Diabetes in California: Findings from the. 2001 California Diabetes Prevalence in Latino/Hispanic Ethnic Groups, Adults Ages 18 and Over, California, 2001 …

Diabetes in California:
Findings from the 2001 California Health Interview Survey
Allison L Diamant, MD, MSHS Susan H Babey, PhD E Richard Brown, PhD Neetu Chawla, MPH

April 2003

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Funded by a grant from The California Endowment

Diabetes in California:
Findings from the 2001 California Health Interview Survey

Allison L Diamant, MD, MSHS Susan H Babey, PhD E Richard Brown, PhD Neetu Chawla, MPH

April 2003

UCLA Center for Health Policy Research 10911 Weyburn Avenue, Suite 300 Los Angeles, CA 90024 wwwhealthpolicyuclaedu

21650 Oxnard Street, Suite 1200 Woodland Hills, California 91367 wwwcalendoworg

The views expressed in this report are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, The California Endowment, or other CHIS 2001 funding agencies

Citation: AL Diamant, SH Babey, ER Brown, N Chawla Diabetes in California: Findings from the 2001 California Health Interview Survey Los Angeles: UCLA Center for Health Policy Research, 2003 Copyright 2003 The Regents of the University of California All Rights Reserved The UCLA Center for Health Policy
Research is affiliated with the UCLA School of Public Health and the UCLA School of Public Policy and Social Research VISIT THE CENTERS WEBSITE AT: wwwhealthpolicyuclaedu

The California Endowment funded the research and development of this report

The California Health Interview Survey CHIS is a collaboration of the UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute Funding for the 2001 California Health Interview Survey was provided by the California Department of Health Services, The California Endowment, the National Cancer Institute, the California Children and Families Commission, the Centers for Disease Control and Prevention CDC, and the Indian Health Service For more information on CHIS and access to CHIS 2001 data and results, visit wwwchisuclaedu

TABLE OF CONTENTS

contents
ii 1 7 9 11 21 21 23 25 25 27 29 31 32 34 37 37 42 44 45 48 51 59

Exhibits Executive Summary Acknowledgements 1 Diabetes in California: Introduction 2 Prevalence of Diabetes 3 Access to Medical Care Health Insurance Coverage Usual Source of Care 4 Diabetes Care and Management Diabetes Medications Home Glucose Monitoring
Behavior-related Health Risks Doctor Visits Foot Exams Delays in Care 5 Identifying At Risk Populations Adult Obesity Adult Physical Activity Adolescents At Risk for Diabetes Adolescent Overweight Adolescent Physical Activity 6 Conclusions and Policy Recommendations Appendix

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EXHIBITS

exhibits
11 12 13 14 14 15 15 16 16 17 18-19 22 22 23 24 25 26 27 28 29 30 31

Exhibit 1 Diabetes Prevalence by Age in California and Nationally, Adults Ages 18 and Over Exhibit 2 Diabetes Prevalence by Race/Ethnicity, Adults Ages 18 and Over, California, 2001 Exhibit 3 Diabetes Prevalence by Age and Race/Ethnicity, Adults Ages 18 and Over, California, 2001 Exhibit 4a Diabetes Prevalence in Latino/Hispanic Ethnic Groups, Adults Ages 18 and Over, California, 2001 Exhibit 4b Diabetes Prevalence in Latino/Hispanic Ethnic Groups, Adults Ages 50 and Over, California, 2001 Exhibit 5a Diabetes Prevalence in Asian Ethnic Groups, Adults Ages 18 and Over, California, 2001 Exhibit 5b Diabetes Prevalence in Asian Ethnic Groups, Adults Ages 50 and Over, California, 2001 Exhibit 6 Diabetes Prevalence by Education, Adults Ages 18 and Over, California, 2001 Exhibit 7
Diabetes Prevalence by Federal Poverty Level, Adults Ages 18 and Over, California, 2001 Exhibit 8 Diabetes Prevalence by Area of Residence, Adults Ages 18 and Over, California, 2001 Exhibit 9 Diabetes Prevalence and Age-adjusted Prevalence in California Counties or County Groups, Adults Ages 18 and Over, 2001 Exhibit 10 Health Insurance Coverage of Nonelderly Adults by Diabetes Diagnosis, Ages 18-64, California, 2001 Exhibit 11 Health Insurance Coverage of Elderly Adults by Diabetes Diagnosis, Ages 65 and Over, California, 2001 Exhibit 12 Percent with Each Type of Usual Source of Care by Type of Insurance, Nonelderly Adults with Diabetes, Ages 18-64, California, 2001 Exhibit 13 Percent with Each Type of Usual Source of Care by Type of Insurance, Elderly Adults with Diabetes, Ages 65 and Over, California, 2001 Exhibit 14 Percent Not Taking Any Diabetes Medications by Race/Ethnicity, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 15 Percent Not Taking Any Diabetes Medications by Insurance Status and Federal Poverty Level FPL, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 16 Percent Who Monitor Glucose at Least Once per Day by Race/Ethnicity,
Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 17 Percent Who Monitor Glucose at Least Once per Day by Type of Insurance, Nonelderly Adults with Diabetes, Ages 18-64, California, 2001 Exhibit 18 Percent Who Monitor Glucose at Least Once Per Day among Insulin Users by Race/Ethnicity, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 19 Prevalence of Body Mass Index BMI, Physical Activity, and Smoking, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 20 Prevalence of Obesity, No Physical Activity, and Smoking by Age and Race/Ethnicity, Adults with Diabetes, Ages 18 and Over, California, 2001

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Exhibit 21 Physician Visits during the Preceding Year by Usual Source of Care and Insurance Status, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 22 Percent with No Foot Exam in the Past Year by Race/Ethnicity, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 23 Percent with No Foot Exam in the Past Year by Insurance Status and Usual Source of Care, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 24 Types of
Delayed Care for Diabetes, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 25 Delays in Care by Current Health Insurance Status, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 26 Percent Who Reported Delaying or Not Receiving Needed Medical Care for Diabetes by Type of Usual Source of Care, Adults with Diabetes, Ages 18 and Over, California, 2001 Exhibit 27 Prevalence of Overweight and Obesity by Age, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 28 Prevalence of Overweight and Obesity by Race/Ethnicity, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 29 Prevalence of Obesity by Federal Poverty Level, Education, and Area of Residence, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 30 Obesity Prevalence and Age-adjusted Prevalence in California Counties or County Groups, Adults Ages 18 and Over, 2001 Exhibit 31 Level of Physical Activity, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 32 Prevalence of Obesity by Physical Activity, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 33 Physical
Activity by Race/Ethnicity, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 34 Physical Activity by Age, Gender, Education, and Federal Poverty Level, Adults Not Diagnosed with Diabetes, Ages 18 and Over, California, 2001 Exhibit 35 Prevalence of Overweight and At Risk for Overweight by Age and Gender, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001 Exhibit 36a Prevalence of Overweight and At Risk for Overweight by Race/Ethnicity, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001 Exhibit 36b Prevalence of Overweight and At Risk for Overweight by Gender and Race/Ethnicity, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001 Exhibit 37 Prevalence of Overweight and At Risk for Overweight by Federal Poverty Level and Area of Residence, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001 Exhibit 38 Physical Activity by Age, Gender, and Race/Ethnicity, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001 Exhibit 39 Physical Activity by Education, Federal Poverty Level, and Area of Residence, Adolescents Not Diagnosed with Diabetes, Ages 12-17, California, 2001

32
33 33 34 34 35 38 38 39 40-41 42 43 43 44 45 46 46 47 48 49

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iii

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXECUTIVE SUMMARY

summary
PREVALENCE OF DIABETES
More than 14 million California adults have been diagnosed with diabetes–59 of Californians ages 18 and over The prevalence of diabetes among adults in California varied with several important population characteristics

iabetes is a serious and growing health problem currently affecting an estimated 17 million adults and children in the United States with approximately 800,000 new cases diagnosed each year1 Diabetes poses a significant public health challenge because approximately one-third of individuals with the condition, or 59 million people, are believed to have diabetes but remain undiagnosed These individuals are at risk for not receiving appropriate and necessary medical care Among those who are diagnosed with diabetes, clinical research has demonstrated the importance of managing blood glucose levels in reducing diabetic complications such as end-stage renal disease, blindness, and amputation Diabetes and obesity, in conjunction
with high blood pressure, high cholesterol, and cigarette smoking increase considerably the risks of cardiovascular disease, stroke, and death This report examines diabetes in California based on data from the 2001 California Health Interview Survey CHIS CHIS is a collaborative project of the UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute, and is the largest statewide health survey conducted in the United States CHIS 2001 was a telephone survey of over 55,000 households across California covering a broad range of public health topics The sample was designed to provide statewide estimates for Californias overall population, its major racial and ethnic groups, and a number of smaller ethnic groups All statements in this report that compare rates for one group with another group reflect statistically significant differences p 005 unless otherwise noted A more detailed description of the data source and variables can be found in the Appendix

Among California adults, racial and ethnic variation in diabetes prevalence was most marked among adults ages 50-64 and 65 and over Among adults ages 50-64, diabetes
prevalence was significantly higher in African Americans 205, Latinos 179, and American Indians and Alaska Natives AIAN 196 than in Asians and Native Hawaiians and other Pacific Islanders NHOPI 109 and whites 832 Latinos of Mexican heritage had higher rates of diabetes than other Latino groups Asian adults whose ancestry was Filipino, Japanese, or Southeast Asian Vietnamese, Cambodian, or other Southeast Asian were also disproportionately affected by diabetes compared with other Asian groups The prevalence of diabetes was twice as high among adults who never attended high school 99 as it was among college graduates 43 Adults living at or below 100 of the Federal Poverty Level FPL suffered from diabetes at a higher rate than those with incomes above 300 FPL 78 and 45, respectively

2 1 Centers for Disease Control and Prevention National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2000 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2002

The number of Native Hawaiians and other Pacific Islanders NHOPI in the CHIS 2001 sample was relatively small Estimates for this group
were reported separately whenever possible When the sample of NHOPI was too small, it was included in the Asian category As a result, we combined NHOPIs with Asians for all analyses conducted in this report except for those included in the Identifying At Risk Populations section

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There was also considerable variation in the prevalence of diabetes by area of residence

The age-adjusted prevalence of diabetes varied among Californias counties, ranging from less than 4 in Marin County, El Dorado County, and Sonoma County to 87 in Imperial County, 88 in Kings County, and 102 in Tulare County3 The results of statistical modeling indicated that this variation among counties in California could be accounted for by differences among the counties in the prevalence of other factors such as obesity, access to health care, and distribution of population characteristics such as age, gender, race and ethnicity, income, and education

Having a usual source of care–a regular connection to a health care provider–is very important for assuring continuity of care and effective medical management of diabetes Adults with diabetes were more likely to have a
usual source of care than adults without diabetes However, over 82,000 58 adults with diabetes reported they had no usual source of care

Lack of health insurance was an important reason why many adults with diabetes had no usual source of care One-fourth 258 of nonelderly adults with diabetes who were uninsured for at least some period during the year had no usual source of care compared with only 38 of those who were insured for the whole year The health care safety net provided by public and community clinics was very important for adults with diabetes who were uninsured and those who were covered by Medi-Cal Among nonelderly adults with diabetes, 198 of those with Medi-Cal and 272 of the uninsured reported that they typically went to a public or community clinic for their health care compared with only 27 of those who had employment-based insurance

ACCESS TO MEDICAL CARE
Access to the health care system is critically important for persons with diabetes because these individuals require effective and ongoing medical care to manage and treat their chronic condition Health insurance coverage is one important indicator of access to health care In California, adults with diabetes
were more likely than those without diabetes to have insurance coverage However, 182,000 adults with diabetes 129 were uninsured for all or part of the year

Nonelderly adults with diabetes were more likely to be covered by Medi-Cal than nonelderly adults not diagnosed with diabetes 220 and 97, respectively Elderly adults with diabetes were more likely to be covered by Medicare plus Medi-Cal than those without diabetes 276 and 171, respectively and were less likely to have Medicare with a private supplement 603 and 716, respectively Nearly 114,000 90 adults with diabetes reported that they had no insurance coverage for prescription drugs

DIABETES CARE AND MANAGEMENT
Appropriate care for diabetes requires careful monitoring on the part of medical professionals as well as on the part of the person with diabetes Appropriate management of this condition includes the following: taking diabetes medications; home glucose monitoring; encouraging more healthful behaviors, including weight loss, physical activity, and smoking cessation; regular visits to a physician; and annual foot exams Appropriate care for diabetes also includes nutrition counseling, annual dilated eye exams,
diagnosis and treatment of high lipids, and assessment for diabetic nephropathy and neuropathy, but CHIS 2001 did not ask respondents about these

The age-adjusted prevalence estimates what the prevalence would be for each county or county group if each countys population had the same age distribution It is important to account for variation due to age because the prevalence of diabetes is strongly correlated with age In addition, the age distribution of California residents varies significantly by county

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

DIABETES MEDICATIONS In California, nearly 340,000 adults with diabetes 240 were not taking any medications for the condition Although not everyone with diabetes needs medication, California had a high proportion of people with diabetes who did not take medications 240 compared with 134 nationally

Nearly one-third of Latino adults with diabetes 324 are not currently taking any medications for the condition compared with approximately 20 of AIANs, Asians and NHOPIs, whites, or African Americans Adults with diabetes who had no usual source of health care were more than twice as likely as
those with a usual source of care to report not taking any diabetes medications 539 and 222, respectively Uninsured adults with diabetes were nearly twice as likely as those with insurance not to be taking any diabetes medications 406 and 223, respectively Among the uninsured, those with incomes below 200 FPL were particularly vulnerable

BEHAVIOR-RELATED HEALTH RISKS Obesity or lack of physical activity make control of diabetes more difficult, and these factors as well as smoking increase the risk of diabetic complications such as end-stage renal disease, blindness, amputation, heart attack and stroke In California, over 570,000 408 adults with diabetes were obese, over 390,000 278 reported they were sedentary, and over 200,000 147 were current smokers

AIANs had the highest rates of obesity 647 and smoking 363 among adults with diabetes African-American adults with diabetes had the highest rates of physical inactivity 293 as well as high rates of obesity 506

DOCTOR VISITS Regular consultation with a health care professional is crucial for people with diabetes In California, 94 of adults with diabetes reported that they had seen a doctor at least once in the past year However,
over 65,000 adults with diabetes 47 had not seen a doctor at all in the past year

HOME GLUCOSE MONITORING In California, 480 of adults with diabetes reported that they measured their blood glucose levels at least once a day–well below the Healthy People 2010 goal of 60

Among adults with diabetes, those with no usual source of care were more likely than those with a usual source of care not to have seen a doctor in the past year, regardless of insurance status

Adults with diabetes who have a usual source of care 498 were more than twice as likely as those with no usual source of care 195 to measure their blood glucose levels at least once a day More than 54 of whites, African Americans, and AIANs with diabetes checked their blood glucose at least once a day compared with less than 40 of Latinos and Asians and NHOPIs Despite the vital importance of blood glucose monitoring among insulin users, only 79 of adults with diabetes using insulin checked their glucose levels at least once a day

