwwndepnihgov/diabetes/pubs/cataloghtmPubsHispLatino and http://wwwndepnihgov/diabetes/pubs/cataloghtmPubsAsianAm Partner with community clinics to provide information about where to go for diabetes care Partner with medical professionals, federal, state, and local governments, and privatesector community entities to help the public understand the importance of managing and treating diabetes Collaborate with public health researchers to test media messages and identify the most appropriate and effective messages to reach people with diabetes Work with officials to provide public access networks to broadcast local conferences or training videos on diabetes management Partner with local schools of nursing, medicine, and other health professionals to encourage young people to pursue careers in health care Invite local celebrities, community leaders, health professionals, and citizens with diabetes to participate on radio or television talk shows and discuss their experiences

with diabetes and the importance of self-management and medical care Similarly, newspapers can include feature stories about community members and their experiences with diabetes Work with local
professional organizations to identify and acknowledge health care providers who have excelled in diabetes treatment and education efforts Recognize local, state, and national programs that have been successful in helping people with diabetes get the care and education they need Researchers and Professional Educators Researchers and professional educators can play an important role to advance knowledge of diabetes treatment, develop new strategies to prevent its complications, and translate the research into messages that can reach those affected by diabetes and those working in this arena Further, researchers and professional educators can help ensure that appropriate information is gathered to help inform policy makers The following are some action items for these groups to consider: Continue research on finding a cure and enhanced treatments for diabetes Explore partnerships with communities and other groups to help translate evidencebased practices and evaluation strategies to activities of these groups Investigate the costs of diabetes and provide this information to officials and policy makers at federal, state, tribal, and local levels Identify and address barriers to
services that limit access to care for persons with diabetes Continue applied qualitative research into successful treatment protocols and diabetes management strategies; studies into quality of life issues; and exploration of future systems capacity issues Employ community-based research methods to engage the community in research ie, needs assessments, clinic site visits, focus groups State and local, Tribal, and Federal Governments State and local, tribal, and federal governments can serve as important role models for other organizations by actively engaging in efforts to advance knowledge and take steps to minimize complications from diabetes, improve patient care, and enhance access to care The following are suggestions for accomplishing this: Review and support policies and programs that help people with diabetes live healthy and productive lives

Examine health plan benefits for government employees to ensure coverage of evidence-based services to prevent or delay complications from diabetes Support research to develop new effective strategies, devices, and medications for diabetes Support efforts that help to decrease racial and ethnic disparities in diabetes care
Conduct surveillance activities to monitor trends in the prevalence of diabetes ie, the number of people who have diabetes to inform diabetes treatment efforts Continue to create and update educational materials for people with diabetes, their caregivers, employers, and schools that are available in various languages and formats to increase knowledge and understanding of this disease and how to help people with diabetes prevent or delay complications Support efforts to recruit and train members of the healthcare workforce that can help people with diabetes in their communities live healthy lives Continue to develop an evidence base of best practices for treating and managing diabetes For example, the National Diabetes Education Programs Better Diabetes Care Web site http://betterdiabetescarenihgov/indexhtm–provides best practice models, links, and resources to professionals for diabetes management–and the Indian Health Services Indian Health Diabetes Best Practice Model Approaches http://wwwihsgov/MedicalPrograms/Diabetes/indexasp–provides 14 best practice model approaches for successful diabetes prevention, treatment, and education practices in American Indian and Alaskan
Native communities

LIST OF ACRONYMS AND ABBREVIATIONS AADE ACOG ADA AHRQ AoA ASPE BPHC CDC CMS DCCT DDT DNPA DPP DRWG FDA HbA1c HDL HHS HP 2010 HRSA IHS LDL LEA NCCDPHP NDAP NDEP NDL NIDDK NIH OMH TRIAD UKPDS USPSTF WISE WOMAN American Association of Diabetes Educators American College of Gynecologists and Obstetricians American Diabetes Association Agency for Healthcare Research and Quality Administration on Aging Assistant Secretary for Planning and Evaluation Bureau of Primary Health Care, HRSA Centers for Disease Control and Prevention Centers for Medicare and Medicaid Services Diabetes Control and Complications Trial Division of Diabetes Translation, CDC Division of Nutrition and Physical Activity, CDC Diabetes Prevention Program Diabetes Research Working Group, NIH Food and Drug Administration glycosylated hemoglobin or hemoglobin A1c High Density Lipoprotein US Department of Health and Human Services Healthy People 2010 Health Resources and Services Administration Indian Health Service Low Density Lipoprotein Lower Extremity Amputation National Center for Chronic Disease Prevention and Health Promotion, CDC National Diabetes Action Plan National Diabetes Education
Program, NIH/CDC National Diabetes Laboratory National Institute of Diabetes and Digestive and Kidney Diseases, NIH National Institutes of Health Office of Minority Health, OPHS Translating Research Into Action for Diabetes UK Prospective Diabetes Study US Preventive Services Task Force Well Integrated Screening and Evaluation for Women Across the Nation

