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Diabetes in Indiana
A Report on Diabetes Morbidity and Mortality

Diabetes in Indiana: A Report on Diabetes Morbidity and Mortality

Published February 2008 by Indiana State Department of Health

State Health Commissioner Judith A Monroe, MD

Human Health Services Commission Loren Robertson, MS, Assistant Commissioner

Primary Author Joan Marciniak, MPH, Epidemiologist, Diabetes Prevention and Control Program, ISDH

Other Contributors Charles M Clark, MD, Associate Dean, Professor of Medicine, Indiana University Laura Heinrich, Director, Diabetes Prevention and Control Program, ISDH Linda W Stemnock, BSPH, Data Analyst and BRFSS Coordinator, ISDH Robert Teclaw, DVM, PhD, MPH, State Epidemiologist, Chronic Disease, ISDH

Indiana State Department of Health 2 North Meridian Street Indianapolis, IN 46204 wwwingov/isdh

Dear Reader: The Indiana State Department of Health, Diabetes Prevention and Control Program, and the Diabetes Advisory Council DAC are pleased to present the most recent Indiana Diabetes Report As much as 81 of Indianas adult population has been diagnosed with diabetes compared to the national average of 75 Diabetes was the 6th leading cause of death in Indiana in
2005 It was the 4th leading cause of death for blacks, 7th for whites, and 6th for Hispanics/Latinos in 2005 While highly effective treatment exists, diabetes is often uncontrolled or poorly controlled, needlessly keeping those who suffer with the disease from school, work, and leisure activities Anyone, anywhere, at any age, can develop diabetes Many adults have had diabetes for several years before their symptoms are recognized By the time they are diagnosed, a great many have already started to develop complications of diabetes — visual impairment, kidney failure, heart disease, stroke, and nerve damage Detecting and diagnosing diabetes early means that it can be treated and the risk of serious complications can be reduced The consequences of diabetes are costly In 2007, the total annual economic cost of diabetes in the United States was estimated to be 174 billion This does not include social costs such as pain and suffering, care provided by non-paid caregivers, or excess medical costs associated with undiagnosed diabetes Those with diabetes have medical expenditures 23 times greater than what expenditures would be in the absence of diabetes The prevalence of obesity in
Indiana contributes to the diabetes burden increasing the number of individuals who are diagnosed with type 2 diabetes Part of the Diabetes Prevention and Control Programs vision is to make the public aware of the impact of diabetes in our state primarily through data surveillance and reporting It is our goal that the data is used as indicators and evidence, to inform strategic plans, for decision-making, for program improvement, and for needs assessment This is our Call To Action Our challenge today is activating our communities and organizations For a Healthier Tomorrow,

JUDITH A MONROE, MD STATE HEALTH COMMISSIONER

Table of Contents
Diabetes in Indiana: An Overview 5 Introduction7 Types of Diabetes 8 Causes of Diabetes9 Symptoms9 Incidence and Prevalence 9 Risk Factors11 Complications30 Treatment 52 Prevention of Complications54 Gaps and Barriers to Diabetes Care 68 Looking to the Future71 References72

Diabetes in Indiana: An Overview
Scope of the Problem 81 of Indianas adult population reported that they had been diagnosed with diabetes1 compared to the national average of 752 It is estimated that 3 of the Indiana population has undiagnosed diabetes3 Diabetes was the 6th
leading cause of death in Indiana in 2005 It was the 4th leading cause of death for Blacks, 7th for Whites, and 6th for Hispanics/Latinos5 Individuals with diabetes incurred an average expenditure of 11,744 per year 6,649 attributed to diabetes, which is about 23 times higher than what expenditures would be in the absence of diabetes4 Assuming that the 384,000 Indiana adults with diagnosed diabetes have similar medical costs, over 45 billion dollars would have been spent on medical care with about 26 billion dollars directly attributed to diabetes in 2006

Populations at Risk Older age Individuals 65 years and older 124 of Indianas population had a diabetes prevalence of 201 Race/Ethnicity o Black adults 81 of Indianas population had a diabetes prevalence of 101 o Hispanic/Latino Americans adults 41 of Indianas population had a diabetes prevalence of 41 Please note: The change in Hispanic diabetes prevalence between years has not been statistically significant o Asian, Native Hawaiian/Pacific Islanders, American Indian/Alaskan Native, or other adults 23 of the population had a diabetes prevalence of 81 o Those identifying themselves as having two or more races 07 of Indianas
population had a diabetes prevalence of 151 Gestational diabetes In 2006, 2 of women reported they had been diagnosed with gestational diabetes diabetes during pregnancy1 Of these women , 2050 have a chance of developing diabetes in the next 510 years and about 510 will have type 2 diabetes immediately following pregnancy3 High blood glucose or pre-diabetes 26 of Indianas have pre-diabetes putting them at risk for developing diabetes later in life3 Overweight or obese 63 of adults in Indiana were overweight or obese in 20061 Sedentary lifestyles 25 of Indiana adults did not get participate in any physical activity in the past month1 Smoking 24 of Indianas adult population in 2006 were current tobacco smokers1

Diabetes in Indiana: An Overview
Complications due to Diabetes Death 1,721 individuals died from diabetes as the underlying cause of death, and 3,163 individuals died from diabetes as a contributing cause of death5 Hospitalizations 9,894 individuals admitted to the hospital as inpatients had the primary diagnosis of diabetes6 Heart attack 17 of individuals with diabetes have had a heart attack, and 16 have been told by a health care professional that they have
angina or coronary heart disease7 Stroke 8 of those with diabetes have been diagnosed with a stroke7 Blindness 554 new cases of legal blindness and 272 new cases of visual impairment were due to diabetic retinopathy in adults over 17 years of age8 Of adults with diabetes, 18 have been told that their diabetes has affected their eyes or caused retinopathy1 Kidney disease 812 of the 2,030 new cases of end stage renal disease were in people with diabetes9 Lower extremity amputations 1,763 individuals with a primary hospital discharge diagnosis of diabetes underwent a lower extremity amputation6 Depression 28 of individuals with diabetes have been diagnosed with a depressive disorder1 Dental Disease 40 of adults with diabetes have had six or more including all teeth removed compared to the 16 in adults without diabetes2

References: All population estimates are from United States Census Bureau American Community Survey, 2006, http://quickfactscensusgov/qfd/states/18000html 1 Indiana State Department of Health Behavioral Risk Factor Surveillance System Survey Data, 2006 2 Centers for Disease Control and Prevention CDC Behavioral Risk Factor Surveillance System Survey Data, 2005
and 2006 3 Centers for Disease Control and Prevention CDC National Diabetes Fact Sheet, 2005, http://wwwcdcgov/diabetes/pubs/pdf/ndfs_2005pdf 4 American Diabetes Association, http://wwwdiabetesorg 5 Indiana State Department of Health, Mortality Data, 2005 6 Indiana State Department of Health, Indiana Hospital Discharge Data, 2005 7 Indiana State Department of Health, Behavioral Risk Factor Surveillance System Survey Data, 2005 8 Indiana Blind Registry Data, 2005 9 The Renal Network, 2005, wwwtherenalnetworkorg