FOOT EXAMS People with diabetes are at particular risk for developing ulcers and other infections on their feet that, if left untreated, can result in amputation Therefore, it is very
important that people with diabetes undergo regular comprehensive foot exams by a clinician In California, 447,000 adults with diabetes 318 had not had their feet examined even once in the past year

In California, nearly half of Asian and NHOPI adults with diabetes 481 had not had a foot exam in the past year compared with less than 30 of whites, AIANs, and African Americans

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Having health insurance coverage and a usual source of care were extremely important factors in timely receipt of a foot exam Adults with diabetes who had no usual source of care were much more likely than those with a usual source of care not to have had a foot exam in the past year 576 and 302, respectively Uninsured adults were also more likely than those with insurance not to have had a foot exam in the past year 496 and 300, respectively

IDENTIFYING AT RISK POPULATIONS
Among adults and adolescents, obesity is a major risk factor for Type 2 diabetes In addition, adolescents who are overweight or at risk for overweight are more likely to be obese or overweight as adults In California, 38 million 170 adults not diagnosed with diabetes were obese An additional
316,000 108 adolescents not diagnosed with diabetes were overweight

DELAYS IN CARE Delaying or not getting needed medical care may result in an increase in complications and worse outcomes for people with diabetes In California, 368,000 adults with diabetes 262 reported that they delayed getting or did not receive needed medical care such as a prescription, a test, or a treatment, including 163,000 116 who reported the care was specifically for their diabetes

Among adults not diagnosed with diabetes, nearly onethird of NHOPIs 310 and over one- fourth of African Americans 264 and AIANs 255 were obese Among adolescents not diagnosed with diabetes, 17 of African Americans and 12 of Latinos were overweight Adults not diagnosed with diabetes who live in rural areas 230 were more likely than those who live in suburban areas 154 to be obese This same pattern was found among adolescents; 136 of those living in rural areas were overweight compared with 89 in suburban areas Among adults not diagnosed with diabetes, those with an 8th grade education or less 232 were twice as likely to be obese as those with a college degree 116

Among adults with diabetes who delayed or did not receive
needed care for their diabetes, 40 reported that it was because the care cost too much, that it was not covered by their insurance, or that they did not have insurance Uninsured adults with diabetes were more likely than those with insurance to have delayed or not received needed medical care for diabetes 187 and 109, respectively

Despite the importance of regular physical activity, nearly 35 million California adults not diagnosed with diabetes 154 did not participate in any physical activity, and only 274 participated in regular physical activity Among adolescents not diagnosed with diabetes, 73 reported participating in regular physical activity However, 152,000 52 did not participate in any physical activity

Among adults not diagnosed with diabetes, nearly onefifth of African Americans, Asians, and Latinos reported being sedentary Adults who were sedentary were more likely to be obese than those who participated in regular physical activity 207 and 131, respectively

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Primary prevention for diabetes cannot wait until adulthood, but should begin during childhood and continue through
adolescence and adulthood

Adolescents who were not enrolled in school were less likely than those who were enrolled to participate in regular physical activity 728 and 652, respectively4 Adolescents living in urban areas 702 were less likely to participate in regular physical activity than adolescents who lived in suburban areas 775

CONCLUSIONS AND POLICY IMPLICATIONS
The focus for all Californians, especially those at increased risk for diabetes, should be on minimizing the risk factors for and effects of diabetes This can be done in two ways: prevention of diabetes and the effective management of diabetes among those who develop the condition PREVENTION OF DIABETES Primary prevention for diabetes cannot wait until adulthood, but should begin during childhood and continue through adolescence and adulthood Type 2 diabetes is being diagnosed in increasing numbers among children and adolescents This surge in the prevalence and incidence of diabetes is overwhelmingly due to the epidemic of obesity that is occurring in this country Regular physical activity and nutritious eating can prevent the development of obesity and reduce the risk for Type 2 diabetes in children and
adolescents as well as adults Public policy and community action can help reduce these risks by facilitating and encouraging healthy choices PREVENTING OBESITY: HEALTHFUL EATING Lifestyle choices such as consuming a nutritious and balanced diet can prevent or delay the onset of Type 2 diabetes

In California, 18 million adults not diagnosed with diabetes 82 were at significant risk for developing diabetes because they were sedentary in conjunction with being overweight or obese An additional 176,000 60 adolescents not diagnosed with diabetes were at risk for being obese as adults because they did not participate in regular physical activity and were overweight or at risk for being overweight

Among adults ages 18-64 not diagnosed with diabetes– after controlling for age, gender, education, income, and measures of access to care–Latinos, NHOPIs, AIANs, African Americans, those living in rural areas, and those who did not participate in regular physical activity were more likely to be obese This greatly increases their risk for Type 2 diabetes Among adolescents not diagnosed with diabetes–after controlling for age, education, income and physical activity–boys, African
Americans, and those living in both urban and rural areas were more likely to be overweight and therefore were more likely to be at risk for developing Type 2 diabetes

Local governments should increase the availability of fresh fruits and vegetables in all neighborhoods The state and local governments as well as private firms should increase the availability of affordable healthy food choices Schools should provide healthier food choices for children and adolescents Both state and local governments should more fully engage community-based organizations, schools, and health care professionals in the development of culturally appropriate interventions that promote healthier diets, and should expand funding for these efforts

Although the contrast comparing regular physical activity between adolescents attending school and those not attending was not significant, adolescents not attending school were less likely to participate in regular physical activity than those attending school after controlling for other factors such as age, gender, and family income

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PHYSICAL ACTIVITY Regular physical activity includes a wide variety of
pursuits that do not require athletic skill Rather, individuals should be encouraged to find aerobic activities they enjoy and that are convenient for them to pursue, such as vigorous walking

EFFECTIVE MANAGEMENT OF DIABETES Effective management of diabetes focuses on reducing the risk for and impact of diabetic complications:

Promote physical activity programs in public schools Develop community policies and practices as well as legislation that promote safe environments for physical activity Develop culturally appropriate and targeted interventions to promote regular physical activity among minority groups

Assure access to medical care for people with diabetes so that they can receive appropriate management of their condition Assure adequate prescription drug coverage for people with diabetes Develop and distribute culturally appropriate multilingual educational materials to people with diabetes on how to manage their condition Provide adequate health care counseling on managing diabetes as well as on nutrition and physical activity for people with diabetes Continue surveillance at the state and local levels

ACCESS TO PREVENTIVE HEALTH CARE Careful monitoring and
screening of groups at elevated risk for developing diabetes can also help in prevention Particular racial and ethnic groups, those with family histories of diabetes, and people who are obese should be educated about their elevated risk for developing diabetes and about lifestyle changes they can make to prevent or delay the onset of diabetes

Assure access to trained health care providers who can counsel and screen at-risk patients Expand public and private health insurance packages to provide adequate coverage for preventive care

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

acknowledgements
ACKNOWLEDGEMENTS

he authors wish to thank a number of people for their assistance with analyses or the preparation of this report Wei Yen, PhD, coordinated the statistical programming with the assistance of Elizabeth Loughren LuMay Chiang, Lida Becerra, MS, Dora Ding, Cathy Nan Zhou, Stanley Yuen, Rong Huang, MS, and Jenny Chia, PhD, conducted the data analyses Hongjian Yu, PhD, provided statistical consultation Paula Y Bagasao, PhD, and Clodagh Harvey, PhD, provided valuable support and oversight for the editorial and production process and
communication services Finally, thanks to Ikkanda Design Group for designing this report The authors would like to thank the following individuals for their insightful comments and helpful suggestions on a draft of this report: Ann Albright, PhD, RD, Chief, Diabetes Control Program, California Department of Health Services; Mayer B Davidson, MD, Director, Clinical Trials Unit, Charles R Drew University, Professor of Medicine, UCLA School of Medicine; Francine Kaufman, MD, President, American Diabetes Association, Professor of Pediatrics, Keck School of Medicine at the University of Southern California, and Head, Center for Diabetes, Endocrinology and Metabolism, Childrens Hospital Los Angeles; John Kurata, PhD, MPH, Chief, Chronic Disease Epidemiology and Control Section, California Department of Health Services; and Roberto Vargas, MD, MPH, Clinical Instructor, Division of General Internal Medicine and Health Services Research, UCLA School of Medicine Despite the important contributions of all these colleagues, any errors or omissions are the responsibility of the authors The authors are grateful for the generous support provided by The California Endowment The California
Endowment, a private, statewide health foundation, was established in 1996 to expand access to affordable, quality health care for underserved individuals and communities The Endowment provides grants to organizations and institutions that directly benefit the health and well-being of the people of California

ABOUT THE AUTHORS
Allison L Diamant, MD, MSHS, is an assistant professor in the Division of General Internal Medicine and Health Services Research at the UCLA School of Medicine Susan H Babey, PhD, is a research scientist at the UCLA Center for Health Policy Research E Richard Brown, PhD, is the director of the UCLA Center for Health Policy Research and a professor in the UCLA School of Public Health Neetu Chawla, MPH, is a graduate student researcher at the UCLA Center for Health Policy Research

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DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

1 DIABETES IN CALIFORNIA: INTRODUCTION

iabetes is a serious and growing health problem currently affecting an estimated 17 million adults and children in the United States with approximately 800,000 new cases diagnosed each year5 The prevalence of
diabetes among persons age 18 years or over increased by 50 between 1990 and 20006 According to the Centers for Disease Control and Prevention CDC, by 2050, the number of people diagnosed with diabetes is expected to rise from almost 11 million to 30 million As one of the most common chronic conditions, diabetes poses a significant public health challenge Diabetes is an even greater public health challenge because approximately one-third of individuals with diabetes, or 59 million people, remain undiagnosed5 According to the American Diabetes Association, an additional 16 million people may have pre-diabetes, putting them at increased risk for developing diabetes7 These individuals as well as those who have diabetes but remain undiagnosed are at increased risk for not receiving appropriate and necessary medical care The increase in the prevalence of diabetes in recent years is problematic because of the complications and costs associated with diabetes Diabetes remains the seventh leading cause of death in the US, and it is the major cause of nontraumatic amputations, blindness, and end-stage kidney disease In addition, diabetes is a significant risk factor for coronary heart
disease and stroke Furthermore, diabetes is expensive The total attributable costs of diabetes are estimated to be 100 billion annually8, 9

Diabetes is an abnormal elevation of the bodys blood glucose, a condition known as hyperglycemia Diabetes is classified into two main types Type 1 diabetes develops primarily in childhood and is characterized by the bodys inability to produce enough insulin to metabolize sugars Type 2 diabetes is much more prevalent and affects predominantly older adults In Type 2 diabetes, the body is not able to use the insulin that is available due to insulin resistance and relative pancreatic beta-cell dysfunction The exact cause of diabetes is unclear, but obesity as well as an inherited predisposition is associated with its onset This report examines diabetes in California based on data from the 2001 California Health Interview Survey CHIS10 First, we report on the prevalence of diabetes in California with particular attention paid to disparities between different population groups and groups of people living in different areas of the state Second, we discuss key factors affecting access to care for people with diabetes Next, we consider the care and
management of diabetes for people who live with the condition In this section, we cover factors that pose significant health risks for adults with diabetes We also examine the medical care received by people with diabetes Finally, we examine the population groups at greatest risk for developing diabetes in two age groups: adults ages 18 and over and adolescents ages 12-17 All comparative statements in this report reflect statistically significant differences p 005 unless otherwise noted

6 7

Centers for Disease Control and Prevention National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2000 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2002 Mokkdad AH, Bowman BA, Ford ES, Vinicor F Marks JS, Koplan JP The , contintuing epidemics of obesity and diabetes in the United States JAMA 2001; 286 10: 1195-1200 Pre-diabetes is a condition in which a persons blood glucose levels are higher than normal but not high enough for a diagnosis of Type 2 diabetes

8 9 10

American Diabetes Association Economic consequences of diabetes mellitus in the US in 1997 Diabetes Care 1998; 21:
296-306 Hodgson T, Cohen A Medical care expenditures for diabetes, its chronic complications and its comorbidities Preventive Medicine 1999; 29: 173-186 The 2001 California Health Interview Survey is discussed in more detail in the Appendix

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DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

2 PREVALENCE OF DIABETES

2
people of all ages Over half 535 of California adults with diabetes were younger than 60, and we estimate that over 195,000 adolescents and adults between the ages of 12 and 40 have been diagnosed with diabetes Nationally, the prevalence of diabetes was similar to the overall rate found in California However, there were differences between the prevalence of diabetes in California and the US among a number of population groups Although the overall prevalence of diabetes in California and the US was the same, rates in California appear to be slightly higher than national rates among age groups under the age of 65 Exhibit 1

ore than 14 million 59 adults in California have been diagnosed with diabetes In addition, over 12,000 04 adolescents ages 12-17 have been diagnosed with diabetes11
Although the majority of adolescents with diabetes have Type 1, the number and proportion with Type 2 have increased The sample size of adolescents in California diagnosed with diabetes was too small to permit further analyses The prevalence of diabetes among adults did not differ significantly between males and females, although there was significant variation by age The prevalence of diabetes increased with age, rising significantly across age groups up to ages 60-64, where the rate leveled off Exhibit 1 Although diabetes was more prevalent among older adults, it affected

EXHIBIT 1 DIABETES PREVALENCE BY AGE IN CALIFORNIA AND NATIONALLY, ADULTS AGES 18 AND OVER

16 14 12 10 8 6 4 2 0 18 and over 23 20 10 08 18-29 30-39 40-49 Age Category
Source: 2001 California Health Interview Survey and 2000 National Health Interview Survey

California US 96

145 129

143 146

59 59

50-59

60-64

65 and over

According to estimates from the 2000 National Health Interview Survey NHIS, the prevalence of any type of diabetes among children under age 18 throughout the United States was 03 According to data from CHIS 2001, the prevalence of diabetes among adolescents ages 12-17 in
California was 04

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The prevalence of diabetes in California varied across several important sociodemographic characteristics, including race and ethnicity, income, and education Diabetes disproportionately affected African Americans, American Indians and Alaska Natives AIANs, Latinos, adults with low incomes, and those with less education Overall, African Americans and AIANs suffered from diabetes at a higher rate than whites, Latinos, or Asians and Native Hawaiians and other Pacific Islanders NHOPI Exhibit 212

EXHIBIT 2 DIABETES PREVALENCE BY RACE/ETHNICITY, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001 RACE/ETHNICITY WHITE LATINO ASIAN AND NHOPI AFRICAN AMERICAN AMERICAN INDIAN AND ALASKA NATIVE
Note:

56 60 47 103 93

Native Hawaiian and other Pacific Islander is abbreviated NHOPI For an explanation of Asian and NHOPI and the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