Appendix A: Steps to a HealthierUS

STEPS TO A HEALTHIERUS

Steps to a HealthierUS Steps is a major initiative of the US Department of Health and Human Services HHS that advances President George W Bushs HealthierUS goal of helping Americans live longer, better and healthier lives Recognizing that the United States is facing several serious public health challenges, Secretary Tommy G Thompson launched Steps to a HealthierUS in 2003 At the heart of this program lie both personal responsibility for the choices Americans make and social responsibility to ensure that policy makers support programs that foster healthy behaviors and prevent disease The Steps initiative envisions a healthy, strong US population supported by a health care system in which diseases are prevented when possible, controlled when necessary, and
treated when appropriate This initiative is a shift in the traditional approach to the health of our citizens, moving us from a disease care system to a health care system Realizing that small changes over time can yield dramatic results, the Steps initiative is committed to identifying and promoting programs that encourage small behavior changes With a strong emphasis on proven interventions and existing science, Steps will promote the following: Health promotion programs to motivate and support responsible health choices Community initiatives to promote and enable healthy choices Health care and insurance systems that put prevention first by reducing risk factors and complications of chronic disease State and Federal policies that invest in the promise of prevention for all Americans Cooperation among policy makers, local health agencies, and the public to invest in disease prevention instead of spending our resources to treat diseases after they occur The goal of the Steps initiative is to reverse the growth in the number of people suffering from chronic diseases like asthma, diabetes, cancer, heart disease and stroke, as well as factors that contribute to them such as obesity,
poor nutrition, physical inactivity, and tobacco use The intent of Steps is to reach the broadest number of Americans by using multiple approaches and involving groups and organizations to foster health, physical activity and good nutrition To date, these approaches have focused on communities, businesses and organizations, and the actions that they can take to influence individuals choices and actions to improve health The Steps initiative has multiple components including: Grants to Communities: As the cornerstone of the Steps initiative, in 2004, HHS funded 22 cooperative agreements to 40 communities for a total of 357 million to establish community-wide partnerships to improve the health and well being of individuals by encouraging people to maintain physically active lifestyles and make healthy lifestyle choices

Grant to a National Organization: In FY 2004, HHS awarded a 2 million grant to the national office of the YMCA With more than 2,500 YMCAs in the country, this funding will help strengthen the network of local YMCA chapters by developing and implementing strategies to work together with the 40 Steps grant communities also funded in 2004 Roundtable Discussions: The
Secretary hosted a series of Roundtable discussions, which brought together interested stakeholders including academia, insurers, business executives, health care providers, and researchers The purpose of these roundtables was to highlight the importance of prevention and specifically discuss best approaches to stem the tide of chronic diseases and encourage healthy lifestyles regular physical activity and balanced diets The roundtables also identified obstacles to adopting healthy habits Secretarys Challenge–Steps to a HealthierHHS: This is an HHS worksite health promotion program encouraging Department employees to become more physically active This voluntary initiative promotes the benefits of a healthy lifestyle by challenging employees to be on the move–at least 30 minutes a day, five days a week for six weeks Nearly 800 employees participated, and 25 percent completed the pilot program in the Washington, DC, area Annual Prevention Summit: Held on April 15-16, 2003 in Baltimore, Maryland, the inaugural Steps to a HealthierUS: Putting Prevention First Summit focused attention on the urgency of prevention and on promising approaches for tackling key challenges At this
conference, the Secretary laid out his priorities and programs for Steps to a HealthierUS The second annual summit was held on April 29-30, 2004, in Baltimore, Maryland Future summits are planned Annual Awards for Innovation: Another component of the Steps initiative is the Steps Innovation in Prevention Awards Program In December 2003, HHS awarded the first set of eight Steps Innovation Awards in seven categories, to groups and organizations recognizing their accomplishments and highlighting the concrete health improvements that each has achieved The second round of awards will be announced in December 2004 Partnerships: Another aspect of the Steps initiative is the partnerships program where HHS seeks to work with other public and private sector organizations to support and promote healthier living It is designed to encourage innovative opportunities to promote healthier living and prevent chronic diseases and conditions Secretarial Workgroups and the Blueprint for Action: Recognizing the importance of many chronic diseases such as cancer, cardiovascular disease, and asthma, the Secretary established five senior staff workgroups on specific areas that were identified as
presenting particular opportunities for cross-Departmental coordination and that are central to advancing health promotion and disease

prevention: overweight and obesity, diabetes, tobacco, media and messages, and health literacy This work provided the basis for the Secretarys Prevention: A Blueprint for Action released in April of 2004 This Blueprint outlines simple action steps to guide individuals in their quest for healthier lifestyles It also encourages other interested parties and organizations, such as providers, employers, communities, insurers, media, schools, and government to collaborate and cooperate to overcome obstacles, to promote healthy lifestyles and reduce the burden of chronic diseases More information about Steps to a HealthierUS is available at: http://wwwhealthierusgov/steps

Appendix B: Medicare and Diabetes

MEDICARE AND DIABETES The Medicare program is a federal health insurance program for people age 65 or older, people under age 65 with certain disabilities, and people with end-stage renal disease ESRD Medicare covers more than 40 million beneficiaries Current Medicare Coverage of Services and Supplies for Individuals with Diabetes
Medicare covers important services and supplies for individuals with diabetes Self-Management Training Services Medicare currently covers diabetes self-management training under Part B for certain beneficiaries who are at risk for complications from diabetes Under Medicare fee-forservice FFS a beneficiary pays 20 of the Medicare-approved amount after the yearly Part B deductible Medical Nutrition Therapy Services Medicare Part B also covers medical nutrition therapy services for people with diabetes or kidney disease These services can be given by a registered dietician or nutrition professional and include diet counseling and therapy services to help a beneficiary manage their diabetes Under Medicare FFS, a beneficiary pays 20 of the Medicare-approved amount after the yearly Part B deductible Diabetic Supplies and Therapeutic Shoes Medicare Part B covers diabetic self-testing equipment and supplies for beneficiaries who have diabetes Medicare covers the same supplies for people with diabetes whether or not they use insulin The self-testing equipment and supplies include glucose testing monitors, blood glucose test strips, lancet devices and lancets, and glucose control solutions
There may be some limits on the supplies or how often a beneficiary may receive the supplies Medicare also covers therapeutic shoes for people with diabetes who qualify under Medicare Part B The coverage includes depth-inlay shoes, custom-molded shoes and shoe inserts