Introduction
In the United States, the diabetes epidemic has been growing rapidly From 1963 to 1975, there was a sharp increase in diabetes during which prevalence went from 136 to 258 per 1,000 Americans Diabetes prevalence leveled off in 1975 but more than doubled by 1990 264 to 545 per 100,000 The prevalence continues to grow, increasing by almost 5 each year1 In 2005, there were 15 million new cases incidence of diabetes diagnosed in people 20 years or older Of those, 202,000 new cases were among individuals aged 20-39 years, 727,000 were aged 40-59 years, and 575,000 were individuals over 60 years of age The estimated total number prevalence of people in the United
States with diabetes in 2005 was 21 million people, roughly 7 of the population Of the estimated 21 million people with diabetes, 146 million were diagnosed cases and 62 million were undiagnosed cases It is estimated that almost onethird of all diabetes cases are undiagnosed2 Diabetes is the most common chronic disease among children in the United States and is becoming more prevalent Approximately 150,000 people aged 18 years or younger have diabetes, meaning roughly one in every 400-600 children and adolescents are affected Typically when diabetes occurs in children, it is assumed to be type 1 or juvenile-onset diabetes More than 13,000 children are diagnosed with type 1 diabetes each year However in the past two decades, the frequency of type 2 diabetes has been increasing among this population Unfortunately, the extent of this increase is unknown To address this data gap, the Centers for Disease Control and Prevention CDC and the National Institutes of Health NIH funded a fiveyear, multi-center study, SEARCH for Diabetes in Youth, to examine the status of diabetes in children and adolescents in the United States They found the crude prevalence to be estimated at 182 cases per
1,000 youth and the overall prevalence estimate for diabetes in children and adolescents was approximately 018 The study is ongoing in hopes of gaining a better understanding of the effect of diabetes on the younger population2 This nationwide increase in diabetes incidence and prevalence is also seen in Indianas population In some cases, the prevalence in Indiana is higher than the national average Diabetes is a public health issue because the disease and its complications are largely preventable The Diabetes Prevention and Control Program DPCP at the Indiana State Department of Health ISDH compiles and disseminates diabetes data based on the most recent mortality and morbidity data available, as well as behavior risk survey information The majority of data available on diabetes relates to adults Therefore, the focus of this report is adults 18 years and older The objective of this report is to provide general information about diabetes including its causes and complications and trends in incidence and prevalence The report also describes diabetes-related morbidity and mortality in the state The hope is that this report will be used to identify areas in diabetes prevention and
care that need more attention, to highlight issues that need funding and resources, and to help evaluate programs and efforts to reduce the burden of diabetes in Indiana3

Types of Diabetes
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both Insulin is necessary for the bodys regulation of blood glucose levels It is a hormone produced in the pancreas and functions to convert sugars, starches, and other foods into energy If diabetes is not controlled, over time, glucose and fat remain in the blood and damage vital organs The build-up of glucose in the blood is called hyperglycemia2 Type 1 diabetes, formerly known as juvenile-onset diabetes or insulin-dependent diabetes mellitus, most often appears during childhood or adolescence and accounts for 5-10 of all diagnosed cases of diabetes In type 1 diabetes, the bodys immune system destroys the cells that produce insulin Since the body produces little or no insulin, people with type 1 diabetes must take insulin daily through injection or an insulin pump to survive Type 1 diabetes is usually diagnosed within a short time, because
the symptoms are severe and the onset is rapid2 Type 2 diabetes, formerly called adult-onset diabetes or non-insulin-dependent diabetes, usually begins as insulin resistance, a disorder in which the cells do not use insulin properly As the need for insulin rises, the pancreas gradually loses its ability to produce insulin Type 2 accounts for 9095 of people diagnosed with diabetes Often people can control their blood glucose by exercising regularly and watching what they eat Type 2 diabetes most often appears in people older than 40 years of age but is increasingly being diagnosed in children and teens and is no longer considered an adults-only disease2 Gestational diabetes is a form of glucose intolerance diagnosed in some women during pregnancy that also increases their risk of developing type 2 diabetes in the future Gestational diabetes requires treatment during pregnancy to normalize maternal blood glucose levels to avoid complications in the infant2 Other types of diabetes mellitus result from specific genetic conditions, surgery, drugs, infections, malnutrition, and other illness Such types only account for 1-5 of all diagnosed cases2 Pre-diabetes is a term used to
distinguish people who are at increased risk of developing type 2 diabetes People with pre-diabetes have higher blood sugar than normal, though not high enough to be diagnosed with diabetes Pre-diabetes is characterized by impaired fasting glucose IFG or impaired glucose tolerance IGT and in some cases both IFG is a condition where the fasting blood sugar level is 100 to 125 milligrams per deciliter mg/dL after an overnight fast, and IGT is a condition where the blood sugar level is 140 to 199 mg/dL after a two-hour oral glucose tolerance test2 Each year about 4-9 of people with pre-diabetes will develop type 2 diabetes4

Causes of Diabetes
The exact causes of developing both type 1 and type 2 are unknown, although they appear to be different The onset of type 1 diabetes is suspected to follow exposure to an environmental trigger, such as an unidentified virus, stimulating an immune attack against the insulinproducing pancreas cells in some genetically predisposed people2 The cause of type 2 appears to be genetic but has a large environmental component Although a person can inherit a tendency to develop type 2 diabetes, it usually takes another factor such as obesity to initiate
disease development5

Symptoms
Symptoms of diabetes include frequent urination, extreme thirst and hunger, unusual weight loss, increased tiredness, irritability, blurred vision, very dry skin, numbness and tingling in the hands and feet, and slow healing of cuts and bruises Nausea, vomiting, and stomach pains can also accompany some of these symptoms in the abrupt onset of type 1 diabetes2

Incidence and Prevalence
The incidence and prevalence of diabetes in Indiana are similar to those at the national level Adult diabetes prevalence data in Indiana come from the Behavioral Risk Factor Surveillance System BRFSS BRFSS is the worlds largest, on-going telephone health survey system, tracking health conditions and risk behaviors for adults 18 years or older in the United States yearly since 1984 According to Indianas 2006 BRFSS data, 81 of Indianas adult population reported that they have been told by a doctor that they have diabetes, which was greater than the national average of 75 Figure 16,7 Figure 2 shows the increasing prevalence of diabetes in Indiana since 19956 The 81 prevalence among adults is just a fraction of the diabetes epidemic in Indiana It is estimated that about 3
of the population has undiagnosed diabetes2 Another 26 of adults are estimated to have pre-diabetes, meaning they have blood sugar levels above normal but not high enough to be diagnosed as diabetes8 Those with pre-diabetes are at higher risk for developing diabetes in their lifetime The concern about pre-diabetes in recent years has prompted the CDC to add a pre-diabetes response to the diabetes question to the BRFSS in 2004 Figure 3 shows the Indiana pre-diabetes prevalence as compared to the United States6,7 These data only capture those who are aware of their pre-diabetes status not those undiagnosed As stated above, it is estimated that 26 of the population falls in this category8 It is likely that the pre-diabetes prevalence will increase in the future especially as the rate of obesity increases