However, because of the differences in the age distributions across racial and ethnic groups in California, it was important to look at the prevalence of diabetes as a function of both race and ethnicity and age
Within the 5064 and 65 and over age groups, African Americans, Latinos, and AIANs had the highest prevalence, with the lowest rates occurring among whites and Asian and NHOPIs Exhibit 3 Among younger adults ages 18-49 diabetes prevalence was relatively low across racial and ethnic groups Among adults ages 50-64, the prevalence of diabetes among African Americans 205, AIANs 196, and Latinos 179 was approximately twice as high as the prevalence among whites 83 or Asian and NHOPIs 109 Among adults 65 and over, rates among African Americans 256 and Latinos 244 were more than twice as high as the rate for whites 122 In addition, the prevalence of diabetes varied within racial and ethnic groups One of the unique features of CHIS 2001 is the ability to examine variation within Latino and Asian ethnic groups Among respondents who identified themselves as Latino or Hispanic, those who reported their Latino/Hispanic ancestry as Mexican or two or more Latino/Hispanic groups had the highest rates of diabetes, while individuals from Central America had the lowest rate Exhibit 4a The estimates for prevalence of diabetes among Puerto Ricans in CHIS 2001 exceed our standards for statistical
reliability However, the high rate among Puerto Ricans is consistent with other research so the estimates are presented here Among Latino adults ages 50 and over, one in four Puerto Ricans 250 and one in five Mexicans 212 had been diagnosed with diabetes Exhibit 4b

The number of Native Hawaiians and other Pacific Islanders NHOPI in the CHIS 2001 sample was relatively small Estimates for this group were reported separately whenever possible When the sample of NHOPI was too small, it was included in the Asian category As a result, we combined NHOPIs with Asians for all analyses conducted in this report except for those included in the Identifying At Risk Populations section

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 3 DIABETES PREVALENCE BY AGE AND RACE/ETHNICITY, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001

30 25 205 20 15 109 10 5 22 0 83 36 18 38 109 122 179 153 196 173 143 244 256

All Groups

African American

Asian and NHOPI

AIAN

All Groups

Latino

White

Asian and NHOPI

Ages 18-49
Note:

Ages 50-64

Ages 65 and over

Rates of diabetes among American Indians and
Alaska Natives were not reported for ages 18-49 because the estimate was not statistically reliable Native Hawaiian and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of Asian and NHOPI and the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

All Groups

White

Latino

AIAN

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EXHIBIT 4A DIABETES PREVALENCE IN LATINO/HISPANIC ETHNIC GROUPS, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001

8 7 6 5 4 3 2 1 0

65 44

Mexican

Central American

Puerto Rican

2 or more Latino Groups

Source: 2001 California Health Interview Survey

EXHIBIT 4B DIABETES PREVALENCE IN LATINO/HISPANIC ETHNIC GROUPS, ADULTS AGES 50 AND OVER, CALIFORNIA, 2001

30 250 25 20 15 10 5 0 Mexican Central American Puerto Rican 2 or more Latino Groups 148 212 206

Source: 2001 California Health Interview Survey

Among Asian ethnic groups, Japanese 65 and Filipinos 59 had the highest rates of diabetes, while Chinese 31 had the lowest Exhibit 5a Although Asian adults of Japanese ancestry had the highest prevalence of diabetes overall,
among Asian adults ages 50 and over,

prevalence was highest among Filipinos 171 and Southeast Asian adults including Vietnamese and Cambodian, 163 significantly higher than among Chinese 82 Exhibit 5b

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 5A DIABETES PREVALENCE IN ASIAN ETHNIC GROUPS, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001

7 6 5 4 3 2 1 0

59 52 31

65 48

Chinese

Filipino

Vietnamese, Cambodian, other Southeast Asian

Japanese

Korean

Source: 2001 California Health Interview Survey

EXHIBIT 5B DIABETES PREVALENCE IN ASIAN ETHNIC GROUPS, ADULTS AGES 50 AND OVER, CALIFORNIA, 2001

18 16 14 12 10 8 6 4 2 0

171

163 131 117

Chinese

Filipino

Vietnamese, Cambodian, other Southeast Asian

Japanese

Korean

Source: 2001 California Health Interview Survey

The independent effects of education and income, as well as their interaction, on health status have been well documented13, 14 They are important factors especially with respect to risk for chronic conditions such as diabetes Their impact includes but is not limited to an elevated risk for

developing diabetes, barriers to care that may result in an increased risk
for complications associated with diabetes, and health-risk behaviors that increase risk for diabetes and diabetic complications

Lynch J, Kaplan G Socioeconomic Position In Social Epidemiology, Berkman LF and Kawachi I Eds, 13-35 New York: Oxford University Press, 2000

Adler NE, Marmot M, McEwen BS, Stewart J Eds Socioeconomic status and health in industrial nations; social, psychological, and biological pathways Annals of the New York Academy of Sciences 1999, vol 896

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 6 DIABETES PREVALENCE BY EDUCATION, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001 EDUCATIONAL ATTAINMENT EIGHTH GRADE OR LESS SOME HIGH SCHOOL HIGH SCHOOL DIPLOMA SOME COLLEGE COLLEGE GRADUATE OR HIGHER
Source: 2001 California Health Interview Survey

99 7 5 59 62 43

EXHIBIT 7 DIABETES PREVALENCE BY FEDERAL POVERTY LEVEL, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001 FEDERAL POVERTY LEVEL FPL 0-99 FPL 100-199 FPL 200-299 FPL 300 FPL
Source: 2001 California Health Interview Survey

7 8 7 6 68 45

Diabetes disproportionately affected less well-educated adults and adults with low incomes Adults who had never attended high school had the highest prevalence of
diabetes, significantly higher than adults who completed high school or adults who went to college Exhibit 6 Furthermore, adults with incomes below 100 of the Federal Poverty Level FPL had the highest prevalence of diabetes, significantly higher than adults with incomes between 200 and 300 FPL or adults with incomes at or above 300 FPL Exhibit 7 Diabetes prevalence also varied by place of residence Adults who live in rural areas had higher rates of diabetes than adults who live in suburban areas Exhibit 8 In addition, the prevalence of diabetes varied among California counties Exhibit 9 shows the prevalence and age-adjusted prevalence of diabetes for each county or county group The age-adjusted prevalence estimates what the prevalence would be for each county or county group if each countys population had the same age distribution It was important to account for variation due to age because diabetes

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 8 DIABETES PREVALENCE BY AREA OF RESIDENCE, ADULTS AGES 18 AND OVER, CALIFORNIA, 2001 AREA OF RESIDENCE URBAN 2ND CITY SUBURBAN SMALL TOWN RURAL
Note:

60 62 54 62 67

Classification of area
of residence is based on the population density of the zip code in which the respondent lives For example, second city refers to a zip code with a population density between 1,000 and 4,150 persons per square mile Rural refers to a zip code with a population density equal to or less than 210 persons per square mile Source: 2001 California Health Interview Survey

prevalence is strongly correlated with age In addition, the age distribution of California residents varies significantly by county Without age adjustment, rates were highest in Tulare 99 and Imperial 90 counties and lowest in Marin 37, El Dorado 37, and Santa Cruz 39 counties After adjusting for age, prevalence was highest in Tulare 102, Kings 88, and Imperial 87 counties, and lowest in Sonoma 39 , El Dorado 32, and Marin 30 counties However, adjusting only for differences in the age of populations residing in different counties did not fully explain the variation in diabetes prevalence between counties To examine possible reasons for the variation in prevalence of diabetes at the county level a statistical model was developed The results indicated that the variation in diabetes prevalence between counties could be
accounted for by differences in the prevalence of other factors such as obesity, access to health care, and the prevalence of sociodemographic characteristics such as age, gender, race and ethnicity, income, and education

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EXHIBIT 9 DIABETES PREVALENCE AND AGE-ADJUSTED PREVALENCE IN CALIFORNIA COUNTIES OR COUNTY GROUPS, ADULTS AGES 18 AND OVER, 2001 DIABETES PREVALENCE ADULTS AGES 18 NORTHERN AND SIERRA COUNTIES BUTTE SHASTA HUMBOLDT, DEL NORTE SISKIYOU, LASSEN, TRINITY, MODOC MENDOCINO, LAKE TEHAMA, GLENN, COLUSA SUTTER, YUBA NEVADA, PLUMAS, SIERRA TUOLOMNE, CALAVERAS, AMADOR, INYO, MARIPOSA, MONO, ALPINE GREATER BAY AREA SANTA CLARA ALAMEDA CONTRA COSTA SAN FRANCISCO SAN MATEO SONOMA SOLANO MARIN NAPA SACRAMENTO AREA SACRAMENTO PLACER YOLO EL DORADO
The 90 Confidence Interval CI provides a more reliable prevalence estimate for persons in the population group than does the point estimate Estimates with narrower ranges are more precise or reliable than those with wider ranges The age-adjusted prevalence provides an estimate of the prevalence for a county as if that county had the same age distribution as the state of California Source:
2001 California Health Interview Survey

AGE-ADJUSTED DIABETES PREVALENCE ADULTS AGES 18 53 60 68 57 55 62 76 40 50 90 CI 40-66 44-7 6 53-84 44-7 1 43-68 48-7 6 61-91 28-51 37-62

61 67 74 72 71 70 80 52 63

90 CI 45-7 7 51-82 57-91 57-88 55-87 54-86 64-97 38-67 48-7 8

51 57 56 40 52 61 66 37 69

41-62 45-69 44-68 32-49 39-65 46-7 6 54-7 7 24-50 52-85

53 58 52 41 49 39 66 30 60

43-63 46-7 0 41-62 33-48 37-62 29-49 55-7 6 19-40 45-7 5

62 52 42 37

50-7 4 37-66 30-54 26-48

61 44 46 32

49-7 3 32-56 34-58 22-42

continued on next page

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 9 DIABETES PREVALENCE AND AGE-ADJUSTED PREVALENCE IN CALIFORNIA COUNTIES OR COUNTY GROUPS, ADULTS AGES 18 AND OVER, 2001 CONTINUED DIABETES PREVALENCE ADULTS AGES 18 SAN JOAQUIN VALLEY FRESNO KERN SAN JOAQUIN STANISLAUS TULARE MERCED KINGS MADERA CENTRAL COAST VENTURA SANTA BARBARA SANTA CRUZ SAN LUIS OBISPO MONTEREY, SAN BENITO LOS ANGELES LOS ANGELES OTHER SOUTHERN CALIFORNIA ORANGE SAN DIEGO SAN BERNARDINO RIVERSIDE IMPERIAL STATEWIDE
The 90 Confidence Interval CI provides a more reliable prevalence estimate for persons in the population group than
does the point estimate Estimates with narrower ranges are more precise or reliable than those with wider ranges The age-adjusted prevalence provides an estimate of the prevalence for a county as if that county had the same age distribution as the state of California Source: 2001 California Health Interview Survey

AGE-ADJUSTED DIABETES PREVALENCE ADULTS AGES 18 75 68 75 61 102 78 88 63 90 CI 61-89 55-81 61-88 46-7 5 83-121 62-94 7 0-106 49-7 7

73 67 76 61 99 77 80 67

90 CI 59-88 53-80 62-91 46-7 6 80-119 61-94 63-97 52-82

49 56 39 55 49

38-60 43-68 28-50 42-69 36-62

47 54 40 49 50

37-58 43-66 29-51 37-62 37-63

59-67

62-7 0

43 52 70 75 90 59

36-50 44-59 58-82 62-89 7 0-110 57-61

44 52 75 71 87 59

37-52 45-60 63-87 58-83 69-106 57-61

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DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

3 ACCESS TO MEDICAL CARE

3
HEALTH INSURANCE COVERAGE Health insurance is important for all persons because it provides at least a minimum level of financial access to health care services It is critically important for persons with diabetes and other chronic conditions to have health insurance
because of the ongoing need for care and medical management of their condition Without health insurance, people with diabetes have no financial protection against medical expenses and thus are at greatly increased risk for not obtaining the medical care they need to manage this serious chronic condition Nearly one in five 188 of the 915,000 California residents under age 65 who had diabetes was uninsured for health care for some period during the year Among nonelderly adults with diabetes, 139 had no public coverage or private health insurance when they were interviewed for CHIS in 2001, and another 49 were insured when they were interviewed but experienced some period without coverage during the preceding 12 months Thus, a total of approximately 172,000 188 nonelderly adults with diabetes were uninsured for all or part of the year, greatly increasing their risk of not receiving the medical care they needed to help them manage their condition Nonelderly adults with diabetes were less likely than those without diabetes to receive employment-based health insurance 577 vs 638, respectively and less likely to be covered by privately purchased insurance 39 compared with 67 of those
without diabetes; Exhibit 10 In addition, nonelderly adults with diabetes were less likely than other adults to be employed 584 vs 747, respectively, reducing their opportunities to obtain jobbased insurance Their lower rates of labor force participation suggest that they were more likely to be disabled, one of the main factors in explaining why one-fifth of nonelderly adults with diabetes depend on Medi-Cal for their coverage–more than twice the proportion of those without diabetes 220 and 97, respectively

ersons with diabetes require careful and effective medical care to manage their chronic conditions Although it is desirable for persons with diabetes to take as much control as feasible in day-to-day monitoring of glucose levels, insulin, other medication, and diet, regular professional medical care is essential to assure optimal control of the condition and to prevent disabling and potentially fatal complications of diabetes Health professionals should regularly monitor blood pressure and cholesterol levels, examine eyes and feet, assess the effectiveness of home monitoring of glucose levels, and provide counseling regarding aspirin use, nutritious eating, regular physical
activity, and smoking cessation These elements of medical management are associated with decreased development and increased identification of endorgan damage associated with diabetes Having health insurance coverage and a place one usually goes when in need of health care ie, a usual source of care are key factors affecting access to medical care People with diabetes cannot receive appropriate and necessary care for diabetes if they do not have access to the health care system CHIS asked all respondents an extensive series of questions about their health insurance coverage and the place that they usually went when they needed health care or advice In this section, we examine the health insurance coverage of California adults with diabetes compared with those not diagnosed with diabetes Next, we describe the types of places to which adults with diabetes typically went for their health care in California and the relationship between this usual source of care and health insurance coverage In subsequent sections the importance of these factors with respect to receipt of needed medical care is discussed

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Among adultswith diabetes who had some
form of health insurance, nearly one in 10 90 reported having no coverage for prescription drugs[but] insulin and other diabetes medications are a substantial, ongoing expense

EXHIBIT 10 HEALTH INSURANCE COVERAGE OF NONELDERLY ADULTS BY DIABETES DIAGNOSIS, AGES 18-64, CALIFORNIA, 2001 ADULTS DIAGNOSED WITH DIABETES N915,000 EMPLOYMENT-BASED MEDI-CAL PRIVATELY PURCHASED OTHER PUBLIC UNINSURED TOTAL
Note: Totals may not add to 100 due to rounding Source: 2001 California Health Interview Survey

ADULTS NOT DIAGNOSED WITH DIABETES N19,488,000 638 97 67 13 184 100

57 7 220 39 26 139 100

Among adults 65 years of age and over, those with diabetes were more likely than those without diabetes to have a combination of Medicare and Medi-Cal and less likely to have Medicare with private supplemental coverage Exhibit 11 However, over 32,000 66 elderly people with diabetes were either covered by Medicare only or were completely uninsured, leaving them vulnerable to the high costs of medications as well as other medical bills

Among adults of all ages with diabetes who had some form of health insurance, nearly one in 10 90 reported having no coverage for prescription drugs These 114,000 90
Californians face significant financial barriers to managing their diabetes effectively because insulin and other diabetes medications are a substantial, ongoing expense