Current Coverage of Preventive Services for Individuals with Diabetes Currently, Medicare Part B covers several preventive services that are important to individuals with diabetes Flu and Pneumococcal Pneumonia Vaccinations Medicare Part B covers flu and pneumococcal pneumonia vaccinations All Medicare beneficiaries are covered Under Medicare FFS, there are no out-of-pocket costs for beneficiaries if the health care provider accepts assignment Glaucoma Screening For beneficiaries who are at high risk for glaucoma, including people with diabetes or a family history of glaucoma Medicare covers glaucoma screening once every 12 months The screening must be performed or supervised by an eye doctor who is legally allowed to do this

service in the State Under Medicare FFS, a beneficiary pays 20 of the Medicare-approved amount after the yearly Part B deductible Other Preventive Services Medicare also provides
coverage for the following preventive benefits under Part B: bone mass measurement, colorectal cancer screening, mammography screening, screening pap smear and pelvic exams and prostate cancer screening

Medicare Modernization Act of 2003 Improvements for Individuals with Diabetes The new law enhances diabetes coverage for beneficiaries by adding several improvements Welcome to Medicare Physical Beginning in 2005, the new law provides new coverage of a one-time preventive physical exam within 6 months of a beneficiarys enrollment under Part B The initial preventive physical will consist of a comprehensive examination that will allow the physician to diagnose problems early when treatment is more effective In addition, the physician and office staff will provide education, counseling and referral to other preventive services covered by Medicare Cardiovascular Screening Tests The new law provides Medicare coverage of cardiovascular screening blood tests, including tests for total cholesterol, high-density lipoprotein, and triglycerides Diabetes Screening Tests Beginning in 2005, the new law will supply new coverage of diabetes screening tests for persons at risk for diabetes,
including a fasting plasma glucose test and such other tests as the Secretary may determine appropriate Eligible risk factors include hypertension, dyslipidemia, obesity, prior identification of impaired fasting glucose or glucose tolerance, or at least two of the following: overweight, family history of diabetes, history of gestational diabetes or delivery of a baby over 9 pounds Medicare Part D Drug Benefit The new Medicare Part D drug benefit will cover insulin and associated diabetic supplies including syringes beginning in 2006 Medication Therapy Management Beginning in 2006, the new comprehensive prescription drug benefit will include drug therapy management for beneficiaries with multiple chronic diseases, including diabetes, who take multiple drugs and spend more than a specified amount annually on drugs covered under the prescription drug benefit The drug management programs will help ensure the best therapeutic outcomes and reduce the risk of adverse medication events

Appendix C: Development of Diabetes: A National Plan for Action

DEVELOPMENT OF DIABETES: A NATIONAL PLAN FOR ACTION

Prompted by the Secretarys commitment to disease prevention and
health promotion, and efforts of interested individuals and organizations, the creation of Diabetes: A National Plan for Action hereby referred to as the National Diabetes Action Plan–NDAP offers an important opportunity to identify and coordinate activities among relevant stakeholders to improve diabetes prevention, detection and care The development of the action plan reflects the cross cutting interest in this topic and the dedication of many entities to the prevention, detection and treatment of diabetes The goals of the NDAP are: 1 Increase national awareness of diabetes, its impact, and what various stakeholders can do to prevent or manage the disease; 2 Reduce the prevalence of diabetes and factors that increase the risk of diabetes; 3 Promote improved detection, monitoring, and treatment of the disease; and 4 Identify existing public and private efforts to facilitate coordination and to leverage existing resources for detection, prevention, and treatment of diabetes

The process to develop the NDAP involved: 1 An Internal Advisory Committee from the US Department of Health and Human Services HHS; 2 A series of three participatory town hall meetings; and 3 A literature
review Internal Advisory Committee The NDAP Internal Advisory Committee, comprised of senior officials from the various HHS agencies, provided advice on the scope and content for the plan In addition, the Advisory Committee provided guidance throughout the NDAP development process and helped to establish the focus and parameters of the plan The committee also reviewed a draft of the plan and provided input on the recommendations and action steps Advisory Committee Members Michael OGrady, PhD Committee Chair Assistant Secretary for Planning and Evaluation

Kevin Keane Assistant Secretary for Public Affairs Howard Zucker, MD, JD, LLM Acting Deputy Assistant Secretary for Health, Office of Public Health and Science Garth Graham, MD, MPH Acting Deputy Assistant Secretary for Minority Health, Office of Minority Health, Office of Public Health and Science Nathan Stinson, Jr, PhD, MD, MPH, Formerly the Deputy Assistant Secretary for Minority Health, Office of Minority Health Carolyn Clancy, MD Director, Agency for Healthcare Research and Quality John Wren Director for Planning and Policy Development, Administration on Aging Frank Vinicor, MD Director, Division of Diabetes Translation,
Centers for Disease Control and Prevention Sean Tunis, MD Chief Medical Officer/Director, Office of Clinical Standards and Quality, Centers for Medicare Medicaid Services Lester Crawford, DVM, PhD Deputy Commissioner of Food and Drugs, Food and Drug Administration Sam Shekar, MD, MPH Associate Administrator, Bureau of Primary Health Care, Health Resources and Services Administration Craig Vanderwagen, MD Acting Chief Medical Officer, Indian Health Service Allen Spiegel, MD Director, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health Town Hall Meetings Three town hall meetings provided public forums for the Secretary to listen to comments from the diabetes community The information gathered in these forums helped to inform the development of NDAP

The general structure of each town hall meeting consisted of a half-day session, which opened with an introduction by the Secretary or a senior HHS official This was followed by a series of statements from HHS staff and invited national, state, and local experts and policymakers on diabetes data concerning prevention, detection, and treatment, for each of the town hall meetings respectively
The presentations were followed by an open-microphone session where individuals and representatives of the diabetes groups asked questions or made comments The meetings were advertised through local newspapers including newspapers with high minority readership and radio In addition, letters of invitation were sent to local groups and leaders in the diabetes community, public health sector, and health services field Both a Web site and a toll-free telephone line were provided for participants to register and obtain additional information The town hall meetings were held in different locations around the country and each focused on a different facet of diabetes:

Putting Prevention Into Practice: A Diabetes Town Hall Meeting The Cincinnati Hilton Netherland Plaza Cincinnati, Ohio March 29, 2004 Expert Panel: Secretary Thompson Allen Spiegel, MD, Director, NIDDK The Honorable Jennette Bradley, Lieutenant Governor and Director of Commerce for Ohio J Nick Baird, MD, Director, Ohio Department of Health James Holsinger, PhD, Secretary of the Cabinet for Health Services, Kentucky Steve Collier, Superintendent, Norwood City Schools Jerry Mallicoat, Vice President of Midwest Marketing,
Anthem Blue Cross/Blue Shield Francine Kaufman, MD, Past President, The American Diabetes Association Nicole Johnson, Miss America 1999

Diabetes Detection and Education: Steps to a HealthierUS Doubletree Hotel Little Rock, Arkansas June 18, 2004 Expert Panel: Secretary Thompson The Honorable Mike Huckabee, Governor of Arkansas Allen Spiegel, MD, Director, NIDDK Donald A Young, MD, Deputy Assistant Secretary for Health Policy/ASPE Jane Kelly, MD, Program Director, National Diabetes Education Program, CDC Fay Boozman, MD, MPH, Director, Arkansas Department of Health Virginia Zamudio, RN, MSN, CDE, President, American Association of Diabetes Educators Victor H Gonzalez, MD, National Board Member, American Diabetes Association Simmie Armstrong, Jr, MD, Pine Bluff Family Medical Center, Arkansas

Treatment of Diabetes:Steps to a HealthierUS Westin Seattle Seattle, Washington July 26, 2004 Expert Panel: Secretary Thompson George R Nethercutt, Jr, JD, US House of Representatives, Chairman of the Congressional Diabetes Caucus Michael OGrady, PhD, Assistant Secretary for Planning and Evaluation, HHS Allen Spiegel, MD, Director, NIDDK Mary Selecky, Secretary, Washington Department of
Health Francine Kaufman, MD, Past President, The American Diabetes Association
Steven Kahn, MB, ChB, Director of Research and Development, VA Puget Sound Health Care System Gerald Nepom, MD, PhD, Director, Benaroya Research Institute at Virginia Mason, Juvenile Diabetes Research Foundation International Joe Finkbonner, RPh, MHA, Director of the Epidemiology Center, Northwest Portland Area Indian Health Board Bradley J Enegren, Vice President and General Manager, Research and Development, Medtronic, Inc Nicole Johnson, Miss America 1999

Angela Bartels, RN, BSN, Diabetes Coordinator, 45th Street Medical Clinic

In total, approximately 1,200 people attended the three town hall meetings The participants represented a broad cross-section from the diabetes community, including people living with diabetes and their friends and family members; people at risk for diabetes who have been successful making behavioral changes; health care providers; physicians; people who have worked with persons with diabetes; experts, public health practitioners, and researchers; legislators; diabetes advocacy groups; and private-sector entities Literature Review In addition to information gathered
through the town hall meetings, additional resources collected from a variety of sources informed the NDAP, including input from the internal HHS advisory group and information shared by HHS agencies A thorough literature review was conducted In addition, information submitted by interested organizations eg, American Diabetes Association, Juvenile Diabetes Research Foundation, American Association of Diabetes Educators was also examined

Appendix D: Current Federal Diabetes Activities/Highlights

CURRENT FEDERAL DIABETES ACTIVITIES/HIGHLIGHTS Multiple agencies within the federal government have initiated a broad range of diabetes prevention, detection, and treatment activities Many state and local agencies have adopted and implemented these activities and programs Selected examples of these federal efforts are listed below Web site addresses are provided where applicable for more detailed information Prevention Various agencies within the US Department of Health and Human Services HHS have developed health communication campaigns to raise awareness of diabetes and educate patients, providers, employers, and school personnel about how to prevent or delay
complications from diabetes Steps to a HealthierUS: Putting Prevention First–This program is part of President Bushs HealthierUS initiative which focuses on preventing chronic diseases and conditions, including obesity, asthma, diabetes, heart disease, stroke, and cancer It includes funds for innovative community-based programs to address asthma, diabetes, and obesity The Steps campaign is a bold shift from a disease care system that relies almost exclusively on physician interventions to a health care system where a community-based public health infrastructure supports individuals in making healthy lifestyle choices More information is available at http://wwwhealthierusgov/steps See Appendix A Initial Preventive Physical Examination and Other New Medicare BenefitsThe Medicare Prescription Drug, Improvement, and Modernization Act MMA of 2003 establishes coverage of a one-time Welcome to Medicare Physical Examination within 6 months of a beneficiarys first coverage under Part B, with the goal of health promotion and disease detection The benefit covers a physical exam including measurement of height, weight and blood pressure, and an electrocardiogram and includes education,
counseling and referral with respect to screening and other preventive services The effective date is January 1, 2005, for new beneficiaries whose coverage period under Medicare Part B begins on or after that date The MMA also adds coverage for cardiovascular and diabetes screening for Medicare beneficiaries, which also begins on January 1, 2005 Small Steps, Big Rewards: Prevent Type 2 Diabetes–A feature of the National Diabetes Education Program, this educational campaign was introduced in November 2002 The campaign and its multicultural components introduced in 2004, are built on the findings of the Diabetes Prevention Program clinical trial conducted by the National Institute of Diabetes and Digestive and Kidney Diseases The program Web site provides tool kits and other products intended to motivate people to reduce their risk for type 2 diabetes by losing a modest amount of weight and being more physically active More information is available at http://wwwsmallstepgov/ or http://wwwndepnihgov/campaigns/SmallSteps /SmallSteps_indexhtm