Figure 1: Diabetes Prevalence, Indiana Compared to the United States, 2006
90 80
Percentage

70 60 50 40 30 20 10 00 Diabetes
Indiana United States

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 2006 BRFSS Data

Figure 2: Diabetes
Prevalence, Indiana, 1995-2006
90 80 70 66 60 50 53 52 60 65 74 78 77 83 81

Percentage

60 50 40 30 20 10 00

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 1995-2006 BRFSS Data

Figure 3: Pre-Diabetes Prevalence, Indiana Compared to the United States, 2004-2006
12 10

Percentage

08 06 04 02 00 Indiana United States

2004 07 09

2005 10 08

2006 10 10

Risk Factors
Risk factors for type 1 include autoimmune, genetic, and environmental factors However, less is known about type 1 than type 2, which is largely preventable Risk factors for type 2 diabetes include both genetic and lifestyle factors that are classified as either non-modifiable or modifiable Although there are two different classifications, interactions can occur between the two For example,
genes can predispose an individual to developing diabetes but often environmental and behavioral factors activate the genetic predisposition5 Non-modifiable risk factors include gender and previous gestational diabetes, age, and genetic factors such as race/ethnicity Although less clear, education and income level play a role in type 2 diabetes as those with lower levels of education and income tend to have a higher prevalence of diabetes Whether these factors are modifiable or not depends on circumstances Modifiable risk factors include obesity, physical inactivity, and nutritional factors Obesity is the most important risk factor for development of type 2 diabetes Other factors worth noting include low birth weight, exposure to a diabetic environment in utero, and a potential inflammatory component, but further research is need in these areas5

Gender and Gestational Diabetes In 2006, adult females in Indiana had a higher diabetes prevalence 84 than males 78 though it was not statistically significant, and they had a higher prevalence than the United States average prevalence 71 Figure 46, 7 Female prevalence has not always been higher than male prevalence as seen in Figure 5
Women are at greater risk, especially those who had gestational diabetes Gestational diabetes increases a womans chances of developing diabetes after pregnancy or years later Women who are diagnosed with gestational diabetes have a 20-50 chance of developing diabetes in the next 5-10 years A portion of women with gestational diabetes 5-10 will have type 2 diabetes immediately following their pregnancy Black, Hispanic/Latino, and American Indian females are at greater risk of developing gestational diabetes, as are those who are overweight or obese 559 of women in Indiana 2006 BRFSS or have a family history of diabetes2 In 2006, 1 of Indiana adult women reported that they had been diagnosed with gestational diabetes which was higher than the national prevalence of 08 The prevalence of gestational diabetes has been steadily increasing since 2001 when prevalence was at its lowest 06 Figure 6 As expected, women most affected by gestational diabetes are those 25-44 years of age Figure 7 Minorities reported a higher prevalence of gestational diabetes when compared to Whites Figure 86 Information from ISDH vital records offers a more comprehensive description of gestational diabetes in
Indiana as it includes all women not just those over 18 years of age In 2005, there were 1,558 births to mothers with gestational diabetes This number has been increasing in the past decade as shown in Figure 9 Overall, the percentage has increased but in the past few years the numbers have remained similar Figure 10 In 2005, there were 1,467 births 17 of all births to mothers who had diabetes prior to pregnancy Figures 11 and 12 As expected, the numbers and percentages have increased in the past ten years9

Figure 4: Diabetes Prevalence by Gender, Indiana Compared to the United States, 2006
9 8 7 6 5 4 3 2 1 0 78 79 84 71

Percentage

Indiana United States

Male
Gender

Female

Figure 5: Diabetes Prevalence by Gender, Indiana, 2001-2006
10 8

Percentage

6 4 2 0 Male Female

2001 63 68

2002 72 76

2003 81 75

2004 80 75

2005 90 78

2006 78 84

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you
ever been told by a doctor that you have diabetes? Source: Indiana 2001-2006 BRFSS Data

Figure 6: Female Prevalence of Pregnancy-Related Diabetes, Indiana, 2001-2006
12 10 10 08 06 06 04 02 00 2001 2002 2003 2004 2005 2006 09 07 10 10

Percentage

Figure 7: Female Pregnancy-Related Diabetes by Age, Indiana, 2004-2006
45 40 35

Percentage

30 25 20 15 10 05 00 2004 2005 2006 18-24 18 08 27 25-34 29 40 34 35-44 33 37 28 45-54 12 10 11 55-64 09 07 17 65 04 06 06

Age
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 2004-2006 BRFSS Data

Figure 8: Female Pregnancy-Related Diabetes by Race/Ethnicity, Indiana, 2004-2006
8 7

Percentage

6 5 4 3 2 1 0 2004 2005 2006 White 16 18 18 Black 18 22 17 Hispanic 48 17 69 21 Other 10 MultiRacial 42

Race/Ethnicity
Note: Data for Other and MultiRacial for 2005 and data for MultiRacial
for 2006 were N/A Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 2004-2006 BRFSS Data

Figure 9: Number of Live Births to Mothers with Gestational Diabetes, Indiana, 1995-2005
1800 1600 1503 1382 1400 1200 1048 1102 1000 800 600 400 200 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 1230 1229 1203 1250 1553 1585 1558

Number of Live Births

Year
Source: Indiana State Department of Health, Vital Records, 1995-2005 Data

Figure 10: Percentage of Live Births to Mothers with Gestational Diabetes, Indiana, 1995-2005
2

Percentage of Live Births

18 16 14 12 1 08 06 04 02 0 13 13 15 16 14 14 14

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year
Source: Indiana State Department of Health, Vital Records, 1995-2005 Data

Figure 11: Number of Live Births to Mothers with Pre-Existing Diabetes, Indiana, 1995-2005
1600 1467 1308 1286 1308 1254 1242 1024 1060 1107 1034 1045

Number of Live Births

1400 1200 1000 800 600 400 200 0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year
Source: Indiana State
Department of Health, Vital Records, 1995-2005 Data

Figure: 12: Percentage of Live Births to Mothers with Pre-Existing Diabetes, Indiana, 1995-2005
18

Percentage of Live Births

17 16 14 13 12 1 08 06 04 02 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 12 13 12 12 15 15 15 14 15