EXHIBIT 11 HEALTH INSURANCE COVERAGE OF ELDERLY ADULTS BY DIABETES DIAGNOSIS, AGES 65 AND OVER, CALIFORNIA, 2001 ADULTS DIAGNOSED WITH DIABETES N491,000 MEDICARE AND MEDI-CAL MEDICARE AND OTHER HMO, PVT SUPPLEMENT, ETC MEDICARE ONLY OTHER ONLY UNINSURED TOTAL
Note: Totals may not add to 100 due to rounding The estimate was not statistically reliable Source: 2001 California Health Interview Survey

ADULTS NOT DIAGNOSED WITH DIABETES N2,927,000 17 1 716 66 42 05 100

27 6 603 58 56 100

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Nonelderly adults with diabetes who were uninsured or covered by Medi-Calrelied heavily on the health care safety net

EXHIBIT 12 PERCENT WITH EACH TYPE OF USUAL SOURCE OF CARE BY TYPE OF INSURANCE, NONELDERLY ADULTS WITH DIABETES, AGES 18-64, CALIFORNIA, 2001 USUAL SOURCE OF CARE DOCTORS OFFICE/KAISER/HMO GOVERNMENT/COMMUNITY CLINIC OTHER CLINIC/HOSPITAL CLINIC NONE OR EMERGENCY DEPARTMENT
Note:

EMPLOYMENT-BASED 911 27 29 31

MEDI-CAL 616 198
106 7 7

PRIVATELY PURCHASED/ OTHER PUBLIC 607 17 9 132

UNINSURED 318 27 2 102 303

People who reported some other type of usual source of care are not included in the table because of their small sample size The estimate was not statistically reliable Source: 2001 California Health Interview Survey

USUAL SOURCE OF CARE Lack of health insurance coverage reduces the probability that persons with diabetes will have a medical home, a place they regularly go for care Having a usual source of care has been shown to greatly enhance the likelihood that individuals will receive care for their chronic conditions as well as preventive screening services15 A usual source of care is especially important for people with diabetes because they require ongoing care and surveillance to adequately control their condition and to prevent complications Among adults of all ages, those with diabetes were more likely than those who had not been diagnosed with diabetes to have a usual source of care other than an emergency department 942 and 839, respectively Among nonelderly adults with diabetes, one in four 258 who were uninsured for at least some period during the year had no usual source of care
in sharp contrast to those who

were insured throughout the year, only 38 of whom did not have a usual source of health care Some of those who were uninsured and had no usual source of care said they simply went to a hospital emergency room, an expensive option that does not allow for continuity of care Nonelderly adults with diabetes who were uninsured or covered by Medi-Cal and who had a regular source of care relied heavily on the health care safety net More than onefourth 272 who were uninsured and one-fifth who were covered by Medi-Cal 198 identified a public or community clinic as their usual source of care, compared with 27 of those with job-based coverage In contrast, 911 of those with job-based coverage relied on private or HMO doctors, nearly three times as many as the uninsured 318 and considerably higher than those covered by Medi-Cal 616 Exhibit 12

Corbie-Smith G, Flagg EW, Doyle JP OBrien MA Influence of usual , source of care on differences by race/ethnicity in receipt of preventive services Journal of General Internal Medicine 2002 Jun; 17 6: 458-64

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EXHIBIT 13 PERCENT WITH EACH TYPE OF USUAL SOURCE OF CARE BY TYPE OF
INSURANCE, ELDERLY ADULTS WITH DIABETES, AGES 65 AND OVER, CALIFORNIA, 2001 USUAL SOURCE OF CARE DOCTORS OFFICE/KAISER/HMO GOVERNMENT/COMMUNITY CLINIC OTHER CLINIC/HOSPITAL CLINIC
Note:

MEDICARE AND MEDI-CAL 807 66 89

MEDICARE AND OTHER 948 14 30

MEDICARE ONLY 767

OTHER ONLY 804

The number of uninsured elderly adults was too small to present estimates for type of usual source of care The number of elderly adults with no usual source of care or who used the emergency room as a usual source of care was too small to present estimates Elderly adults who reported some other type of usual source of care were not included in the table because of their small sample size The estimate was not statistically reliable Source: 2001 California Health Interview Survey

Virtually all 980 elderly Californians with diabetes had a usual source of care regardless of their particular type and combination of health insurance coverage However, those covered by a combination of Medicare and Medi-Cal were more likely to rely on public or community clinics for their care than were those with Medicare plus some type of private supplemental insurance or HMO coverage 66 compared to 14 Exhibit
13

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

4 DIABETES CARE AND MANAGEMENT

edical care for diabetes focuses on the management of blood glucose levels, blood pressure, and blood lipids through the use of medication as well as the reduction of behavior-related health risks through appropriate nutrition, weight loss, and physical activity At the time of a patients initial diagnosis with Type 2 diabetes, medical management may rely primarily on behavioral interventions that focus on weight loss, a balanced diet, and increased physical activity If this form of medical management fails to control a patients blood glucose, the treatment plan is expanded to include oral medications If satisfactory glycemic control is not achieved using multiple oral-diabetic medications, treatment with insulin is instituted either alone or in conjunction with oral medications In this section we discuss two ways in which adults with diabetes participate in the management of their condition: taking medications for diabetes and home glucose monitoring Next, we discuss some important behavioral factors that affect a persons ability to manage their diabetes
We also discuss heart disease and hypertension, comorbidities closely associated with diabetes and diabetic complications Then

we discuss two indicators of medical management of diabetes: reported visits to a physician and receipt of foot exams among adults with diabetes Finally, we discuss unmet needs for health care among people with diabetes DIABETES MEDICATIONS In California, over 75 of adults with diabetes were taking some form of medication for diabetes compared with 863 nationally16 However, nearly 340,000 240 adults with diabetes in California were not taking any medications to control the condition–compared with 134 in a national sample of adults with diabetes Although some of these adults may have been controlling their diabetes with diet and exercise, nearly 40 of those not taking any medications had been living with diabetes for more than five years, making it more likely that they needed medication to help control blood glucose levels Furthermore, certain racial and ethnic groups, people with no insurance, and those with no usual source of care, were more likely not to be taking medications Latinos were more likely not to be taking medications for diabetes than
AIANs, Asian and NHOPIs,

EXHIBIT 14 PERCENT NOT TAKING ANY DIABETES MEDICATIONS BY RACE/ETHNICITY, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

35 30 25 20 15 10 5 0 White 217

324

210 180

203

Latino

Asian and NHOPI

African American

AIAN

Note:

Native Hawaiian and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of Asian and NHOPI and the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

Based on data from the 2000 National Health Interview Survey NHIS

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EXHIBIT 15 PERCENT NOT TAKING ANY DIABETES MEDICATIONS BY INSURANCE STATUS AND FEDERAL POVERTY LEVEL FPL, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 UNINSURED 0-199 FPL 200 FPL ALL ADULTS WITH DIABETES
Source: 2001 California Health Interview Survey

INSURED 218 227 223

444 308 406

African Americans, or whites Exhibit 14 This finding was disturbing considering the high rates of diabetes among Latinos ages 50 and over In addition, women had higher rates of not taking any medications than men 274 and 207, respectively For some
people with diabetes, the fact that they were not taking medications is undoubtedly due to limited access to care For instance, more than half of all adults with diabetes who did not have a usual source of care were not taking any diabetes medications compared with less than one-quarter of those with a usual source of care 539 and 222, respectively Health insurance status was also related to whether someone with diabetes takes medications Uninsured adults with diabetes were nearly twice as likely as adults with insurance not to be taking any medications for diabetes 406 and 223, respectively In addition, among respondents 18-64 years of age with diabetes, the uninsured had the highest rate of not using diabetes

medication 418 compared with those with Medi-Cal or employment-based insurance 244 and 243, respectively This finding suggests that the safety net provided by Medi-Cal was working for those adults with diabetes who qualified for it However, many of those adults with diabetes who did not have insurance or did not have a usual source of care might not have been receiving the medications they needed to control their condition Furthermore, although there was no direct
relationship between income and not taking medications, income affected the relationship between insurance and taking medications Among adults with diabetes, the uninsured with incomes below 200 FPL had the highest rate for not using any diabetes medication compared to adults with higher incomes or those with health insurance Exhibit 15 This finding suggests that although lack of insurance increases the likelihood that persons with diabetes will not be taking any diabetic medication, lack of insurance affects low-income persons more adversely than those with higher incomes

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 16 PERCENT WHO MONITOR GLUCOSE AT LEAST ONCE PER DAY BY RACE/ETHNICITY, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

80 70 60 50 40 30 20 10 0

684 541 352 396 547

White

Latino

Asian and NHOPI

African American

AIAN

Note:

HOME GLUCOSE
MONITORING Home monitoring of blood glucose levels is essential in the management of diabetes in order to prevent diabetic complications One of the diabetes-focused objectives of Healthy People 2010 HP2010 is to increase the proportion of adults with diabetes who perform self-blood-glucose monitoring at least once daily from 42 to 60 Nationally, the median rate for home glucose monitoring was 46, with a range from 30 to 66 between 1997 and 199917 Although Californias rate is not very different from the national median home glucose-monitoring rate, it is well below the HP2010 goal of 60

In California, 480 of adults with diabetes reported measuring their blood glucose levels at least once each day However, 424,000 302 reported that they measured their blood glucose less frequently than once per week Rates of measuring blood glucose levels at home varied with several important characteristics Latinos and Asians and NHOPIs had the lowest rates of monitoring their glucose level at least once each day, rates significantly lower than those of African Americans, whites, and AIANs Exhibit 16 AIANs had the highest reported rate of monitoring, higher than whites, Asian and NHOPIs, and
Latinos Among adults with diabetes, those with insurance were more than twice as likely

S Leatherman, D McCarthy Quality of Health Care in the United States: A Chartbook The Commonwealth Fund New York, 2002

UCLA CENTER FOR HEALTH POLICY RESEARCH

as the uninsured to check their blood glucose levels at least once each day 506 and 228, respectively Rates for checking blood glucose levels daily also varied by insurance type Adults ages 18-64 with Medi-Cal had the highest rate for checking their blood glucose at least once each day– significantly higher than adults with employment-based insurance, other public insurance, or no insurance Exhibit 17 Having a usual source of care was also important in monitoring blood glucose levels at home Adults with diabetes who had a usual source of care were more than twice as likely as those without a usual source of care to measure their blood glucose at least once each day 498 vs 195

Although it is important for any person with diabetes to monitor his or her blood glucose level, it is vital for those using insulin People using insulin to treat their diabetes should be measuring their blood glucose levels more than once each day;
however, we found that in California only 79 of adults with diabetes using insulin reported doing so Among adults with diabetes using insulin, over 65,000 204 measured their blood glucose levels less frequently than once per day

EXHIBIT 17 PERCENT WHO MONITOR GLUCOSE AT LEAST ONCE PER DAY BY TYPE OF INSURANCE, NONELDERLY ADULTS WITH DIABETES, AGES 18-64, CALIFORNIA, 2001

70 60 50 40 30 20 10 0 Uninsured Medi-Cal EmploymentBased Privately Purchased Other Public 228 584 490 533 377

Source: 2001 California Health Interview Survey

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

The rates of monitoring blood glucose among insulin users varied by race and ethnicity Only 557 of Asian and NHOPIs and 639 of Latinos checked their blood glucose levels at least once each day compared with more than 85 of AIANs and whites Exhibit 18 BEHAVIOR-RELATED HEALTH RISKS As mentioned previously, control of blood glucose levels among individuals with diabetes is crucial for managing the condition and for reducing the risk of complications

associated with this condition Factors such as lack of physical activity, being overweight, or being obese can make the
control and regulation of blood glucose more difficult or increase the risk for diabetes-related complications In addition, diabetes itself is a significant risk factor for heart disease, and the presence of diabetes with high blood pressure hypertension significantly elevates risk for end-stage kidney disease and stroke Among people with diabetes, smoking increases the risk for amputation and nonhealing ulcers

EXHIBIT 18 PERCENT WHO MONITOR GLUCOSE AT LEAST ONCE PER DAY AMONG INSULIN USERS BY RACE/ETHNICITY, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

100 80

879 763 639 557

897

60 40 20 0 White Latino

Asian and NHOPI

African American

AIAN

Note:

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 19 PREVALENCE OF BODY MASS INDEX BMI, PHYSICAL ACTIVITY, AND SMOKING, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 BMI UNDERWEIGHT: BMI 185 KG/M2 NORMAL WEIGHT: BMI 185 - 249 KG/M2
OVERWEIGHT: BMI 250 299 KG/M2 OBESE: BMI 300 KG/M2 PHYSICAL ACTIVITY REGULAR PHYSICAL ACTIVITY SOME PHYSICAL ACTIVITY NO PHYSICAL ACTIVITY SEDENTARY SMOKING CURRENT SMOKER CURRENTLY NONSMOKER
Source: 2001 California Health Interview Survey

06 212 344 408

198 523 27 8

147 851

In California, over 570,000 408 adults with diabetes were obese, and an additional 484,000 344 were overweight Exhibit 1918 Over 11 million 801 adults with diabetes reported that they did not participate in regular physical activity, and of these over 390,000 278 reported that they had not participated in any physical activity during the preceding thirty days19 Furthermore, although smoking is seriously contraindicated for individuals with diabetes because of the increased risk of vascular complications, over 200,000 California adults with diabetes 147 were current smokers In California, over 790,000 adults with diabetes 562 also had high blood pressure, and nearly 300,000 212 also had heart disease

Certain population groups among those with diabetes were at greater risk for complications because they had a higher prevalence of obesity, lower rates of regular physical activity and/or higher rates of
being sedentary, or were more likely to smoke Among adults with diabetes, females were more likely to be sedentary than males 320 and 237, respectively and were also more likely to be obese than males 433 and 383, respectively

Obesity and overweight are based on Body Mass Index BMI, a standardized measure of weight and height that is used to classify adults as underweight, normal weight, overweight, or obese BMI is an important predictor for future medical conditions such as diabetes and cardiovascular disease Adults are classified as follows: underweight if BMI 185 kg/m2, normal weight if BMI is between 185 to 249 kg/m2, overweight if BMI is between 250 and 299 kg/m2, and obese if BMI is 300 kg/m2 or greater Adults were asked if they had participated in any physical activity in their free time for at least 10 minutes in the past 30 days Adults who said they had not and who also said that they did not walk or bike to work or to run errands were categorized as not participating in any physical activity sedentary

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 20 PREVALENCE OF OBESITY, NO PHYSICAL ACTIVITY, AND SMOKING BY AGE
AND RACE/ETHNICITY, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 OBESITY AGE AGES 18-39 AGES 40-64 AGES 65 AND OVER RACE/ETHNICITY WHITE LATINO ASIAN AND NHOPI AFRICAN AMERICAN AIAN
Note: Native Hawaiian and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of Asian and NHOPI and the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