Weight Control Information Network WIN– This network is a national information service of the National Institute of Diabetes and Digestive
and Kidney Diseases WIN develops and distributes science-based materials on obesity, weight control, physical activity, and nutrition for patients, health care professionals, and others in English and Spanish WIN also created the Sisters Together: Move More, Eat Better media program that encourages Black women 18 and over to maintain a health weight by becoming more physically active and eating healthier foods More information on WIN is available at http://winniddknihgov/indexhtm National Diabetes Information Clearinghouse NDIC–The NDIC is an information dissemination service of the National Institute of Diabetes and Digestive Kidney Diseases The NDIC was established to increase knowledge and understanding about diabetes among patients, health care professionals, and the general public through the effective dissemination of information Patients and health care providers can contact the NDIC with inquiries about diabetes and order educational material More information is available at http://diabetesniddknihgov National Agenda for Public Health Action: A National Public Health Initiative on Diabetes and Womens Health–This initiative offers recommendations to help health
professionals, women and their families, health care systems, worksites, communities, and schools address the burden of diabetes among women The Centers for Disease Control and Prevention is working with public- and private-sector partners to implement the plan More information is available at http://wwwcdcgov/diabetes/pubs/action/indexhtm Take Time to Care About Diabetes–This campaign developed by the Food and Drug Administration Office of Womens Health is intended to raise womens awareness of the seriousness of diabetes and the importance of taking steps to treat the disease to avoid heart and kidney problems, blindness, stroke, or amputation of a lower limb More information is available at http://wwwfdagov/womens/taketimetocare/diabetes/defaulthtm Diabetes Today Developed by the Centers for Disease Control and Preventions CDC Division of Diabetes Translation, Diabetes Today is a course that provides training for public health professionals and community leaders to learn how to mobilize communities to address diabetes This curriculum is based on the philosophy that people can take charge of diabetes at the community level Rather than relying on expensive medical treatment after
the complications of diabetes have developed, community members–such as people with diabetes and their families, health professionals, and other concerned individuals–can work together to prevent and control diabetes For more information, call toll-free 1-877-CDC-DIAB, e-mail diabetes@cdcgov, or visit the Diabetes Today National Training Center and the Pacific Diabetes Today Resource Center More information is available at http://wwwdiabetestodayntcorg/ Making Systems Change for Better Diabetes Care As part of National Diabetes Education Program, this comprehensive Web site provides information and tools to make effective systems changes and provide better quality care for the diagnosis, treatment, and prevention of diabetes More information is available at http://betterdiabetescarenihgov/

Diabetes Prevention Program DPP The Diabetes Prevention Program DPP was a multi-center clinical trial led by the National Institute of Diabetes and Digestive and Kidney Diseases at 27 sites around the country The study demonstrated that sustained lifestyle changes, including modest weight loss and regular physical activity, substantially reduced progression to type 2 diabetes, especially
among older adults who were at very high risk DPP showed that people with pre-diabetes ie, elevated blood glucose levels that are not yet high enough to be classified as diabetes can prevent or delay the onset of type 2 diabetes by losing 5 percent to 7 percent of their body weight and participating in moderate physical activity eg, walking 30 minutes per day 5 days per week Results from DPP were so compelling that the trial was ended a year early The lifestyle intervention worked equally well for men and women and all racial/ethnic groups, and it was most effective among people aged 60 and older81 Nutrition and Physical Activity to Prevent Obesity and Other Chronic Diseases program The Centers for Disease Control and Preventions Division of Nutrition and Physical Activity developed this program in response to the growing epidemic of overweight and obesity in the United States This is a comprehensive program designed to help states maximize the effectiveness of their efforts to prevent obesity by addressing two related risk factors: nutrition and physical activity The goal of the program is to make the United States a nation where all people can achieve and maintain a healthy body
weight Through a cooperative agreement process, this initiative provides funds to states for up to five years for programs aimed at reducing the rate of obesity among their citizens More information is available at http://wwwcdcgov/nccdphp/dnpa/obesity/state_programs/indexhtm Diabetesatworkorg–The National Diabetes Education Programs business and managed care Web site wwwdiabetesatworkorg is an online diabetes and health resource kit that can help businesses and managed care companies assess the impact of diabetes in the work place It presents employers with an interactive assessment tool to demonstrate the economics of better diabetes prevention and control guidance for choosing health care plans, and tools for developing worksite interventions and wellness programs It also provided easy-to-understand information for employers to help employees manage their diabetes and take steps toward reducing the risk for diabetes-related complications such as heart disease More information can be found at http://wwwwdiabetesatworkorg National Diabetes Prevention Center NDPCThis Centers for Disease Control and Prevention funded national center, is working to identify, design, adapt, and share
effective programs for diabetes prevention and control in American Indian and Alaskan Native communities The NDPC supports initiatives in tribal education systems, information technology, diabetes self-management education, sharing diabetes prevention efforts across American Indian and Alaska Native communities, and translating promising practices that are both culturally relevant and science-based More information is available at http://wwwcdcgov/diabetes/projects/ndpchtm
81The Finnish Diabetes Prevention Study conducted by the National Public Health InstituteHelsinki yielded

similar findings supporting the importance of maintaining a healthy weight to prevent type 2 diabetes; and Diabetes Prevention Program Research Group 2002 Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin New Eng J Med 3466:393-403