Year
Source: Indiana State Department of Health, Vital Records, 1995-2005 Data

Age Over 12 of the Indiana population is 65 years or older, representing an approximate increase of 57 from 1995 to 2005 It is estimated that by 2025, the number of older Indiana residents will increase to 19 or 13 million older persons10 This will present a challenge, because individuals 65 years and older have the greatest diabetes prevalence 199 compared to all other age groups Figure 136 Indiana had a higher diabetes prevalence in all age categories compared to the United States except for those 45-54 years of age Figure 136, 7 Figure 14 shows the diabetes prevalence in each age category since 2001 The majority of adults with diabetes reported that they were first diagnosed between 46-60 years of age, which has been consistent since 2002 Figure 156

Figure 13: Diabetes Prevalence by Age, Indiana
Compared to the United States, 2006
25 20

Percentage

15 10 5 0 Indiana United States

18-24 10 08

25-34 20 16

35-44 50 37

45-54 66 77

55-64 147 142

65 199 181

Figure 14: Diabetes Prevalence by Age, Indiana, 2001-2006
25 20

Percentage

15 10 5 0
2001 2002 2003 2004 2005 2006

1 8-24 06 07 02 1 7 06 1 0

25-34 25 1 4 1 2 1 6 1 1 20

35-44 37 47 42 42 51 50

45-54 75 81 95 78 87 66

55-64 1 8 1 1 41 1 48 1 51 1 48 1 47

65 1 35 1 71 1 75 1 77 205 1 99

Figure 15: Age when Diabetes was First Diagnosed, Indiana, 2002-2006
45 40 35 30 25 20 15 10 5 0 1-15 16-30 31-45
Age
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: How old were you when you were told you have diabetes? Source: Indiana
2002-2006 BRFSS Data

2002 2003 2004 2005 2006

Percentage

46-60

Race/Ethnicity United States Census Data for 2006 indicated that 87 of Indianas population was Black, 47 was Hispanic/Latino, and 13 was Asian American/Pacific Islander Compared to surrounding Midwest states, Indiana had the second largest Hispanic/Latino population and the fourth largest Black population Although Indiana does not have Native Americans living in exclusive communities reservations, 03 of Indianas population was Native American10 Blacks and Hispanic/Latinos are much more likely to have diabetes, to develop its complications, and to die from the disease at an earlier age compared to their White counterparts According to the 2006 BRFSS, Blacks had a 10 prevalence, Hispanic/Latinos had a 4 prevalence, and Whites had an 8 prevalence Figure 16 Whites, multiracial, and individuals identified as other had a higher diabetes prevalence than the United States averages Figure 16, however the differences were not statistically significant When comparing the prevalence among years, nearly all categories showed an increase in diabetes prevalence Figure 17 Please note that while the prevalence of diabetes
for Hispanics/Latinos, other and multiracial respondents fluctuated from 2001 to 2006, the differences were not statistically significant The fluctuation was most likely due to the number of respondents from those race/ethnicity categories For example, the number of other race respondents ranged from 73 to 121 in those six years

Figure 16: Diabetes Prevalence by Race/Ethnicity, Indiana Compared to the United States, 2006
16 14 12

Percentage

10 8 6 4 2 0 Indiana United States White 8 72 Black 10 119 Hispanic 4 63 Other 83 77 MultiRacial 152 88

Race/Ethnicity
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 2006 BRFSS Data

Figure 17: Diabetes Prevalence by Race/Ethnicity, Indiana, 2001-2006
20

Percentage

15 10 5 0 White Black Hispanic Other MultiRacial

2001 59 117 98 95 100

2002 69 148 55 59 115

2003 76 115 68 79 63

2004 75 121 64 56 86

2005 78 104 100 165

2006 80 100 40 83 152

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a
doctor that you have diabetes? Source: Indiana 2001-2006 BRFSS Data

Education and Income Prevalence of diabetes and income level are related Individuals with less income tend to have a higher prevalence of diabetes In 2006, the prevalence of diabetes was the greatest among adults with less than a high school diploma 98 and the prevalence was the lowest 53 among those with a college degree Figure 18 The differences between the levels of education were statistically significant This trend has been consistent for the past six years Figure 196 Also, the less income individuals have the more likely they are to have diabetes In 2006, the prevalence for those with an annual household income from all sources of less than 15,000 was 141 compared to only a 5 prevalence in those that had a yearly income of 50,000 Figure 20 The differences between the levels of income in relation to diabetes prevalence are statistically significant This trend has been fairly consistent since 2001 Figure 216

Figure 18: Diabetes Prevalence by Education, Indiana Compared to the United States, 2006
14 12
Percentage

10 8 6 4 2 0
Indiana United States Less than HS 98 127 HS or GED 94 88 Some Post- College HS
Graduate 82 77 53 54

Figure 19: Diabetes Prevalence by Education, Indiana, 2001-2006
20
Percentage

15 10 5 0
Less than HS HS or GED Some Post-HS College Graduate 2001 116 68 62 44 2002 116 77 71 55 2003 149 84 61 52 2004 141 81 67 51 2005 127 92 89 49 2006 98 94 82 53

Figure 20: Diabetes Prevalence by Annual Income, Indiana Compared to the United States, 2006
15

Percentage

152515,000 24,999 34,999 141 142 114 105 106 9

3550,000 49,999 60 75 50 51

Indiana United States

Income
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever been told by a doctor that you have diabetes? Source: Indiana 2006 BRFSS Data

Figure 21: Diabetes Prevalence by Income, Indiana,
2001-2006
20
Percentage

15 10 5 0
15,000 15-24,999 25-34,999 35-49,999 50,000 2001 146 115 59 49 31 2002 114 127 78 54 49 2003 138 103 100 57 45 2004 156 125 84 66 45 2005 127 134 90 66 51 2006 141 114 106 60 50

Obesity, Physical Inactivity, and Nutrition More than 80 of people with type 2 diabetes are overweight or obese11 According to the 2006 BRFSS, 63 of Indianas adults were overweight or obese compared to the national level of 62 Figure 22 Figure 23 shows the relationship and change among the body mass index BMI categories as the Indiana progresses towards greater obesity Figures 24 and 25 show the specific percentages of overweight and obese adults in Indiana Males tended to be more overweight than females; however females were just slightly more obese than males Figure 26 In 2006, Black adults had the highest obesity prevalence, and Hispanic adults had the highest prevalence of overweight Figure 276 Physical activity has decreased over recent decades and has
been a major contributing factor in the increase in obesity Studies have shown physical activity to be an independent predictor of type 2 diabetes development5 In 2005, 73 of Indiana adults did not get 20 minutes or more of vigorous physical activity three times a week Nearly 78 of women and 68 of men reported that they did not meet this standard When comparing race/ethnicity, 26 of Whites and 29 of Blacks reported meeting the standard Hispanics/Latinos reported getting the most exercise 36 but the percentage was still low6 Obesity is occurring at an earlier age The increase in childhood obesity is now being accompanied by a rapid increase in type 2 diabetes in children and adolescents Twenty years ago, type 2 diabetes was a disease of the middle and late years of life Now, among some populations, type 2 is almost as prevalent as type 1 in young people2 The Youth Risk Behavior System YRBS was developed in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth 9th through 12th grades in the United States In 2003, 12 of 9th12th graders were overweight which increased to 15 in 2005 and
decreased in 2007 to 14 Figure 28 In 2007, 44 of high school-aged adolescents reported that they were physical active, a statistically significant increase from 32 in 2005 Figure 29 In 2007, 29 reported watching three or more hours of television a day which was a statistically significant decrease from 32 in 200512 Nutritional factors also play a role, yet their role is more uncertain because of the difficulty of collecting accurate dietary data High total calorie and low dietary fiber intake, high glycemic load and low polyunsaturated to saturated fat ratio may lead to type 2 diabetes Data on food intake in Indiana residents is limited However in 2005, only 22 of adults reported that they consumed fruits or vegetables five or more times a day6