NO PHYSICAL ACTIVITY

CURRENT SMOKING

402 483 299

134 227 408

188 186 7 4

419 421 156 506 647

286 256 242 293 252

160 128 104 182 363

Older adults with diabetes were at greater risk for complications because they had high rates of obesity and were more likely to be sedentary compared to younger adults Exhibit 20 Younger adults were more likely to be smokers than older adults American Indians and Alaska Natives had the highest rates of obesity as well as the highest smoking rates African Americans had the highest rates of physical inactivity as well as high rates of obesity and smoking Among adults with diabetes, almost two-thirds of AIANs were obese; half of African Americans were obese; and over two-fifths of
Latinos and whites were obese Asian and NHOPIs had the lowest rates of obesity and smoking

DOCTOR VISITS People with diabetes require careful medical monitoring to prevent dangerous complications In California, 94 of adults with diabetes reported that they had seen a doctor at least once in the past year However, over 65,000 47 adults with diabetes reported that they did not visit a doctor at all during the preceding year20 The degree to which people with diabetes received care or experienced barriers in the timely receipt of care was strongly related to health insurance coverage and having a usual source of care Among nonelderly adults with diabetes who were uninsured at least some time during the year, 133 did not visit a doctor even once during the year, compared with 45 of

Approximately 16 of adults with diabetes reported that they did not know how many times they had seen a doctor in the past 12 months

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 21 PHYSICIAN VISITS DURING THE PRECEDING YEAR BY USUAL SOURCE OF CARE AND INSURANCE STATUS, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

No visits 100 80 60 958 40 20 0 26 Insured with Usual Source of Care
94 Uninsured with Usual Source of Care 889

1 or more visits

665

704

308 Insured with No Usual Source of Care

297 Uninsured with No Usual Source of Care

Note:

Totals do not add to 100 percent because some respondents did not recall how many times they saw a doctor in the past year Source: 2001 California Health Interview Survey

those with continuous coverage In addition, among all adults with diabetes, those without an identifiable source of care, whether insured or uninsured 308 and 297, respectively, were more than three times as likely not to have seen a physician during the preceding year as those who were uninsured but had a usual source of care 94, and th ey were more than ten times as likely not to have seen a physician as those who had both insurance and a usual source of care 26 Exhibit 21 These findings underscore the importance of having a usual source of care for persons with diabetes People with diabetes should have a connection to the health care system through which they can receive regular monitoring of and assistance in managing their condition

FOOT EXAMS People with diabetes are at particular risk for developing ulcers and other infections on their feet
that require treatment and which, if present, may put them at increased risk for amputation of all or part of a lower extremity Exams by both providers and patients are advocated by many organizations One objective of Healthy People 2010 is to increase the proportion of adults with diabetes who have at least one annual foot exam from 55 to 75 The median rate for foot exams in the US between 1997 and 1999 was 5821 In California, over two-thirds 666 of respondents with diabetes reported that a doctor examined their feet for sores at least once within the preceding year Although this rate was higher than other samples, 447,000 318 adults with diabetes did not have their feet examined by a health care provider even once during the preceding year In addition, there were certain population groups whose rates of foot exams were considerably lower

S Leatherman, D McCarthy Quality of Health Care in the United States: A Chartbook The Commonwealth Fund New York, 2002

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 22 PERCENT WITH NO FOOT EXAM IN THE PAST YEAR BY RACE/ETHNICITY, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

60 50
40 30 20 10 0 White Latino Asian and NHOPI African American AIAN 292 241 195 359 481

Note:

Certain racial and ethnic groups, the uninsured, and those with no usual source of care were much less likely to report having their feet examined in the past year Asian and NHOPIs and Latinos had the highest rates for having no foot exam in the past year 481 and 359, respectively, significantly higher than most other racial/ethnic groups Exhibit 22 In addition, having insurance and having a

usual source of care were important factors in receiving a foot exam Adults with diabetes who had no usual source of care were nearly twice as likely as those with a usual source of care to have had no foot exam during the preceding year Exhibit 23 Adults with diabetes who were uninsured were also more likely than those with insurance to have had no foot exam in the past year 496 and 300, respectively

EXHIBIT 23 PERCENT WITH NO FOOT EXAM
IN THE PAST YEAR BY INSURANCE STATUS AND USUAL SOURCE OF CARE, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 NO FOOT EXAM BY PHYSICIAN IN THE PAST 12 MONTHS INSURED UNINSURED USUAL SOURCE OF CARE NO USUAL SOURCE OF CARE OR EMERGENCY ROOM
Source: 2001 California Health Interview Survey

300 496 302 57 6

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 24 TYPES OF DELAYED CARE FOR DIABETES, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 OF ADULTS WITH DIABETES DELAYED PRESCRIPTION MEDICATION FOR DIABETES DELAYED TEST OR TREATMENT FOR DIABETES DELAYED OTHER MEDICAL CARE FOR DIABETES DELAYED ANY CARE FOR DIABETES
The estimated N for adults with diabetes who delayed specific types of care does not add up to the number who delayed any care because some adults with diabetes delayed more than one type of care Source: 2001 California Health Interview Survey

ESTIMATED N 76,000 59,000 70,000 163,000

54 42 50 116

EXHIBIT 25 DELAYS IN CARE BY CURRENT HEALTH INSURANCE STATUS, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 UNINSURED DELAYED PRESCRIPTION MEDICATION FOR DIABETES DELAYED ANY MEDICAL CARE FOR DIABETES
Source: 2001 California Health Interview
Survey

INSURED 51 109

84 187

DELAYS IN CARE Delaying or not getting needed health care may result in an increase in complications and worse outcomes for people with diabetes Delays in receipt of medical care may include not receiving prescription medications, specific tests or treatment, and other types of medical care Health insurance coverage and having a usual source for getting health care are important factors in the timely receipt of needed medical care In California, 368,000 262 adults with diabetes reported that they delayed or did not receive necessary medical care This includes 163,000 116 who reported that the delayed care was specifically for their diabetes Exhibit 24

Among individuals with diabetes, 54 delayed or did not get their prescription diabetes medication Over half 515 of the adults with diabetes who delayed or did not get a prescription for their condition reported that the delay was because the medication cost too much or because they did not have insurance to cover the medication Overall, one-tenth 116 of respondents with diabetes reported having delayed or failed to obtain needed medical care directly related to diabetes Among these individuals, 40
attributed their unmet need for care to financial or insurance related barriers

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 26 PERCENT WHO REPORTED DELAYING OR NOT RECEIVING NEEDED MEDICAL CARE FOR DIABETES BY TYPE OF USUAL SOURCE OF CARE, ADULTS WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

18 16 14 12 10 18 6 4 2 0

160

114

Doctors Office or HMO

Government or Community Clinic

No Usual Source of Care or Emergency Room

Source: 2001 California Health Interview Survey

In California, people with diabetes who were uninsured, had low incomes, or had no usual source of care were at increased risk for unmet health care needs Among adults with diabetes, those who were uninsured were more likely to delay or not obtain needed care for diabetes 187 and 109, respectively; Exhibit 25 In addition, adults with diabetes who experienced interruptions in their health care coverage during the preceding year were more likely than those with continuous coverage to have delayed or not received needed health care 195 and 104, respectively For persons with diabetes, delayed care increases the risk of poor outcomes

Among adults with
diabetes, nearly one in six 160 without a usual source of care reported that they had delayed or not received care for diabetes such as prescription medicine, a test, or treatment Among adults with a usual source of care, those who utilized the health care safety net provided by public or community clinics 114 reported similar rates of delay to those who reported having a private doctor or HMO as their usual source of care 114 Exhibit 26

UCLA CENTER FOR HEALTH POLICY RESEARCH

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

5 IDENTIFYING AT RISK POPULATIONS

he prevalence of diabetes is expected to double in the next 25 years, with particular risk for Latinos, African Americans, and Pacific Islanders Early diagnosis of diabetes is especially important because individuals may already have developed complications by the time of their diagnosis Furthermore, it is currently estimated that one-third of people who have diabetes have not been diagnosed and are therefore not receiving appropriate and necessary medical care The Centers for Disease Control and Prevention CDC estimate that 17 million people nationwide have diabetes, 59 million
of whom have not yet been diagnosed22 According to the American Diabetes Association, an additional 16 million people may have pre-diabetes, putting them at increased risk for developing diabetes23 The group of people we discuss as being at risk for Type 2 diabetes almost certainly includes a large proportion of individuals who currently have diabetes but who remain undiagnosed These individuals with undiagnosed diabetes may not be receiving appropriate and necessary medical care As mentioned previously, the risk for Type 2 diabetes increases significantly with age In addition, individuals with particular comorbidities and health behaviors are at elevated risk for developing diabetes Specifically, individuals who are obese and sedentary are at greater risk for developing Type 2 diabetes Furthermore, research has demonstrated that individuals in certain racial and ethnic groups, such as African Americans and Latinos, are at elevated risk for

developing diabetes independent of obesity and level of physical activity Research studies have found that lifestyle changes can prevent or delay the onset of Type 2 diabetes among adults at risk for developing diabetes Lifestyle interventions
include consuming nutritious food and engaging in moderate physical activity In this section, we discuss major risk factors for Type 2 diabetes We focus on two population groups that have not been diagnosed with diabetes: adults ages 18 and over and adolescents ages 12-17 Among adults we examined rates of being overweight and obese, and among adolescents we report rates of being overweight and at risk for overweight In addition, among each group we examined self-reported physical activity among various sociodemographic populations and report findings from multivariate statistical models predicting the largest risk factor for Type 2 diabetes obesity ADULT OBESITY Obesity is the major risk factor for Type 2 diabetes in this country, and it has reached epidemic proportions among both adults and children Recent evidence strongly suggests that lifestyle and behavioral interventions that promote weight loss, increase physical activity, and improve diet can significantly decrease the incidence and prevalence of Type 2 diabetes24 In California, over 77 million adults not diagnosed with diabetes were overweight 346, and an additional 38 million were obese 170 The prevalence of obesity
varied by age Approximately one in five adults between the ages of 40 and 64 was obese compared with one in eight between the ages of 18 and 29 Exhibit 27

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF Lachin JM, , Walker EA, Nathan DM Reduction in the incidence of type diabetes with lifestyle intervention or metformin New England Journal of Medicine 2002; 346 6: 393-403

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 27 PREVALENCE OF OVERWEIGHT AND OBESITY BY AGE, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

Obese 70 60 50 40 30 20 10 0 18-29 30-39 40-49 50-59 60-64 65 124 276 349 379 380 415 366 182 196 215 203 138 Overweight

Age Category
Note:

Overweight was defined as having a BMI between 250 and 299 Obese was defined as having
a BMI of 300 or higher Source: 2001 California Health Interview Survey

EXHIBIT 28 PREVALENCE OF OVERWEIGHT AND OBESITY BY RACE/ETHNICITY, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

70 60 50 40 30 20 10 0

Obese Overweight 218 162 54 348 380 243 White Latino Asian African American AIAN NHOPI 366 337 270 264 255 310

Note:

Overweight was defined as having a BMI between 250 and 299 Obese was defined as having a BMI of 300 or higher Native Hawaiian and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Among adults not diagnosed with diabetes, nearly one in three NHOPIs, one in four African Americans and AIANs, and one in five Latinos were obese

Rates of obesity also varied by race and ethnicity Among adults not diagnosed with diabetes, nearly one in three NHOPIs, one in four African Americans and AIANs, and one in five Latinos were obese compared to one in 20 Asians Exhibit 2825 In addition,
the racial and ethnic groups most at risk in terms of obesity also varied by gender Among adult males, NHOPIs had much higher rates of obesity 359 than most other racial and ethnic groups, while among adult females, African Americans had the highest rate of obesity 292, with high rates also found among NHOPIs 265, AIANs 259, and Latinas 224 Interestingly, although Asians had the lowest rates of obesity relative to other racial and ethnic groups for both males 69 and females 38, Asian males were twice as likely to be overweight or obese as Asian females Rates of obesity also varied by several other sociodemographic characteristics Adults with lower incomes, less education, or living in rural areas were disproportionately affected by obesity Among adults not diagnosed with diabetes, those with incomes at or above 300 FPL were less likely to be obese than adults with lower incomes Exhibit 29 In addition, one in four adults who had not attended school beyond the eighth grade and one in five adults who started but did not complete high school were obese compared to about one in nine adults who had a college degree Adults who lived in rural areas had higher rates of obesity than adults
who lived in suburban areas

To assess whether differences in obesity by race and ethnicity or urban-rural area of residence may be due to differences in the demographic profiles of these groups, we controlled for respondent characteristics such as age, gender, education, and income, physical activity, and measures of access to health care among adults ages 18-64 Race and ethnicity and area of residence were both significantly associated with elevated risk for obesity even after controlling for these other characteristics Latinos, NHOPIs, American Indians and Alaska Natives, and African Americans were all more likely than whites to be obese, while Asians were less likely Additionally, respondents living in rural areas were more likely to be obese than people living in urban or suburban areas These findings suggest that

EXHIBIT 29 PREVALENCE OF OBESITY BY FEDERAL POVERTY LEVEL, EDUCATION, AND AREA OF RESIDENCE, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 FEDERAL POVERTY LEVEL FPL 100 100-199 200-299 300 EDUCATION EIGHTH GRADE OR LESS SOME HIGH SCHOOL HIGH SCHOOL DIPLOMA SOME COLLEGE COLLEGE DEGREE OR HIGHER AREA OF RESIDENCE URBAN 2ND CITY SUBURBAN
SMALL TOWN RURAL ALL ADULTS NOT DIAGNOSED WITH DIABETES 167 17 5 154 191 230 170 232 209 184 189 116 200 191 190 153

Although the number of Native Hawaiians and other Pacific Islanders NHOPI in the CHIS 2001 sample was relatively small, estimates for this group were reported separately whenever possible Estimates for the NHOPI group were reported separately for analyses of adults and adolescents not diagnosed with diabetes These analyses are reported in the section on Identifying At Risk Populations

Note:

Classification of area of residence is based on the population density of the zip code in which the respondent lives For example, second city refers to a zip code with a population density between 1,000 and 4,150 persons per square mile Rural refers to a zip code with a population density equal to or less than 210 persons per square mile Source: 2001 California Health Interview Survey

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 30 OBESITY PREVALENCE AND AGE-ADJUSTED PREVALENCE IN CALIFORNIA COUNTIES OR COUNTY GROUPS, ADULTS AGES 18 AND OVER, 2001 OBESITY PREVALENCE ADULTS AGES 18 NORTHERN AND SIERRA COUNTIES BUTTE SHASTA HUMBOLDT, DEL NORTE SISKIYOU, LASSEN,
TRINITY, MODOC MENDOCINO, LAKE TEHAMA, GLENN, COLUSA SUTTER, YUBA NEVADA, PLUMAS, SIERRA TUOLOMNE, CALAVERAS, AMADOR, INYO, MARIPOSA, MONO, ALPINE GREATER BAY AREA SANTA CLARA ALAMEDA CONTRA COSTA SAN FRANCISCO SAN MATEO SONOMA SOLANO MARIN NAPA SACRAMENTO AREA SACRAMENTO PLACER YOLO EL DORADO
Obesity is defined as BMI 300 The 90 Confidence Interval CI provides a more reliable prevalence estimate for persons in the population group than does the point estimate Estimates with narrower ranges are more precise or reliable than those with wider ranges The age-adjusted prevalence provides an estimate of the prevalence for a county as if that county had the same age distribution as the state of California Source: 2001 California Health Interview Survey
Note:

AGE-ADJUSTED OBESITY PREVALENCE ADULTS AGES 18 196 210 209 228 224 224 248 159 158 90 CI 168-223 17 9-240 180-238 197-260 193-256 197-252 218-27 8 125-192 132-184

191 210 208 232 229 229 247 154 168

90 CI 164-218 183-238 17 9-237 203-261 201-257 202-257 217-27 6 127-180 143-193

145 175 197 112 169 135 224 115 162

128-162 153-195 17 5-219 97-126 144-195 113-157 204-244 91-138 137-187

145 173 194 114 167 128 222 105
153

129-162 152-193 17 2-216 99-128 141-193 106-150 201-242 7 9-130 128-17 8

211 158 175 175

190-233 133-182 148-202 147-204

211 154 188 169

189-232 128-181 160-215 140-197

continued on next page

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 30 OBESITY PREVALENCE AND AGE-ADJUSTED PREVALENCE IN CALIFORNIA COUNTIES OR COUNTY GROUPS, ADULTS AGES 18 AND OVER, 2001 CONTINUED OBESITY PREVALENCE ADULTS AGES 18 SAN JOAQUIN VALLEY FRESNO KERN SAN JOAQUIN STANISLAUS TULARE MERCED KINGS MADERA CENTRAL COAST VENTURA SANTA BARBARA SANTA CRUZ SAN LUIS OBISPO MONTEREY, SAN BENITO LOS ANGELES LOS ANGELES OTHER SOUTHERN CALIFORNIA ORANGE SAN DIEGO SAN BERNARDINO RIVERSIDE IMPERIAL STATEWIDE
Obesity is defined as BMI 300 The 90 Confidence Interval CI provides a more reliable prevalence estimate for persons in the population group than does the point estimate Estimates with narrower ranges are more precise or reliable than those with wider ranges The age-adjusted prevalence provides an estimate of the prevalence for a county as if that county had the same age distribution as the state of California Source: 2001 California Health Interview
Survey
Note:

AGE-ADJUSTED OBESITY PREVALENCE ADULTS AGES 18 257 247 255 240 231 288 269 238 90 CI 231-282 223-27 1 229-282 211-27 0 204-257 257-319 240-298 208-268

252 246 255 241 227 285 263 238

90 CI 226-27 9 222-27 1 229-282 211-27 0 199-255 253-317 232-293 208-268

163 159 144 152 245

139-186 138-180 118-169 127-17 6 213-27 6

161 165 142 154 246

138-185 144-186 118-166 128-17 9 215-27 7

188

181-195

189

182-196

145 153 230 194 270 184

131-159 141-166 210-251 17 4-215 238-302 180-187

146 156 231 195 272 184

132-159 143-168 210-251 17 5-216 241-304 180-187

UCLA CENTER FOR HEALTH POLICY RESEARCH

Nearly 35 million adults 154 of those not diagnosed with diabetes reported that they did not participate in any physical activity

these groups were at elevated risk for diabetes as well as other medical conditions because of the consequences of obesity The identification of groups at risk for obesity may facilitate the development of specifically targeted, culturally appropriate interventions to increase community awareness and to combat rising rates of obesity in this country The prevalence of obesity also varied across California counties Exhibit 30 shows the
prevalence and age-adjusted prevalence of obesity for each county or county group The age-adjusted prevalence estimates what the prevalence would be for each county or county group if each county population had the same age distribution It was important to take variation due to age into account because rates of obesity are related to age and there were differences among California counties in the age distribution of their populations Overall, the age-adjusted prevalence of obesity including adults diagnosed and those not diagnosed with diabetes was greatest among adults in Merced 288, Imperial 272, and Kings 269 counties and lowest among adults in Sonoma 128, San Francisco 114, and Marin 105 counties ADULT PHYSICAL ACTIVITY Physical activity is important for all adults and children for a variety of reasons, including cardiovascular and aerobic benefits, increase in lean muscle mass, optimization of bone mineral density, positive effects on metabolism, and stress reduction Regular physical activity is important for maintaining lean muscle mass, controlling weight, and reducing the level of risk for a number of chronic medical conditions, including Type 2 diabetes Adult respondents
were asked a series of questions about the type and duration of their physical activity during the 30 days preceding their interviews

EXHIBIT 31 LEVEL OF PHYSICAL ACTIVITY, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 PHYSICAL ACTIVITY REGULAR PHYSICAL ACTIVITY SOME PHYSICAL ACTIVITY NO PHYSICAL ACTIVITY SEDENTARY
Source: 2001 California Health Interview Survey

27 4 57 2 154

In California, the vast majority of adults not diagnosed with diabetes, nearly 163 million 726, did not meet the current standards for regular physical activity26 In fact, less than one-third of adults 274 not diagnosed with diabetes reported participating in regular physical activity Exhibit 31 Nearly 35 million adults 154 of those not diagnosed with diabetes reported that they did not participate in any physical activity27 This lack of physical activity greatly increases the risk of obesity and, as a result, the risk of developing Type 2 diabetes Among adults not diagnosed with diabetes, rates of physical activity were related to obesity Exhibit 32 One in five adults who were sedentary was obese compared to one in eight adults who participated in regular activity Among adults not
diagnosed with diabetes, level of physical activity was related to age and gender Older adults were twice as likely to be sedentary as younger adults Exhibit 34, and females were more likely to be sedentary than males There was also significant variation in level of physical activity by race and ethnicity Almost one-fifth of African Americans, Latinos, and Asians were sedentary

Regular physical activity refers to participating in vigorous activity for at least 20 minutes three or more times a week or participating in moderate activity for at least 30 minutes five or more times per week Adults were considered to participate in some physical activity if they said they participated in physical activity but they did not meet the levels for our definition of regular physical activity Adults were asked if they had participated in any physical activity in their free time for at least 10 minutes in the past 30 days Adults who said they had not and who also said that they did not walk or bike to work or to run errands were categorized as participating in no physical activity sedentary

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 32
PREVALENCE OF OBESITY BY PHYSICAL ACTIVITY, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 OBESITY NO PHYSICAL ACTIVITY SEDENTARY REGULAR PHYSICAL ACTIVITY
Note:

207 131

Obesity was defined as BMI 300 Regular physical activity was defined as at least 3 days per week of vigorous physical activity for at least 20 minutes or at least 5 days per week of moderate physical activity for at least 30 minutes The category of no physical activity/sedentary included the participants who responded no to any form of physical activity Source: 2001 California Health Interview Survey

EXHIBIT 33 PHYSICAL ACTIVITY BY RACE/ETHNICITY, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001

Regular Activity 35 30 25 20 15 10 5 0 White Latino Asian African American AIAN NHOPI 131 303 271 231 186 219 188 196 146 102 No Activity 326 323

Native Hawaiian and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey

Note:

UCLA CENTER FOR HEALTH POLICY RESEARCH

compared with only 102 of
NHOPI and 131 of whites Exhibit 33 Although Asians had a low prevalence of obesity, their rates for being overweight were not very different from other racial/ethnic groups, particularly among males Furthermore, Asians in California had the lowest reported rates of regular physical activity and one of the highest rates of physical inactivity This may indicate the need to target preventive educational information to this population Level of participation in physical activity was also related to education and family income Exhibit 34 Adults with less education were the most likely to be sedentary In addition, adults living below 200 FPL were nearly twice as likely to be sedentary as adults with family incomes at or above 300 FPL

ADOLESCENTS AT RISK FOR DIABETES In the past, Type 2 diabetes was most commonly found among adults who were overweight or obese and ages 40 or over Now, as more children and adolescents in the United States become overweight and inactive, there is an increasingly high prevalence of Type 2 diabetes among young people While the identification of diabetes is important among adults, adolescents, and children, so is prevention of diabetes Diabetes prevention
should begin among children and adolescents Eating nutritious foods, engaging in regular physical activity, and reducing rates of obesity reduce the risk for future development of diabetes as well as other medical conditions such as high blood pressure and heart disease

EXHIBIT 34 PHYSICAL ACTIVITY BY AGE, GENDER, EDUCATION, AND FEDERAL POVERTY LEVEL, ADULTS NOT DIAGNOSED WITH DIABETES, AGES 18 AND OVER, CALIFORNIA, 2001 REGULAR PHYSICAL ACTIVITY AGE AGES 18-49 AGES 50-64 AGES 65 AND OVER GENDER MALE FEMALE EDUCATION EIGHTH GRADE OR LESS SOME HIGH SCHOOL HIGH SCHOOL GRADUATE SOME COLLEGE COLLEGE GRADUATE FEDERAL POVERTY LEVEL FPL 0-99 100-199 200-299 300
Source: 2001 California Health Interview Survey

NO PHYSICAL ACTIVITY

292 246 222

124 17 4 286

317 234

123 184

142 235 254 292 318

27 9 220 185 137 97

231 227 259 307

205 210 17 8 114

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

In California, over 736,000 adolescents ages 12-17 not diagnosed with diabetes were either overweight 108 or were at risk for being overweight 143

An increasing proportion of younger individuals are being diagnosed with diabetes, and those groups at
elevated risk should be targeted for disease prevention and screening The CDC estimates that 151,000 people under the age of 20 have diabetes28 Furthermore, the CDC reports that Type 2 diabetes is becoming more common among American Indian, African-American, and Hispanic/Latino children and adolescents, suggesting that adolescents who have these racial/ethnic backgrounds are at particular risk For children and teens at risk, health care providers can encourage, support, and educate the entire family to make lifestyle changes that may delay–or prevent–the onset of Type 2 diabetes Such changes include maintaining a healthy weight

and staying physically active For adolescents, being overweight is a major risk factor for diabetes In addition, overweight adolescents are more likely to become overweight or obese as adults29, 30 ADOLESCENT OVERWEIGHT31 In California, over 736,000 adolescents ages 12-17 not diagnosed with diabetes were either overweight 108 or were at risk for being overweight 14332 Among adolescents in California, certain groups appeared to be more likely to be overweight or at risk for overweight Adolescent males were nearly twice as likely to be overweight as
adolescent females 142 and 72, respectively; Exhibit 35

EXHIBIT 35 PREVALENCE OF OVERWEIGHT AND AT RISK FOR OVERWEIGHT BY AGE AND GENDER, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001 AT RISK FOR OVERWEIGHT1 ALL ADOLESCENTS AGE AGES 12-14 AGES 15-17 GENDER MALE FEMALE
1 85th 94th percentile for gender- and age-appropriate height and weight 2 95th percentile for gender- and age-appropriate height and weight Source: 2001 California Health Interview Survey

OVERWEIGHT2 108

143

156 130

102 114

149 137

142 7 2

29 30

Centers for Disease Control and Prevention National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2000 Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2002 Whitaker RC, Pepe MS, Wright JA, Seidel KD, Dietz WH Early adiposity rebound and the risk of adult obesity Pediatrics, 1998; 101 5 See http://wwwpediatricsorg/cgi/content/full/101-3/e5 Guo SS, et al The predictive value of childhood BMI values for overweight at age 35 years American Journal of Clinical Nutrition 1994; 59: 810-819

31 32

The overweight category among adolescents
used to be referred to as obese and roughly corresponds to the obese BMI range among adults At risk for overweight is defined as at or above the gender- and agespecific 85th percentile of BMI and below the 95th percentile of BMI based on the revised CDC Growth Charts for the United States Overweight is defined as at or above the gender- and age-specific 95th percentile of BMI based on the revised CDC Growth Charts for the United States

UCLA CENTER FOR HEALTH POLICY RESEARCH

EXHIBIT 36A PREVALENCE OF OVERWEIGHT AND AT RISK FOR OVERWEIGHT BY RACE/ETHNICITY, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001

40 35 30 25 20 15 10 0 137 White 99

Overweight At Risk for Overweight 170 119 64 153 129 Latino Asian 165 105 African American AIAN 105

Note:

The sample size of adolescent Native Hawaiians and other Pacific Islanders was too small to make a reliable estimate for rates of overweight and at risk for overweight At risk for overweight was defined as 85th 94th percentile for gender- and age-appropriate height and weight Overweight was defined as 95th percentile or greater for genderand age-appropriate height and weight American Indian and Alaska Native is
abbreviated AIAN For an explanation of the exclusion of other race/ethnicity, see the Appendix

Source: 2001 California Health Interview Survey

EXHIBIT 36B PREVALENCE OF OVERWEIGHT AND AT RISK FOR OVERWEIGHT BY GENDER AND RACE/ETHNICITY, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001

45 40 35 30 25 20 15 10 5 0

Overweight At Risk for Overweight 146 143 181 143 White 171 87 Latino Males African American 54 132 White 90 133 Latina Females
Source: 2001 California Health Interview Survey

156

265

African American

Note:

The sample sizes for adolescent males and females were too small to present estimates for overweight or at risk for overweight for Native Hawaiians and other Pacific Islanders, American Indians and Alaska Natives, and Asians For an explanation of the exclusion of other race/ethnicity, see the Appendix At risk for overweight was defined as 85th 94th percentile for gender- and age-appropriate height and weight Overweight was defined as 95th percentile or greater for gender- and age-appropriate height and weight

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 37 PREVALENCE OF OVERWEIGHT AND AT
RISK FOR OVERWEIGHT BY FEDERAL POVERTY LEVEL AND AREA OF RESIDENCE, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001 AT RISK FOR OVERWEIGHT FEDERAL POVERTY LEVEL FPL 0 - 99 FPL 100-199 FPL 200-299 FPL 300 FPL AREA OF RESIDENCE URBAN 2ND CITY SUBURBAN SMALL TOWN RURAL
Note:

OVERWEIGHT

151 141 188 125

140 115 105 89

147 146 137 134 152

115 112 89 111 136

At risk for overweight refers to adolescents in the 85th to 94th percentile for age- and gender-appropriate height and weight Overweight refers to adolescents at or above the 95th percentile for age and gender appropriate height and weight Classification of area of residence is based on the population density of the zip code in which the respondent lives For example, second city refers to a zip code with a population density between 1,000 and 4,150 persons per square mile Rural refers to a zip code with a population density equal to or less than 210 persons per square mile Source: 2001 California Health Interview Survey

Rates of being overweight or at risk for overweight among adolescents also varied by race and ethnicity African American and Latino adolescents had higher rates of being overweight than
whites or Asians Exhibit 36a, and these rates also varied by gender Among Latinos and whites rates of overweight were higher among adolescent boys than adolescent girls However, rates of being at risk for overweight were highest among African-American girls, far higher than among African-American boys Exhibit 36b

Rates of overweight among adolescents also varied with several other important characteristics Adolescents in families with lower incomes and those living in rural areas were more likely to be overweight Exhibit 37 One in seven 140 adolescents with family incomes less than 100 FPL was overweight compared to one in eleven 89 adolescents with family incomes at or above 300 FPL In addition, adolescents living in rural areas were somewhat more likely to be overweight than adolescents living in suburban areas