You Can CampaignDeveloped by the Administration on Aging, the You Can–Steps to a Healthier Aging campaign is a part of the Steps to a HealthierUS initiative The You Can campaign is designed to increase the number of older adults who are active and healthy through a partnership approach to mobilizing communities These community
partnerships will increase public awareness and provide appropriate programs to help older Americans improve their nutrition and physical activity Health Disparities Collaborative Diabetes PreventionThe Health Resources and Services Administration, Bureau of Primary Health Care in collaboration with the Centers for Disease Control and Prevention, National Institutes of Health, and other partners, including the Institute for Healthcare Improvement are working to prevent diabetes among high risk individuals served by Federally Funded Health Centers A Health Disparities Collaborative Diabetes Prevention pilot has been completed with excellent results in patient outcomes The learning from the Diabetes Prevention collaborative will be integrated with the Cardiovascular Collaborative for improved primary health care in Federally Funded Health Centers See Current Activities– Treatment section for additional information on the Health Disparities Collaboratives Detection Agencies within the US Department of Health and Human Services HHS have developed a number of initiatives to promote detection of diabetes in the US Agencies are also conducting research into the most effective strategies
for screening pre-diabetes as well as type 2 diabetes Diabetes Detection InitiativeThis HHS initiative is a community-based effort to identify persons with undiagnosed type 2 diabetes and refer them for follow-up blood testing and treatment, if appropriate It uses community involvement strategies within health systems in communities throughout HHS regions It is being pilot tested in 10 locations through 2004 Early diagnosis and proper treatment of diabetes can prevent or delay serious diabetes-related health problems More information is available at http://wwwndepnihgov/ddi SEARCH for Diabetes in YouthRising rates of diabetes among youths are a growing public health concern The Centers for Disease Control and Prevention and the National Institutes of Health are funding this 5-year, multicenter study to examine the status of diabetes among US children and adolescents More information is available at http://wwwsearchfordiabetesorg/indexcfm The US Preventive Services Task Force USPSTF This Task Force was convened by the US Public Health Service to conduct comprehensive reviews of clinical research to assess the merits of preventive measures, including screening tests, counseling,
immunizations, and chemoprevention The Task Force comprises an independent panel of primary care and prevention experts from the private sector To date, USPSTF has conducted reviews of evidence related to screening for type 2 diabetes and gestational diabetes, obesity in adults, and counseling for physical activity and healthy diet http://wwwahrqgov/clinic/uspstfixhtm

Healthy Aging InitiativeA joint project by the Administration on Aging and the Centers for Disease Control and Prevention in which grants are awarded to states to implement evidence-based disease prevention programs at the community level There are fourteen collaborative projects with State Units on Aging and State Health Departments, including one project focused on diabetes screening, 7 projects focused on physical activity, and three projects focusing on assisting older Americans with disease self-management Treatment The availability of high-quality diabetes care services is crucial to support persons with diabetes in their efforts to manage the disease and prevent complications Agencies within HHS support a variety of programs intended to measure and inform the quality of diabetes care in the United States
National Healthcare Quality and Disparities Reports–These congressionally mandated annual reports on health care quality and health disparities in the United States include a broad set of performance measures that will be used to monitor the nations progress toward improved health care quality Each of these reports contains measures that specifically address diabetes care More information is available at http://wwwqualitymeasuresahrqgov The National Quality Measures ClearinghouseTM NQMCTM, Sponsored by HHSs Agency for Healthcare Research and Quality AHRQ, The National Quality Measures Clearinghouse NQMC is a database and Web site for information on specific evidencebased health care quality measures and measure sets NQMC is sponsored by AHRQ to promote widespread access to quality measures by the health care community and other interested individuals As of spring 2004, the NQMC contained 23 measures that address diabetes care More information is available at http://wwwahrqgov/qual/measurixhtm Diabetes Care Quality Improvement: A Resource Guide for State Action The Agency for Healthcare Research and Quality AHRQ, in partnership with The Council of State Governments, produced the
Diabetes Care Quality Improvement: A Resource Guide for State Action and its companion workbook, to help states assess the quality of diabetes care and develop quality improvement strategies These tools provide an overview of the factors that affect quality of care for diabetes; present the core elements of health care quality improvement; assist state policymakers in using the data from AHRQs 2003 National Healthcare Quality Report for planning state-level quality improvement activities; and, provide a variety of best practices and policy approaches that national organizations, the Federal Government, and states have implemented related to diabetes quality improvement The Diabetes Care Quality Improvement: A Resource Guide for State Action is available online at http://wwwahrqgov/qual/diabetes/ The companion workbook is available at http://wwwahrqgov/qual/diabetes/workbkhtm Printed copies may be ordered by calling 1-800-358-9295 or by sending an e-mail to ahrqpubs@ahrqgov The Community Guide to Preventive ServicesThe Task Force on Community Preventive Services is a 15-member nonfederal task force supported by the Centers for

Disease Control and Prevention CDC CDC scientists
review the effectiveness of health care interventions for the task force, which then makes recommendations to the public health community and health care delivery organizations The recommendations generated by the task force are combined to form the Guide to Community Preventive Services, which includes a section on diabetes To improve the health of people with diabetes, the task force reviewed the evidence of the effectiveness of diabetes disease and case management and self-management education More information is available at http://wwwthecommunityguideorg/diabetes/defaulthtm Health Disparities Collaborative -DiabetesThe Health Resources and Services Administration, Bureau of Primary Health Care in collaboration with the Centers for Disease Control and Prevention, National Institutes of Health, and other partners, including the Institute for Healthcare Improvement are working to improve diabetes care within Federally Funded Health Centers The purpose of the Health Disparities CollaborativeDiabetes is to improve diabetes care and performance measures through improved health care delivery systems, and to increase access and decrease health disparities among medically underserved
populations The learning from the Diabetes collaborative will be integrated with the Cardiovascular Collaborative for improved primary health care in Federally Funded Health Centers In addition, the Diabetes and Diabetes Prevention see Current Activities–Prevention section collaboratives are intended to generate and document improved health outcomes for underserved populations and transform clinical practice through models of patient centered care, improvement, and learning; develop infrastructure, expertise, and multidisciplinary leadership to support and drive improved health status; and build strategic partnerships, which have increased access to expertise, computer software, discounted pharmaceuticals and HbA1c tests, laboratory equipment, direct community resources for patients, health education materials, and community-level marketing and educational resources More information is available at http://wwwhealthdisparitiesnet/ Indian Health Service IHS–The Indian Health Service IHS, National Diabetes Program NDP promotes collaborative strategies for the prevention of diabetes and its complications in the 12 IHS Service Areas through coordination of a network of 19 Model
Diabetes Programs and 13 Area Diabetes Consultants The NDP also manages the Special Diabetes Program for Indians grant program with 332 grantees in 35 states In addition, the IHS has developed standards of care that are routinely updated to help provide consistent, quality care to patients with diabetes More information is available at http://wwwihsgov/MedicalPrograms/Diabetes/ Healthy People 2010 HP2010 Healthy People 2010 is a set of disease prevention and health promotion objectives for the nation to achieve by 2010 It includes 17 objectives specifically aimed at reducing the disease and economic burden of diabetes and improving the quality of life for all persons who have or are at risk for diabetes In addition, Centers for Disease Control and Prevention, Division of Diabetes Translations National Objectives include measures for tracking the quality of diabetes care received For example, these programs assess the number of foot exams, eye exams, and annual HbA1c tests conducted