Figure 22: Overweight and Obese Adults, Indiana Compared to the United States, 2006
40 35 30
Percentage

37 28 25
Indiana United States

25 20 15 10 5 0 Overweight Obese

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Overweight as BMI 25 299, and obese as BMI 30 Source: Indiana 2006 BRFSS Data

Figure 23: Overweight and Obese Adults, Indiana, 1998-2006
50 40
Percentage

30
20 10 0
19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06

Not Overw eight/Obese Overw eight Obese

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Normal is defined as BMI 249, overweight as BMI 25 299, and obese as BMI 30 Source: Indiana 2006 BRFSS Data

Figure 24: Overweight Adults, Indiana, 1998-2006
40 35 30 25 20 15 10 5 0
19

Percentage

05 20

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Overweight as BMI 25 299 Source: Indiana 2006 BRFSS Data

Figure 25: Obese Adults, Indiana, 1998-2006
30 25
Percentage

25 20 20 22

20 15 10 5 0

05 20

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Obese as BMI 30 Source: Indiana 2006 BRFSS Data

Figure 26: Overweight and Obese Adults by Gender, Indiana, 2006
45 40 35
Percentage

30 25 20 15 10 5 0 Overweight Obese

Male Female

Percentages are weighted to
population characteristics Survey was asked of individuals 18 years or older Overweight as BMI 25 299, and obese as BMI 30 Source: Indiana 2006 BRFSS Data

Figure 27: Overweight and Obese Adults by Race/Ethnicity, Indiana, 2006
50 40
Percentage

30 20 10 0
Overweight Obese White 35 28 Black 33 37 Hispanic 46 21 Other 23 19

Race/Ethnicity
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Overweight as BMI 25 299, and obese as BMI 30 Source: Indiana 2006 BRFSS Data

Figure 28: Overweight Students, Indiana, 2003 and 2005
16 14 12 10 8 6 4 2 0 15 12 14

Percentage

2003

2005
Year

2007

At or above the 95th percentile for body mass index, by age and gender The body mass index is calculated based on self reported weight and height data Percentages are weighted to population characteristics Survey was asked of individuals in 9th through 12th grades Overweight as BMI 25 299 Source: Indiana 2003 and 2005 YRBS Data

Figure 29: High School Students who were Physically Active for 60 Minutes on at Least Five of the Past Seven Days, Indiana, 2005
50 45 40 35 30 25 20 15 10 5 0 44 32

Percentage

2005
Percentages are weighted to
population characteristics Survey was asked of individuals in 9th through 12th grades Source: Indiana 2005 YRBS Data

2007

Complications
Diabetes is a serious disease, at times causing death even in those who have not developed complications Cardiovascular complications are the leading cause of mortality and long-term morbidity for individuals with diabetes Diabetes is a leading cause of blindness, kidney disease, and lower extremity amputations Cardiovascular Complications High blood pressure and high cholesterol lead to coronary artery disease heart disease, myocardial infarction heart attack, and stroke Heart disease and stroke account for about 65 of deaths in people with diabetes Adults with diabetes are two to four times more likely to die of heart disease than adults without diabetes, and they are two to four times more at risk of having a stroke2 In 2005, 66 of adults in Indiana with diabetes had high blood pressure Figure 30, and 91 were taking medication for it Sixty-seven percent reported having high cholesterol Figure 30 Approximately 16 of adults with diabetes reported having coronary artery disease compared to 4 of adults without diabetes Figure 31 Almost 17
reported having had a myocardial infarction compared to 4 of adults without diabetes Figure 31, and 8 reported having had a stroke compared to 2 of adults without diabetes Figure 316

Figure 30: High Blood Pressure and High Cholesterol in Those with and without Diabetes, Indiana, 2005
80 60 40 20 0
With Diabetes Without Diabetes

Percentage

High Blood Pressure 66 22

High Cholesterol 67 34

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Questions: Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure? and Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high? Source: Indiana 2005 BRFSS Data

Figure 31: Coronary Artery Disease, Myocardial Infarction, and Stroke in Adults with and without Diabetes, Indiana, 2005
20
Percentage

15 10 5 0
With Diabetes Without Diabetes Coronary Artery Disease 16 4 Myocardial Infraction 17 4

Stroke 8 2

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Questions: Has a doctor, nurse, or other health professional ever told you that
you any of the following? Heart attack, also called a myocardial infarction? Angina or coronary heart disease? Stroke? Source: Indiana 2005 BRFSS Data

Blindness and Visual Impairment High blood glucose and high blood pressure cause small blood vessels to swell and leak liquid into the retina of the eye, which blurs vision and sometimes leads to blindness Diabetes is the leading cause of new cases of blindness among adults 2074 years of age Diabetic retinopathy is the cause in 12,00024,000 new cases of blindness every year in the United States2 In 2005 for Indiana adults aged 17 and older, there were 554 new cases of legal blindness Figure 32 and 272 new cases of visual impairment due to diabetic retinopathy Figure 33 added to the Indiana Blind Registry13 In 2006, 18 of adults with diabetes reported that they had retinopathy or that their diabetes had affected their eyes Figure 346

Figure 32: New Cases of Blindness due to Diabetes, Indiana, 2000-2005
700
Cases of Blindness

642 572 554

600 500 400 300 200 100 0 2000 2001 2002 2003 145 355 350

2004

2005

Year
Source: Indiana Blind Registry 20002005 Data

Figure 33: New Cases of Visual Impairment due to Diabetes, Indiana,
2002-2005
Cases of Visual Impairment

350 300 250 200 150 100 50 0

317 283 229 272

2002

2003
Year

2004

2005

Source: Indiana Blind Registry 20022005 Data

Figure 34: Percentage of Adults with Diabetes who had Retinopathy, Indiana, 2002-2006
25 20
Percentage

23 21 19 21 18

15 10 5 0 2002 2003 2004
Year

2005

2006

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy? Source: Indiana 2002-2006 BRFSS Data