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EXHIBIT 38 PHYSICAL ACTIVITY BY AGE, GENDER, AND RACE/ETHNICITY, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001 REGULAR PHYSICAL ACTIVITY AGE AGES 12-14 AGES 15-17 GENDER MALE FEMALE RACE/ETHNICITY WHITE LATINO ASIAN AFRICAN AMERICAN AIAN NHOPI
The estimate was not statistically reliable Native Hawaiian
and other Pacific Islander is abbreviated NHOPI and American Indian and Alaska Native is abbreviated AIAN For an explanation of the exclusion of other race/ethnicity, see the Appendix Source: 2001 California Health Interview Survey Note:

NO PHYSICAL ACTIVITY

723 731

56 48

77 3 67 8

53 51

765 692 658 746 698 661

30 84 50 54

ADOLESCENT PHYSICAL ACTIVITY Participation in regular physical activity is at least as important for adolescents as it is for adults Adolescents interviewed by CHIS were asked several questions about their level of physical activity during the past seven days In California, 73 percent of adolescents not diagnosed with diabetes reported that they participated in regular physical exercise in the week preceding the interview33 However, over 800,000 273 adolescents in California not diagnosed with diabetes reported not participating in regular physical activity, including 152,000 52 who participated in no physical activity at all

Reported rates of participation in physical activity among adolescents not diagnosed with diabetes varied according to some important population characteristics Adolescent males were more likely to report participating in
regular physical activity than females; however, there were no differences between males and females in rates of no physical activity Exhibit 38 White and African-American adolescents reported the highest rates of regular physical activity 765 and 746, respectively, and rates among whites were significantly higher than among Asian adolescents 658 Latino adolescents reported high rates of no physical activity, significantly higher than whites

For an explanation of the definitions of regular physical activity and no physical activity, please see the Appendix

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

EXHIBIT 39 PHYSICAL ACTIVITY BY EDUCATION, FEDERAL POVERTY LEVEL, AND AREA OF RESIDENCE, ADOLESCENTS NOT DIAGNOSED WITH DIABETES, AGES 12-17, CALIFORNIA, 2001 REGULAR PHYSICAL ACTIVITY EDUCATION ATTENDING SCHOOL NOT ATTENDING SCHOOL FEDERAL POVERTY LEVEL FPL 0-99 FPL 100-199 FPL 200-299 FPL 300 FPL AREA OF RESIDENCE URBAN 2ND CITY SUBURBAN SMALL TOWN RURAL
The estimate was not statistically reliable Source: 2001 California Health Interview Survey

NO PHYSICAL ACTIVITY

728 652

691 689 713 768

7 9 89 39 25

702 744 730 746 77
5

68 42 40 39

Rates of physical activity among adolescents also varied according to socioeconomic factors Exhibit 39 Adolescents with family incomes below 200 FPL were three times as likely to be sedentary as those with family incomes at or above 300 FPL Adolescents attending school were more likely to report regular physical activity than those not attending school34 Finally, adolescents living in urban areas reported the lowest rates of regular physical activity, lower than those living in rural areas Latino adolescents, African-American adolescents, adolescents whose families had lower incomes, and adolescents not attending school appeared to be at greatest risk for developing diabetes because of their relatively high rates of being overweight and at risk for overweight, and high rates

of being sedentary In addition, adolescents living in rural areas were more likely to be overweight, but adolescents living in urban areas were more likely to be sedentary After adjustment for sociodemographic variables age, education, and income, adolescent boys were more likely than adolescent girls to be overweight African Americans were more likely than whites to be overweight, and Asians
were less likely than whites to be overweight In addition, adolescents in urban or rural areas were more likely than adolescents living in suburban areas to be overweight Surprisingly, level of physical activity was not a significant determinant for being overweight among adolescents However, the majority of adolescents 727 reported engaging in regular physical activity

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DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

6 CONCLUSIONS AND POLICY RECOMMENDATIONS

early 15 million adults in California 59 have been diagnosed with diabetes, and at least 18 million 82 were at significant risk for diabetes This latter group almost certainly includes a large number of individuals who currently have diabetes but who remain undiagnosed In addition, over 12,000 04
adolescents ages 12-17 had been diagnosed with diabetes, with an increasing number at risk for developing diabetes as adolescents or adults In California the prevalence of diabetes is expected to double by the year 202035 This increase will pose a great burden on the health of the state as well as on health care costs because diabetes is the number one risk factor for coronary heart disease as well as blindness and chronic renal failure Therefore greater emphasis should be placed on the impact of factors such as obesity and lack of physical activity that put individuals at risk for diabetes and worsen diabetic complications The focus for all Californians, especially those at particular risk for diabetes, should be on minimizing the risks for and effects of diabetes This can be done in two ways: prevention of diabetes and the effective management of diabetes among those who develop the condition Primary prevention of diabetes focuses on a reduction in the factors that put individuals at risk and greater emphasis on healthpromoting behaviors Effective management involves the early diagnosis of diabetes, especially among groups already identified as being at increased risk, to ensure
that people receive appropriate medical care Furthermore, effective management emphasizes the need to provide coordinated care to individuals with diabetes to ensure their access to and receipt of adequate and appropriate health services to decrease the development of diabetes-related complications

PREVENTION OF DIABETES
Primary prevention for diabetes cannot wait until adulthood, but should begin during childhood and continue through adolescence and adulthood In the twenty-first century, Type 2 diabetes is being diagnosed increasingly among children and adolescents This surge in the prevalence and incidence of diabetes is due overwhelmingly to the epidemic of obesity that has occurred among adults and children Regular physical activity and nutritious eating can prevent the development of obesity and the increased risk for diabetes in children and adolescents as well as adults PREVENTING OBESITY: HEALTHFUL EATING In California, over 77 million 346 adults not diagnosed with diabetes were overweight, and an additional 38 million 170 were obese Nearly one in three Native Hawaiian and other Pacific Islanders NHOPI, one in four African Americans, and American Indians and Alaska Natives
AIAN, and one in five Latinos were obese compared with one in twenty Asians Among adult males not diagnosed with diabetes, NHOPIs had much higher rates of obesity than other racial and ethnic groups Among adult females not diagnosed with diabetes, the prevalence of obesity was high among African Americans, NHOPIs, AIANs and Latinas The prevalence of obesity also varied by level of education and income–obesity was highest among adults with low income or less education Age-adjusted obesity rates also varied considerably by county Among adolescents in California not diagnosed with diabetes, 736,000 251 were either at risk for being overweight or were already overweight Adolescent males were nearly twice as likely as adolescent females to be overweight or at risk for overweight, and African-American and Latino adolescents had higher rates of overweight than whites or Asians

Diabetes Facts and Figures California Diabetes Control Program, 2001 See http://wwwcaldiabetesorg/html/rs-factsfigurescfm

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Public policy and community action can help reduce these risks by facilitating and encouraging healthy choices

Local governments should
increase the availability of fresh fruits and vegetables in all neighborhoods Many health care providers and policy makers assume that people have equal access to healthy food This assumption unfortunately is not true and is further complicated by cost constraints faced by many people with diabetes Access to markets that carry healthy food options, including fresh fruits and vegetables and low-salt and low-fat foods, is limited in many urban areas of the country In addition, healthy food options are less accessible in traditionally minority and low-income areas To obtain the five servings of fruits and vegetables that people are learning they should consume daily, individuals may choose to purchase less expensive canned fruits and vegetables that do not retain the benefits of fresh produce and contain higher levels of salt and sugar as well as preservatives In many areas, the increase in the number of farmers markets has improved access to fresh fruits and vegetables However, disparities in access to healthy food options persist Supermarket chains and farmers markets should be encouraged to open in all neighborhoods, including low-income communities One example of a program that
promotes access to fresh fruits and vegetables is the WIC Women, Infants, and Children Farmers Market Nutrition Program Many WIC recipients are lowincome mothers who may be struggling to find nutritious food choices for themselves and their children This program provides these mothers access to a wider selection of fruits and vegetables than they might otherwise experience and represents a model program that should continue to be funded and expanded Similar programs should also be developed for other low-income groups

The state and local governments as well as private firms should increase the availability of affordable healthy food choices In the US, risk factors for unhealthful eating include the widespread availability and use of fastfood establishments that mainly provide low-cost highcalorie meals to adults and children These outlets often promote consumption of super-size portions, thus increasing the fat intake and calories associated with many of these meals The prevalence and promotion of fast-food restaurants coupled with the absence of alternative, healthier food choices is especially problematic in low-income neighborhoods Additionally, the increased consumption of
high-calorie diets has facilitated the epidemics of obesity and diabetes Schools should provide healthier food choices for children and adolescents Children should have access to healthier school lunches and other school-based meals In addition, the sugary snacks and sodas available in vending machines on school campuses should be replaced with more nutritious snacks and healthier drinks such as water For example, the Los Angeles Unified School District recently banned the sale of soda in schools This was an important step towards improving food choices for schoolchildren In addition, Senate Bill 1520 SB 1520, considered in the legislature in 2002, would have limited and eventually prohibited the sale of carbonated beverages in California schools This bill also set forth nutritional requirements for foods served and sold in schools including food in vending machines Enacting this bill or one similar to it would greatly improve the availability of healthy food choices for schoolchildren

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

The State and local governments should more fully engage community-based organizations, schools, and health
care professionals in developing culturally appropriate interventions that promote healthier diets, and should expand funding for these efforts Minority groups including African Americans, Latinos, and AIANs are at particular risk for the development of diabetes Targeted interventions that promote healthier diets with culturally appropriate healthy food choices are needed to reduce the risk of developing diabetes among minority groups Programs and organizations such as the Children and Adolescent Nutrition and Fitness Program CANFit and the California Latino 5-a-Day Campaign are examples of California programs focusing on improving nutrition and physical fitness among minority groups that should continue to receive support Additional programs that increase knowledge about the importance and attainment of nutrition and fitness among minority groups should also be developed

PHYSICAL ACTIVITY In California, nearly 163 million 726 adults not diagnosed with diabetes did not meet the current guidelines for regular physical activity, including 35 million 154 who did not participate in any physical activity Participation in regular physical activity varied by race and ethnicity as well as
by education and income Almost three-quarters of adolescents not diagnosed with diabetes reported engaging in regular physical activity However, 800,000 273 adolescents did not participate in regular physical activity Regular physical activity includes a wide variety of pursuits and does not require athletic skill Rather, individuals should be encouraged to find aerobic activities that they enjoy and that are convenient for them to pursue, such as vigorous walking The US Preventive Services Task Force recently changed its recommendation for optimal physical activity to 60 minutes of continuous physical activity at least 5 days per week Up to that time the recommendations for regular physical activity were set at a lower standard And yet, only two-fifths of California adults have been participating in regular physical activity although almost one-half are doing some type of leisure-time activity These latter individuals have incorporated some level of physical activity into their lives and should be encouraged to increase the frequency and duration of activity to meet the new recommendations

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Promote physical activity programs in public
schools Community and state boards of education can allocate funding or increase funding for physical activity programs offered before, during, and after school Physical activity among children and adolescents is an important riskreduction factor for obesity and diabetes, perhaps even more so than for adults Regular exercise habits developed early and continued through ones lifetime may have long lasting and protective effects against diabetes and other chronic medical conditions Unfortunately, schools have been reducing and even eliminating physical activity curricula Nevertheless, we find that adolescents enrolled in school were more likely than those not enrolled to participate in regular physical activity Legislation enacted in 2002 mandates an increase in time spent for physical activity in the schools However, the implementation of this legislation may be hindered by budget limitations and availability of facilities for students in underserved areas Local efforts have also been made to ensure the continuation of physical activity programs in schools For example, the Los Angeles County Board of Supervisors approved recommendations to promote physical activity and healthy
eating from the county Blue Ribbon Task Force on Childhood Fitness In addition, a project spearheaded by California Project LEAN Leaders in Encouraging Activity and Nutrition, called Food on the Run, is a student-driven campaign that seeks to empower high school students to improve their own nutrition and fitness through peer counseling, dance classes, nutrition lessons, and low-fat menu offerings Another project called Operation FitKids is a program that provides fitness equipment and facilities to lowincome communities through the use of recycled commercial fitness equipment Operation FitKids works with high schools, community organizations, and youth groups across the nation to create fitness centers that

provide adolescents and teenagers greater access to comprehensive physical fitness programs Other such innovative programs are needed to capture the interest of students and create viable options for underserved communities in working towards maintaining their health and fitness

Develop community policies and practices as well as legislation that promote safe environments for physical activity State and local governments and community members can work together to increase
the number of parks, build and maintain sidewalks, and have well-lit neighborhoods, particularly for urban and low-income populations A variety of community programs have been developed and implemented to increase the level of physical activity among adults; however, many people still face limited access to appropriate facilities and lack security in their own neighborhoods The California Department of Health Services in partnership with the University of California, San Francisco, Institute for Health and Aging developed the Physical Activity and Health Initiative PAHI PAHI was organized to provide leadership in the state for the promotion of physical activity to improve the publics health One of the goals of PAHI is to increase the proportion of community and neighborhood policies and environments that encourage and support walking and biking There have also been an increasing number of public and private businesses that are providing physical activity opportunities for employees However, there is little information available on the longterm sustainability of these programs and on their continued impact on rates of regular physical activity among adults, and these programs are
more likely to be available to more affluent workers

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Develop culturally appropriate and targeted interventions to promote regular physical activity among minority groups, including NHOPIs, African Americans, Latinos, and AIANs Many interventions regarding physical activity do not account for differences in culture and living conditions among different racial and ethnic groups As a result, different groups may not feel that current interventions promote viable options for lifestyle improvement In order to encourage healthpromoting behaviors such as regular physical activity, more culturally sensitive, multilingual interventions addressing healthy lifestyle choices are needed

ACCESS TO PREVENTIVE HEALTH CARE Careful monitoring and screening of groups at elevated risk for developing diabetes can also help in prevention efforts Particular racial and ethnic groups, those with family histories of diabetes, and people who are obese should be educated about their elevated risk for developing diabetes and about lifestyle changes they can make to prevent or delay the onset of diabetes In addition,
these groups should be screened regularly so that if diabetes develops they can begin receiving care as soon as possible In California, 36 million nonelderly adults not diagnosed with diabetes 184 have no health insurance coverage These adults are less likely to have access to the health care system As a result, they are less likely to receive preventive health care such as cholesterol screening, monitoring for high blood pressure, and testing for high levels of blood glucose

Assure access to trained health care providers who can counsel and screen at-risk patients Primary-care providers should be knowledgeable about their patients risks for diabetes and vigilant in their screening for signs and symptoms of pre-diabetes and diabetes Those individuals with specific risk factors such as family histories of diabetes, obesity, and limited physical activity should be monitored and counseled to reduce their risk factors eg, weight loss, nutritious eating, physical activity Health care providers should consider using documentation systems that will allow them to monitor patients risk factors for diabetes and to ensure regular screening In addition, primary-care providers such as
physicians, nurse practitioners, and physician assistants should be adequately trained to provide nutrition and physical activity counseling to their patients, or to refer them to appropriate health and community resources Expand public and private health insurance packages to provide adequate coverage for preventive care Preventive care should include health promotion, health and nutritional education, physical activity, and screening for diabetes–particularly among high-risk groups Many health insurance packages provide limited coverage for health education and preventive care Though emphasis on prevention is increasing, health insurance packages still need to expand coverage to include interventions that address nutrition education, physical-activity promotion, and screening