The Centers for Medicare Medicaid Services CMS The Centers for Medicare Medicaid Services CMS provides benefits to Medicare beneficiaries for diabetes selfmanagement training, medical nutrition
therapy, prescription drugs, and select testing equipment for persons with diabetes In addition, CMS sponsors the National Diabetes Eye Exam Program that matches Medicare beneficiaries aged 65 and older who have diabetes and have not had a medical eye exam in the past 3 years with a volunteer ophthalmologist in their area to receive a free comprehensive eye exam and up to 1 year of follow-up care for any condition diagnosed at the initial exam For more information about Medicare coverage of diabetes services, go to http://wwwcmshhsgov The National Institute of Diabetes and Digestive and Kidney Diseases NIDDK This Institute of the National Institutes of Health supports basic and clinical research at universities and medical centers throughout the US and at research facilities in Bethesda, Maryland and Phoenix, Arizona NIDDK research forms the scientific foundation for improvements in diabetes care and for messages delivered via the National Diabetes Education Program Examples of NIDDK-supported research include the Diabetes Control and Complications Trial and the Diabetes Prevention Program previously discussed There are many other ongoing diabetes research efforts One important
effort is Trial Net, an international network of investigators, clinical centers, and core support facilities whose aim is to recruit patients and support studies that will result in an improved understanding of type 1 diabetes disease development and conduct prevention trials http://wwwdiabetestrialnetorg Another is TEDDY The Environmental Determinants of Diabetes in the Young, which is developing and carrying out research to identify environmental causes of type 1 diabetes in genetically susceptible individuals http://wwwteddystudyorg/ A third is STOPP-T2D Studies to Treat or Prevent Pediatric Type 2 Diabetes, which is conducting pilot studies for a school-based trial directed at preventing the risk factors for type 2 diabetes in middle school children, and a multicenter clinical trial of optimal treatment for adolescents with type 2 diabetes http://wwwtodaystudyorg/ For more information on type 1 and type 2 diabetes research, please visit http://diabetesniddknihgov/ The Diabetes Control and Complications Trial DCCT provided evidence that improving control of blood glucose levels delays the onset and progression of eye, kidney, and nerve diseases caused by diabetes An ongoing
epidemiologic follow-up study of this population, Epidemiology of Diabetes Interventions and Complications EDIC study, has shown that the effectiveness of a limited period of intensive glycemic control on reducing complications persist 20 years after the study began and become even stronger over time More information is available at http://diabetesniddknihgov/dm/pubs/control/indexhtm National Diabetes Education Program NDEP–Helping the Student with Diabetes Succeed: A Guide for School Personnel–This comprehensive guide is designed to empower school personnel, parents, and students to create a safe learning environment and provide equal access to educational opportunities for all children with diabetes More information is available at http://wwwndepnihgov/resources/schoolhtm The Diabetes Research Working Group DRWG was established in 1997 to develop a comprehensive plan of recommended future diabetes research initiatives The group met over the period of one year and generated Conquering Diabetes: A Strategic Plan for the 71

21st Century available at http://wwwniddknihgov/federal/dwg/dwgmainhtm, which addressed three main topics: Extraordinary Opportunities in Diabetes
Research–rapidly expanding, crosscutting areas in which increased investment or development of new mechanisms will significantly speed research in areas such as genetics of diabetes, autoimmunity and the beta cell, and obesity Special Needs for Special Problems–research targeted to specific populations, complications, and methodological approaches Resource and Infrastructure Needs–expanding research infrastructure eg, trained professionals and technology Be Smart About Your Heart: Control the ABCs of Diabetes–This campaign, developed by the National Diabetes Education Program, encourages people with diabetes to control not only their blood glucose sugar, but also their blood pressure and cholesterol More information is available at http://wwwndepnihgov/campaigns/BeSmart/BeSmart_indexhtm National Kidney Disease Education Program NKDEP–The National Kidney Disease Education Program, sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, aims to raise awareness of the seriousness of kidney disease, the importance of testing those at high risk, and the availability of treatment to prevent or slow kidney failure The NKDEP is designed to close the gap
between evidence and practice by educating people at risk and physicians, with the goal of identifying kidney disease in its early, treatable stages More information on the NKDEP can be found at http://wwwnkdepnihgov National High Blood Pressure Education Program NHBPEP–This goal of this program, which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health, is to reduce death and disability related to high blood pressure through programs of professional, patient, and public education The NHBPEP is a cooperative effort among professional and voluntary health agencies, state health departments, and many community groups More information is available at http://wwwnhlbinihgov/about/nhbpep National Cholesterol Education Program NCEP–The goal of the National Cholesterol Education Program is to contribute to reducing illness and death from heart disease in the US by reducing the percent of Americans with high blood cholesterol The NCEP directs educational efforts targeted at both health professionals and the public The program aims to raise awareness and understanding about high blood cholesterol as a risk factor for heart disease and the
benefits of lowering cholesterol levels as a means of preventing heart disease More information about this program, which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health, can be found at http://wwwnhlbinihgov/about/ncep/ National Eye Health Education Program NEHEP–The focus of the National Health Education Program is on public and professional education programs that encourage early detection and timely treatment of diabetic eye disease and glaucoma and the appropriate treatment for low vision This program is coordinated by the National Eye 72