Kidney Failure In diabetic kidney disease, cells and blood vessels in the kidneys are damaged which affect the organs ability to filter out waste When kidneys fail, waste builds up in the blood and the blood needs to be filtered through a machine dialysis or a kidney transplant becomes necessary In the United States, diabetes was the leading cause of kidney failure in 2002, accounting for 44 of new cases In 2002, there were 44,400 people who began treatment for end-stage renal disease ESRD, and 153,730 people with ESRD due to diabetes were living on chronic dialysis or with a kidney transplant in the United States and
Puerto Rico2 In 2005, there were 812 new cases of diabetes-related ESRD Figure 35 in Indiana which accounted for 40 of all ESRD incident cases Figure 36 While it appears the incidence has decreased in the past few years, the prevalence continues to rise In 2005, there were 2,479 total cases of diabetes-related ESRD Figure 37, representing 412 of all ESRD cases Figure 38 Eighty-one individuals with diabetes-related kidney failure received a kidney transplant in 2006 Figure 39 The number of people with diabetes receiving kidney transplants has doubled since 199514

Figure 35: New Cases of Diabetic-Related End-Stage Renal Disease, Indiana, 2000-2005
900 800 777 805 830 848 743 812

Number of Cases

700 600 500 400 300 200 100 0 2000 2001 2002 2003 2004 2005

Year
Source: The Renal Network 20002005 Data

Figure 36: Percentage of New End-Stage Renal Disease Patients who have Diabetes, Indiana, 2000-2005
50 45 40 35 30 25 20 15 10 5 0 Incidence 2000 419 2001 423 2002 429 2003 445 2004 419 2005 40

Percentage

Year
Source: The Renal Network 20002005 Data

Figure 37: Prevalence of Diabetic-Related End-Stage Renal Disease, Indiana, 2000-2005
3000 2500 2350 2354 2479

Number of
Cases

2077 2000 1500 1000 500 0 2000

2166

2253

2001

2002

2003

2004

2005

Year
Source: The Renal Network 20002005 Data

Figure 38: Percentage of All End-Stage Renal Disease Patients who have Diabetes, Indiana, 2000-2005
45 40 35

Percentage

30 25 20 15 10 5 0 Prevalence 2000 387 2001 393 2002 40 2003 411 2004 414 2005 412

Year
Source: The Renal Network 20002005 Data

Figure 39: Adults who Received a Kidney Transplants Because of Their Diabetes, Indiana, 1995-2006
120
Number of People

105 87 63 66 51 46 50 44 44 92

100 81

100 80 60 40 20 0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year
Source: The Renal Network 19952006 Data

Nerve Damage and Amputations Having high blood glucose in the body for several years can damage the blood vessels that carry oxygen to nerves and nerve coverings Nerve damage caused by diabetes is called diabetic neuropathy and results in impaired sensation or pain in the feet or hands, slowed digestion of food, carpal tunnel syndrome, and other nerve problems About 6070 of people with diabetes experience mild to severe forms of neuropathy The most common type is peripheral neuropathy which affects the arms and legs
Almost 30 of people with diabetes over 40 years of age have impaired sensation in their feet Severe forms of nerve disease can lead to amputations with more than 60 of nontraumatic lower extremity amputations occurring in people with diabetes Amputations can be a result of ulcers developing on the feet when there is not a sensation to warn the individual that damage is occurring or amputations can be a result of poor circulation2 According to the 2006 Indiana BRFSS data, 11 of adults with diabetes reported having sores or irritation on their feet that took more than four weeks to heal Figure 40 If circulation becomes progressively worse, lower extremity amputation may be necessary In 2005 among Indiana residents hospitalized with a primary discharge diagnosis of diabetes, 1,763 individuals underwent a lower extremity amputation Of those that had an amputation, 598 were female 167 per 100,000, and 1,165 were male 406 per 100,000 Figure 41 Figure 42 shows the racial/ethnic breakdown for lower extremity amputation There were 1,229 amputations in the White population 208 per 100,000 and 274 in the Black population 663 per 100,000 Black males had the highest rate 928 per 100,000
followed by Black females 454 per 100,000, White males 3 09 per 100,000, and White females 125 per 100,000 Figure 4315

Figure 40: Adults with Diabetes who had Sores or Irritations on Their Feet that took Longer than Four Weeks to Heal, Indiana, 2002-2006
16 14 12 10 8 6 4 2 0 15 11 12 11 11

Percentage

2002

2003

2004
Year

2005

2006

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever had any sores or irritations on your feet that took more than four weeks to heal? Source: Indiana 2002-2006 BRFSS Data

Figure 41: Rates of Diabetes-Related Lower Extremity Amputations by Gender, AgeAdjusted, Indiana, 2005
45 40 35 30 25 20 15 10 5 0 406

Rate per 100,000

167

Male
Gender
Source: Indiana Inpatient Hospital Discharge 2005 Data

Female

Figure 42: Rates of Diabetes-Related Lower Extremity Amputations by Race, AgeAdjusted, Indiana, 2005
70 60
Rate per 100,000

663

50 40 30 20 10 0 White
Race

208

Black

Source: Indiana Inpatient Hospital Discharge 2005 Data

Figure 43: Rates of Diabetes-Related Lower Extremity Amputations by Race and Gender, Age-Adjusted, Indiana, 2005
100
Rate per
100,000

928

80 60 40 20 0
Black Males Black Females White Males White Females

454 309 125

Race Gender
Source: Indiana Inpatient Hospital Discharge 2005 Data

Dental Disease Because of high glucose levels in the blood, people with diabetes tend to have more problems with their gums and teeth Periodontal gum disease is more common in people with diabetes Young adults with diabetes have about twice the risk of having periodontal disease than those without diabetes Around one-third of people with diabetes have severe periodontal disease with loss of attachment of the gums to the teeth measuring five millimeters about 3/8 inch or more Other problems include fungal infections, poor post-surgery healing, and dry mouth2 In 2006, 73 of Indiana adults with diabetes reported that they had at least one permanent tooth removed compared to 44 of adults without diabetes Twenty-three percent of people with diabetes had six or greater permanent teeth removed but not all their teeth compared to those without diabetes 10 Figure 44 Of adults with diabetes, 17 had all their teeth removed compared to 6 of adults without diabetes6

Figure 44: Number of Teeth Removed, Adults with and without
Diabetes, Indiana, 2006
60 Percentage 50 40 30 20 10 0
None With Diabetes Without Diabetes 25 55 1 to 5 33 28 6 But Not All 23 10 All 17 6

Number of Teeth Removed
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics Source: Indiana 2006 BRFSS Data

Depression Studies show that diabetes doubles the risk of depression The psychological stress of having diabetes as well as the metabolic effect of the disease on the brain both play a role in causing depression The risk of depression increases as more diabetic complications develop2 In 2006, 28 of adults with diabetes reported that they have been diagnosed with depression compared to 19 of adults who did not have diabetes Figure 456

Figure 45: Depressive Disorder in Adults with and without Diabetes, Indiana, 2006
30 25
Percentage