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EFFECTIVE MANAGEMENT OF DIABETES
To manage diabetes effectively the condition should be identified at its earliest stage so that diabetes care can be instituted as appropriate Early diagnosis of diabetes is important to limit the extent of complications However, early diagnosis is unlikely if individuals do not have access to appropriate medical care Improving
the rates of early diagnosis of diabetes is the joint responsibility of individuals and the community, health care providers, and the health care system Individuals are less likely to be diagnosed with diabetes if they do not have health insurance and a usual source of health care, or if their health care-seeking behavior is episodic and does not include primary care and prevention AVAILABILITY OF TIMELY DATA In California, diabetes prevalence rises considerably with increasing age and varies by race and ethnicity Overall, African Americans and AIANs had the highest rates of diabetes, with the lowest rates among Asians Among older adults, Latinos, African Americans, and AIANs had the highest rates of diabetes Due to the large sample size and the diversity of the population in California, we were able to measure the prevalence of diabetes within Latino and Asian ethnic groups Having diabetes was also associated with lower levels of education and income The findings from CHIS provide county-level data and indicate significant variation in the prevalence of diabetes throughout the state In addition, adults with diabetes were disproportionately overweight 34 or obese 41, and more
likely to be sedentary than to participate in regular physical activity although there was significant racial and ethnic variation Continue surveillance at the state and local levels Timely data on diabetes at the state and local levels are needed to support the design and implementation of effective public health and clinical interventions

IMPROVING ACCESS TO MEDICAL CARE
AND DIABETES EDUCATION

Effective management of diabetes focuses on reducing the risk for and impact of diabetic complications Research demonstrates that it is common for people with diabetes to under-use general preventive services as well as preventive services specific to diabetes36 Appropriate care for individuals with diabetes includes optimization of glycemic control through diet, physical activity, medication, home glucose monitoring, and regular measurement of hemoglobin A1C by the health care provider It also must involve careful monitoring for diabetes-related complications such as diabetic retinopathy with annual dilated retinal exams; diabetic nephropathy and end-stage renal disease by monitoring microalbuminuria and kidney function; diabetic foot ulcers through regular foot exams; hypertension with
regular blood pressure checks; and hypercholesterolemia with checks of blood lipid levels People with diabetes are also at increased risk for developing comorbid conditions such as high blood pressure, high cholesterol, heart disease, and obesity Appropriate diabetes care also includes the use of aspirin as prophylaxis for coronary artery disease and peripheral vascular disease including heart attack, stroke, and lower extremity disease People with diabetes are also at increased risk for pneumonia and influenza and should receive appropriate immunizations Diabetes care can be improved although this requires the efforts of health care providers and the healthcare system ie, public and private health plans and public health programs in conjunction with patients

Beckles et al Population-based assessment of the level of care among adults with diabetes in the US Diabetes Care 1998; 21: 1432-1438

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Although the majority of adults with diabetes had health insurance, approximately 172,000 188 adults under age 65 were uninsured for health care during all or a portion of the year preceding the survey
There was considerable variation in receipt of health care between adults with insurance and without insurance, and between those with and without a usual source of care The adverse effects of being uninsured are seen across all income groups, but uninsured adults below 200 of the Federal Poverty Level FPL were far more likely than those with higher incomes not to get needed health care, including prescription medications for diabetes Many adults with diabetes in California did not receive appropriate medical care for their condition Over 65,000 adults with diabetes 47 had not visited a physician within the past year Nearly 340,000 adults with diabetes in California 24 were not taking any medications to control the condition compared with 134 nationally Furthermore, there was racial and ethnic variation in medication use Latinos, for example, were the least likely to be taking medication for diabetes

Assure access to medical care for people with diabetes so that they can receive appropriate management of their condition In 2000, California enacted legislation that requires health insurance plans to cover diabetes education, supplies, and equipment This law will help assure that
those with diabetes who have insurance coverage will obtain the information and supplies they need to manage their condition However, people with diabetes who do not have health insurance will continue to have limited access to medical care for their diabetes Assure adequate prescription drug coverage for people with diabetes Access to prescription medications is an integral component of diabetes management Much of diabetes treatment involves either use of insulin or oral medications to maintain appropriate blood glucose levels Assuring access to these treatments is a necessary step in improving both the management of diabetes and the prevention/reduction of associated comorbidities such as high blood pressure, high cholesterol, and heart disease The diabetes insurance coverage enacted in 2000 specifies that medications for diabetes be covered– but only for insurance plans that already offer prescription drug coverage Home glucose monitoring is important especially for people using insulin to treat diabetes, yet one-fifth measured their blood glucose level less frequently than once per day Additionally, rates of home glucose monitoring among insulin users varied significantly by
race and ethnicity, with only 56 of Asian and NHOPIs and 64 of Latinos checking their blood glucose at least once per day Over two-thirds of adults with diabetes had undergone at least one foot exam by a health professional during the preceding year; however, 447,000 318 had not had any foot exam in the past year

Increase access to medical care to promote early diagnosis of diabetes With increasing budget cuts in the health care system, particularly in Los Angeles County, the number of individuals with undiagnosed diabetes is likely to increase In order to provide timely and appropriate treatment as well as reduce the risk of diabetes-related complications, Californians need appropriate access to medical care to diagnose the condition early

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Conduct culturally appropriate multilingual education for people with diabetes on how to appropriately manage their condition People with diabetes should know how often to monitor their blood glucose levels and should have the supplies and knowledge to conduct this monitoring at home They should also be aware of the potential complications of diabetes and the medical monitoring that they should
obtain to prevent these complications, such as an annual foot exam, a dilated eye exam, regular monitoring of blood pressure and cholesterol levels, and regular hemoglobin A1C tests The California Diabetes Control Program and the Diabetes Coalition of California have developed a health record card and an accompanying presentation called Take Charge This presentation can be used by nonhealthcare professionals to teach those with diabetes about the necessary tests and exams for appropriate diabetes care These tools are available in multiple languages Health care providers should provide adequate counseling on managing diabetes as well as on nutrition and physical activity for people with diabetes The California Diabetes Control Program DCP is helping to develop innovative models for diabetes management that can be used in managed-care health systems as well as by fee-for-service Medi-Cal providers These models are based on findings from the Diabetes and Complications Control Trials DCCT and have been developed in conjunction with public and private entities eg, Harbor General/UCLA Hospital, UC San Diego, and the Santa Barbara Health Authority In addition, the California DCP provides
electronic access to important diabetesspecific information for health care providers in California and around the country

State and local governments, as well as health care professionals and community health advocates, should focus on the ethnic and racial diversity of people with diabetes, the variety of languages spoken by those with diabetes, and the varied levels of educational attainment of those with diabetes People with diabetes have diverse racial and ethnic backgrounds and they speak a variety of languages In addition, the prevalence of diabetes is much higher among those who never attended high school than it is among those with higher levels of educational attainment Because of this diversity, it is crucial that all those in the health care system who interact with people with diabetes, as well as those in state and local governments who create policy that affects those with diabetes, be aware of cultural differences and work to communicate effectively

CONCLUSION
In California, 14 million adults and 12,000 adolescents have been diagnosed with diabetes An additional 18 million adults and 176,000 adolescents are at significant risk for developing Type 2 diabetes
because of overweight and obesity in conjunction with limited physical activity The focus for all Californians should be on minimizing the risks for and complications of diabetes Strategies and policies that promote prevention of Type 2 diabetes and the effective management of diabetes need to be implemented To achieve this, individuals, communities, health care providers, the health care system, and government programs need to work together to address the disparities in risk, prevalence, level of care, and outcomes for diabetes

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

APPENDIX

appendix
Community-outreach campaigns were conducted in communities of color to encourage the participation of populations that often have low participation rates in surveys These campaigns used media and materials that were both culturally and linguistically appropriate to particular communities CHIS covered a broad range of public health concerns, including health insurance coverage, eligibility for and participation in public health care programs, access to and use of health care services, health and mental health status, chronic conditions asthma, cancer,
cardiovascular disease, arthritis, and diabetes, health behavior including diet and physical activity, alcohol and tobacco use, and cancer screening and prevention, dental health, womens health, and demographic characteristics including employment; income; race; Latino, Asian, and Pacific Islander ethnicity; nativity of the respondent and his or her parents; citizenship; immigration status; and English proficiency CHIS is a collaboration of the UCLA Center for Health Policy Research, the California Department of Health Services, and the Public Health Institute Funding for CHIS 2001 has been provided by the California Department of Health Services, the National Cancer Institute, The California Endowment, the California Children and Families Commission, the Centers for Disease Control and Prevention CDC, and the Indian Health Service For more information on CHIS, please visit wwwchisuclaedu

DATA SOURCE
The findings presented in this report are based on data from the 2001 California Health Interview Survey CHIS 2001 CHIS 2001 interviewed 55,428 households drawn from every county in California for its random-digit dial RDD telephone survey, providing a sample that is representative of
the states noninstitutionalized population living in households Data were weighted to the 2000 Census CHIS interviewed one sample adult in each household In households with children, CHIS interviewed one adolescent ages 12-17 a total of 5,801, and obtained information for one child under age 12 by interviewing the adult who was most knowledgeable about the child a total of 12,592 Westat, a private survey research organization, conducted the RDD portion of the CHIS interviews between November 2000 and September 2001 In addition to the RDD sample, CHIS conducted an oversample of American Indians and Alaska Natives residing in both urban and rural areas and oversamples of Japanese, Vietnamese, South Asians, Koreans, and Cambodians; this report does not include data from these oversamples Expert teams reviewed all CHIS questionnaires to ensure that question wording was culturally appropriate for a variety of population groups Questionnaires were also translated, and interviews were conducted in six languages: English, Spanish, Chinese Mandarin and Cantonese dialects, Vietnamese, Korean, and Khmer Cambodian

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BRIEF DESCRIPTION OF VARIABLES
USED
CHIS 2001 includes a wide range of demographic and health information obtained from respondents, including extensive information on race and ethnicity as well as information on the prevalence of diabetes, medical care for diabetes, height and weight, and physical activity Race and Ethnicity Respondents were first asked if they are of Latino or Hispanic origin They were then asked which one or more of the following racial groups they would use to describe themselves: Native Hawaiian and other Pacific Islander, American Indian and Alaska Native, Asian, African American, or white Respondents who selected more than one racial group or who said they were Latino and selected a racial group were asked which group they most identified with Responses to this question were used to categorize respondents who identified more than one race or ethnicity into the following racial and ethnic categories: Latino, white, African American, Asian, Native Hawaiian and other Pacific Islander NHOPI, American Indian and Alaska Native AIAN, and Other Respondents who did not select a single race or ethnicity with which they most identified were assigned to the other race category Finally, any respondent
who selected AIAN and reported that he or she was enrolled as a member of a tribe was assigned to be AIAN The number of NHOPI in the CHIS 2001 sample is relatively small n 219 adults using the classification described in the previous paragraph Estimates for this group were reported separately whenever possible When the sample of NHOPI was too small, it was included in the Asian category As a result, we combined NHOPIs with Asians for all analyses conducted in this report except for those included in the Identifying At Risk Populations section In addition, we did not report any estimates for the other race and ethnicity category in this report

Diabetes-specific Variables The prevalence of diabetes was calculated from adult and adolescent respondent answers to the question Has a doctor ever told you that you have diabetes or sugar diabetes? Women were asked a variation of this question: Other than during pregnancy, has a doctor ever told you that you have diabetes or sugar diabetes? Adult respondents who said yes were asked additional items, including age at first diagnosis; use of insulin or oral medication; frequency of home glucose-monitoring; and number of foot exams by a
physician during the preceding year Please note that the estimates of diabetes prevalence presented in this report are based on respondents reporting that they received a diagnosis of diabetes from a doctor, which may underestimate the prevalence due to limitations of respondent recall or limited access to medical care In addition, persons who reported having diabetes were asked about the number of times a doctor checked for hemoglobin A one C in the past year It is unclear whether respondents were able to accurately answer this item Hemoglobin A1C glycosylated hemoglobin is a type of blood test that measures blood sugar control over an extended period in individuals with diabetes It requires that a specific test be done at the laboratory Although respondents are likely to know if they had blood drawn in the past year, they may not know which specific blood tests were performed unless they specifically asked their doctor or were told the test had been conducted Experts agree that the best way to determine the true rate at which Hemoglobin A1C is measured among people with diabetes is to conduct a chart review However, there is a major educational initiative by the California
Diabetes Control Program in partnership with the National Diabetes Education Program to increase patients knowledge, understanding, and awareness of this important measure for evaluating glycemic control

DIABETES IN CALIFORNIA: FINDINGS FROM THE 2001 CALIFORNIA HEALTH INTERVIEW SURVEY

Body Mass Index Body Mass Index BMI was calculated based on respondent reports of weight in pounds or kilograms and height in feet/inches or meters/centimeters Wherever necessary, responses were converted to metric values, and BMI was calculated in kg/m2 The values for adolescents were compared to age- and gender-appropriate growth charts for the United States Adolescents in the 85th to 94th percentiles are considered at risk for being overweight, and adolescents in the 95th percentile and higher are categorized as overweight These percentiles roughly correspond to the overweight and obese BMI ranges for adults There is evidence that respondents may underestimate their weight and overestimate their height when self-reporting this information Although self-reported height and weight are highly correlated with measured height and weight, BMI derived from self-reported height and weight may
underestimate the true prevalence of overweight and obesity37 Physical Activity Physical activity for adults was based on the frequency and duration of participation in moderate and vigorous leisuretime activities and other nonleisure activities during the month preceding the interview The individual measures were used to construct a 3-level physical activity variable in which regular physical activity was defined as at least 3 days per week of vigorous physical activity for at least 20 minutes

or at least 5 days per week of moderate physical activity for at least 30 minutes The category of some physical activity includes those individuals who responded yes to participating in either vigorous or moderate physical activity but did not meet the standards for regular physical activity The category of no physical activity/sedentary includes the participants who responded no to any form of physical activity Adolescents were asked about their participation in physical activities during the preceding 7 days Their responses are categorized similarly to those of adults: participating in regular physical activity, some physical activity, or no physical activity using the same
criteria

STATISTICAL ANALYSES AND REPORTING OF FINDINGS
All estimates presented in this study have a coefficient of variation CV less than or equal to 030 unless otherwise noted The CV provides information about the precision of estimates from survey data It was determined that estimates with a CV greater than 030 should not be presented because the true estimate might be very different from the one that was calculated In addition, all comparative statements reflect statistically significant differences p 005 unless otherwise noted

Kuczmarski MF Kuczmarski RJ, Najjar M Effects of age on validity of self, reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994 J Am Diet Assoc, 2001; 101 1: 28-34

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UCLA CENTER FOR HEALTH POLICY RESEARCH 10911 WEYBURN AVENUE, SUITE 300 LOS ANGELES, CALIFORNIA 90024 PHONE: 310 794-0909 FAX: 310 794-2686 chpr@uclaedu wwwhealthpolicyuclaedu 21650 OXNARD STREET, SUITE 1200 WOODLAND HILLS, CALIFORNIA 91367 PHONE: 818 703-3311 FAX: 818 703-4193
wwwcalendoworg

RT2003-2

Source:healthpolicy.ucla.edu

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