Institute of the National Institutes of Health in partnership with a variety of public and private organizations More information can be found at http://wwwneinihgov/nehep/ Family Center Support ProjectThe Centers for Disease Control and Prevention, Division of Diabetes Translation has undertaken a 5-year behavioral research project that will identify and examine nontraditional psychosocial factors regarding diabetes education and the family These factors include community characteristics, health care reimbursement, family processes, diabetes education, provider-patient characteristics,
acculturation or westernization, as well as psychological factors Previously unrecognized factors include racism, living arrangements, perceptions of safety, and intergenerational coping skills, and their overall impact on psychological well being More information is available at http://wwwcdcgov/diabetes/projects/familyhtm Translating Research Into Action for Diabetes TRIAD Translating Research Into Action for Diabetes is a 5-year, six-center prospective study of managed care and diabetes quality of care, costs, and outcomes in the United States In its third year, this important study is the first and largest multicenter study of diabetes quality of care, quality of life, and factors affecting them TRIAD is currently developing plans to carry out a detailed assessment of socioeconomic status and how it relates to quality of care and health status with diabetes Sponsored by Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases, TRIADs overall goal is to examine the influence of managed care structure on processes and outcomes of diabetes care More information is available at http://wwwtriadstudyorg/ National Diabetes
LaboratorySince 1997, the Centers for Disease Control and Prevention CDC has dedicated 3 million annually to a National Diabetes Laboratory NDL to support emerging scientific efforts to help prevent and treat type 1 diabetes CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation, and the National Center for Environmental Health are collaborators on this project For example, scientists are working to develop and evaluate laboratory technology for improving the measurement of genetic risk factors for type 1 diabetes and its complications, to study autoantibodies of type 1 diabetes, and to develop other projects that will improve the lives of people with type 1 diabetes For more information, call toll-free 1-877-CDC-DIAB, e-mail diabetes@cdcgov, or visit CDCs National Center for Environmental Healths National Diabetes Laboratory at http://wwwcdcgov/nceh/dls/diabeteshtm Administration on Aging–Evidenced-Based Disease Prevention Program: In 2003, the Administration on Aging launched a new grants program and a public/private partnership to increase older peoples access to programs that have proven to be effective in reducing their risk
of disease, disability and injury One of the focus areas, disease selfmanagement, funds community chronic disease efforts, including those for diabetes For more information, please visit http://wwwaoagov/prof/evidence/evidenceasp National Agenda for Public Health Action: A National Public Health Initiative on Diabetes and Womens Health–This initiative offers recommendations to help health professionals, women and their families, health care systems, worksites, communities, and schools address the burden of diabetes among women The Centers for Disease Control and Prevention is working with public- and private-sector partners to implement

the plan More information is available at http://wwwcdcgov/diabetes/pubs/action/indexhtm Take Time to Care About Diabetes–This campaign developed by the Food and Drug Administration, Office of Womens Health is intended to raise womens awareness of the seriousness of diabetes and the importance of taking steps to treat the disease to avoid heart and kidney problems, blindness, stroke, or amputation of a lower limb More information is available at http://wwwfdagov/womens/taketimetocare/diabetes/defaulthtm

Appendix E: Are You at Risk for
Diabetes?

DIABETES: YOU COULD BE AT RISK — TAKE THE TEST, KNOW YOUR SCORE

iabetes means your blood sugar glucose is too high How would you know? Are you often thirsty, hungry, or tired? Do you urinate often? Do you have sores that heal slowly, tingling in your feet, or blurry eyesight? Even without these signs, you could still have diabetes

Diabetes is a serious disease It can cause heart attack or stroke, blindness, kidney failure, or loss of feet or legs But diabetes can be controlled You can reduce or avoid these health problems Take the first step Find out if you are at high risk

Know your risk of having diabetes now Answer these quick questions For each Yes answer, add the number of points listed All No answers are 0 points
Question Are you a woman who has had a baby weighing more than 9 pounds at birth? Do you have a sister or brother with diabetes? Do you have a parent with diabetes? Find your height on the chart Do you weigh as much as or more than the weight listed for your height? Are you under 65 years old and get little or no exercise in a typical day? Are you between 45 and 64 years old? Are you 65 years old or older? Add Your Score
These questions are
from the American Diabetes Associations on-line Diabetes Risk Test http://wwwdiabetesorg/info/risk/risktestjsp

Yes 1 1 1 5 5 5 9

No 0 0 0 0 0 0 0

Height

Weight Pounds 410 129 411 133 50 138 51 143 52 147 53 152 54 157

AT RISK WEIGHT CHART Height Weight Pounds 55 162 56 167 57 172 58 177 59 182 510188 511193 KNOW YOUR SCORE then your risk is

Weight Pounds 60 199 61 204 62 210 63 216 64 221

Height

If you scored 10 or more points

High for having diabetes now Please bring this form to your health care provider soon If you dont have insurance and cant afford a visit to your provider, contact your local health department Probably low for having diabetes now Keep your risk low If youre overweight, lose weight Be active most days, and dont use tobacco Eat low-fat meals with fruits, vegetables, and whole-grain foods If you have high cholesterol or high blood pressure, talk to your health care provider about your risk for diabetes

3 to 9 points

I SCORED 10 OR MORE — HOW CAN I GET TESTED FOR DIABETES?
If you have Individual or group private health insurance Medicaid Medicare No insurance then do this See your health care provider If you dont have a provider, ask your
insurance company about providers who take your insurance Deductibles and co-pays will apply See your health care provider If you dont have a provider, contact a state Medicaid office or contact your local health department See your health care provider Medicare will pay the cost if the provider has a reason for testing If you dont have a provider, contact your local health department Contact your local health department for more information about where you could be tested or call your local health clinic

For more information, contact the Department of Health and Human Services, National Diabetes Education Program at 1-800-438-5383 or online at http://wwwndepnihgov SOURCE: US Department of Health and Human Services, Diabetes Detection Initiative Diabetes You could be at risk–take the test–know your score Available at: http://wwwndepnihgov/ddi/resouces/risktestpdf Adapted from the American Diabetes Associations risk assessment

Source:eed.state.ak.us

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