20 15 10 5 0 With Diabetes

Without Diabetes

Percentages are weighted to population characteristics Survey was asked of individuals
18 years or older Question: Has a doctor or other healthcare provider ever told you that you have a depressive disorder including depression, major depression, dysthymia, or minor depression? Source: Indiana 2006 BRFSS Data

Pregnancy Complications Poorly controlled diabetes before conception and during the first trimester of pregnancy can result in major birth defects in 5-10 of pregnancies and can cause spontaneous abortions in 1520 of pregnancies Uncontrolled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to the mother and child2 Other Complications If diabetes is not managed, it can lead to biochemical imbalances that can cause acute lifethreatening events such as diabetic ketoacidosis DKA and hyperosmolar nonketotic coma DKA is a state of inadequate insulin levels resulting in high blood sugar and accumulation of organic acids and ketones in the blood and is primarily seen in individuals with type 1 diabetes It is common in DKA to have severe dehydration and significant alterations of the bodys blood chemistry DKA can lead to coma and death in some individuals DKA is seen primarily in

patients with type 1
insulin-dependent diabetes The incidence is roughly 2/100 patient years of diabetes, with about 3 of type 1 diabetic patients initially presenting with DKA It can occur in type 2 noninsulin-dependent diabetic patients as well Hyperglycemic hyperosmolar nonketotic coma is characterized by severe hyperglycemia, dehydration, and altered mental status in the absence of ketosis It typically occurs in those with type 2 diabetes particularly older persons following a cerebral vascular accident The incidence is 175 cases per 100,000 people16 Overall, people with poorly controlled diabetes are more susceptible to illness and once they become sick, they often have a worse prognosis For example, those with diabetes are more likely to be hospitalized or die because of pneumonia or influenza than people without diabetes2 Having diabetes affects general health and daily physical activity Almost 50 of adults with diabetes reported in 2006 that in general their health was fair or poor Figure 46 Very few reported their health to be excellent or very good especially when compared to adults without diabetes Figure 46 The status of a persons health has a great impact on their daily activities In 2006,
twice as many adults with diabetes reported having activity limitations compared to those without diabetes Figure 476

Figure 46: General Health of Adults with and without Diabetes, Indiana, 2006
40
Percentages

30 20 10 0
Excellent With Diabetes Without Diabetes 4 19 Very Good 11 35

Good 36 33

Fair 32 10

Poor 17 3

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Would you say that in general your health is ? Source: Indiana 2006 BRFSS Data

Figure 47: Activity Limitations due to Health Problems, Adults with and without Diabetes, Indiana, 2006
40 35 30
Percentage

25 20 15 10 5 0 With Diabetes Without Diabetes 17

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Are you limited in any way in any activities because of physical, mental, or emotional problems? Source: Indiana 2006 BRFSS Data

Inpatient Hospitalizations In 2005 among Indiana residents of all ages, there were 9,894 inpatient hospitalizations with a primary discharge diagnosis of diabetes, corresponding to an age-adjusted rate of 1559 per 100,000 The number of
hospitalizations were similar in males 5,259 and females 4,635, though the age-adjusted rate for females was lower 1384 per 100,000 than for males 1767 per 100,000 Figure 48 There were large differences between racial/ethnic groups; the number of hospitalizations for Whites was 6,793 compared to 1,884 for Blacks However, the age-adjusted hospitalization rates were 1185 per 100,000 for Whites and 3988 per 100,000 for Blacks Figure 49 Black males had the highest rate 4535 per 100,000 followed by Black females 3569 per 100,000, White males 1328 per 100,000, and White females 1064 per 100,000 Figure 5015

Figure 48: Inpatient Hospitalization Rates where Diabetes was the Primary Cause by Gender, Age-Adjusted, Indiana, 2005
200
Rate per 100,000

1767 1384

150 100 50 0
Male
Gender

Female

Source: Indiana Inpatient Hospital Discharge 2005 Data

Figure 49: Inpatient Hospitalization Rates where Diabetes was the Primary Cause by Race, Age-Adjusted, Indiana, 2005
450 400 350 300 250 200 150 100 50 0 3988

Rate per 100,000

1185

White
Race
Source: Indiana Inpatient Hospital Discharge 2005 Data

Black

Figure 50: Inpatient Hospitalization Rates where Diabetes was the Primary Cause by Race
and Gender, Age-Adjusted, Indiana, 2005
500
Rate per 100,000

4535 3569

400 300 200 100 0
Black Males

1328

1064

Black Females

White Males

White Females

Race Gender
Source: Indiana Inpatient Hospital Discharge 2005 Data

Mortality Diabetes was the sixth leading cause of death in the United States in 2004 This ranking is based on the 73,249 death certificates that identified diabetes as the underlying cause of death According to death certificate reports, diabetes contributed to 224,092 deaths However, this number is likely to be underreported, because studies have found that only 35-40 of decedents with diabetes had it listed anywhere on the certificate, and only 10-15 had it listed as the underlying cause of death Those with diabetes have twice the risk for death compared to people of the same age who do not have diabetes2 Premature mortality caused by diabetes results in an estimated 12-14 years of life lost5 In 2005, there were 1,721 Indiana residents who died due to diabetes as the underlying cause of death, making it the sixth leading cause of death Figure 51 in Indiana Diabetes was the 4th leading cause of death in residents aged 55 to 64 years, the 5th leading
cause of death for those 65 years and older, and the 7th for those 25-34 years The overall age-adjusted diabetes mortality rate for 2005 was 267 per 100,000 population which was a slight increase from 2004 but an overall decrease from prior years Figure 52 Though number of deaths are higher in females 906 than males 815, males are more likely 307 per 100,000 to die due to diabetes than females 236 per 100,000 Figure 53 and 5417 In 2005, diabetes was the 4th leading cause of death for Blacks, 3rd for Asian/Pacific Islanders, 7th for Whites, and 6th for Hispanics/Latinos in Indiana The number of deaths in the White population was higher than in the Black population Figure 55 However when examining death rates, more than twice as many Blacks died because of diabetes than Whites in 2005 Figure 56 The age-adjusted death rate for Hispanics/Latinos in 2005 was 2725 per 100,000 White females had the highest number of deaths from diabetes in the past five years, but when comparing rates, Black males and females have the highest number of deaths per population Figures 57 and 5817 Please note that the mortality data come from death certificates that list diabetes as an underlying cause of
death, meaning that diabetes was the disease which initiated the chain of morbid events leading directly to death This is just a small portion of the number of deaths where diabetes played a role When looking at diabetes as a contributing cause of death, the number of deaths is much larger Diabetes as a contributing cause of death means that diabetes was listed on the death certificate and contributed to the death but was not the main underlying cause of death An example of a contributing cause of death would be if an individual with diabetes died of acute renal failure, diabetes did not cause the death but was a significant disease contributing to the death Figure 59 shows the number of deaths for the past five years in which diabetes was a contributing cause When the contributing cause is added to the underlying cause, the mortality burden is much greater and gives a more comprehensive description of the toll of diabetes in the state

Figure 51: Deaths due to Diabetes, Indiana, 2001-2005
2000 1800 1600 1400

Deaths

1200 1000 800 600 400 200 0 Total Deaths 2001 1668 2002 1677 2003 1722 2004 1671 2005 1721

Year
Source: Indiana State Department of Health 20012005 Mortality
Data

Figure 52: Diabetes Death Rates, Age-Adjusted, Indiana, 2001-2005
30 28 25 273 276 263 267

Rate per 100,000

20 15 10 5 0 2001 2002 2003 2004 2005

Year
Source: Indiana State Department of Health 20012005 Mortality Data

Figure 53: Deaths due to Diabetes by Gender, Indiana, 2001-2005
1000 900 800 700

Deaths

600 500 400 300 200 100 0 Male Female 2001 757 911 2002 800 877 2003 799 923 2004 795 876 2005 815 906

Source: Indiana State Department of Health 20012005 Mortality Data

Figure 54: Diabetes Death Rates by Gender, Age-Adjusted, Indiana 2001-2005
35 30 317 254 319 311 247 308 307

Rate per 100,000

25 20 15 10 5 0

239

232

236

Male Female

2001

2002

2003

2004

2005

Year
Source: Indiana State Department of Health 20012005 Mortality Data

Figure 55: Deaths due to Diabetes by Race, Indiana, 2001-2005
1600 1400 1200

Deaths

1000 800 600 400 200 0 White Black 2001 1450 213 2002 1486 184 2003 1493 233 2004 1470 191 2005 1494 214

Source: Indiana State Department of Health 20012005 Mortality Data

Figure 56: Diabetes Death Rates by Race, Age-Adjusted, Indiana, 2001-2005
70 60 607 492 603 552 50 40 30 20 10 0 2001 2002 2003 2004 2005 498

Rate per 100,000

White
Black
262 26 257 249 25

Year
Source: Indiana State Department of Health 20012005 Mortality Data

Figure 57: Deaths due to Diabetes by Race and Gender, Indiana, 2001-2005
900 800 700 600 500 400 300 200 100 0 White Males White Females Black Males Black Females 2001 653 797 102 111 2002 705 781 91 93 2003 695 798 101 122 2004 713 757 78 113 2005 708 786 101 113

Source: Indiana State Department of Health 20012005 Mortality Data

Figure 58: Diabetes Death Rates by Race and Gender, Age-Adjusted, Indiana 2001-2005
80 70 60 50 40 30 20 10 0 White Males White Females Black Males Black Females 2001 297 239 713 531 2002 304 227 566 433 2003 291 229 693 548 2004 299 215 484 498 2005 288 219 645 492

Source: Indiana State Department of Health 20012005 Mortality Data

Rate per 100,000

Deaths

Figure 59: Deaths where Diabetes is a Contributing Cause, Indiana, 2001-2005
3500 3000 2500
Deaths

2000 1500 1000 500 0
Total Deaths 2001 3109 2002 3080 2003 3207 2004 3177 2005 3163

Year
Source: Indiana State Department of Health 20012005 Mortality Data

Treatment
People with type 1 must take insulin via injection or insulin pump to survive Type 2 diabetes can often be controlled by
eating healthy foods, exercising, maintaining a healthy weight, and taking oral medications Those with type 2 may also take insulin2 In 2006 among Indiana adults with diabetes, 13 used insulin only, 60 used oral medication only, 13 used both insulin and oral medication, and 14 did not use either insulin or oral medication Figure 60 The type of treatment used by adults with diabetes has remained consistent over the years Figure 616 In addition, many individuals with diabetes also need to take medication to control high blood pressure and cholesterol2

Figure 60: Medications Taken by Adults with Diabetes, Indiana, 2006
70 60
Percentage

50 40 30 20 10 0
Insulin Diabetes Pills Both Insulin Diabetes Pills Neither

Diabetes Treatment
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Are you now taking insulin? and Are you taking diabetes pills? Source: Indiana 2006 BRFSS Data

Figure 61: Insulin or Diabetes Pills Use among Adults with Diabetes, Indiana, 2002-2006
80
Percentage

60 40 20 0
Insulin Pill 2002 29 66 2003 28 69 2004 29 68 2005 26 72 2006 26 73

Year
Categories are not mutually exclusive In
some cases, individuals use both insulin and pills Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Questions: Are you now taking insulin? and Are you taking diabetes pills? Source: Indiana 2002-2006 BRFSS Data

Prevention of Complications
Diabetes can affect many parts of the body and can lead to serious complications if not managed well A team-based health care approach for the care and treatment of individuals with diabetes is best The individual should also take an active role in his/her self-management It is important for individuals with diabetes to learn about their condition, treatment goals, and preventive measures Self-management courses, regular contact with a physician, and help from diabetes educators can offer the education and guidance to manage diabetes well Controlling blood glucose, blood pressure, and blood lipids as well as receiving regular preventive care may reduce the likelihood of developing complications18 Treatment Goals Goals for diabetes treatment focus on the ABCs A1C, blood pressure, and cholesterol of diabetes An A1C also known as glycosylated hemoglobin or HbA1c test measures an individuals
average blood glucose control for the past 2 to 3 months The results indicate whether the diabetes treatment plan is effective The goal for A1C tests is to be less than 7 Blood pressure is a measurement of the force applied to the walls of the arteries as the heart pumps blood through the body and tends to be higher in those with diabetes The goal for blood pressure mmHg is 130 / 80 The treatment goal for cholesterol lipid profile is three-prong: 100 for LDL; 40 for male HDL levels and 50 for female HDL levels; and 150 for triglycerides Individual treatment goals include getting A1C results as close to normal 6 in people without diabetes as possible without significant hypoglycemia, less stringent goals for those with severe or frequent hypoglycemia or if other factors exist eg limited life expectancy, and lower blood pressure goals for people with nephropathy19 Individuals with diabetes should receive medical care from a physician-coordinated team of health care professionals There are specific measures that should be taken during the individuals lifetime in order to maintain health and avoid complications The table below outlines these treatment measures that should be used to
guide health care professionals when working with individuals with diabetes19

Treatment Measures
Measure weight and blood pressure Inspect feet Review self-monitoring glucose record Review/adjust medications to control glucose, lipids, and blood pressure Review self-management skills, dietary needs, and physical activity Assess for depression or other mood disorders Counsel on smoking cessation and alcohol use Obtain A1C in patients whose therapy has changed or who are not meeting glycemic goals Obtain fasting lipid profile every two years if at goal Obtain serum creatinine and estimate glomerular filtration rate Perform urine test for albumin-to-creatinine ratio in patients with type 1 diabetes 5 years and in all patients Refer for dilated eye exam if normal, an eye care specialist may advise an exam every 2-3 years Perform a comprehensive foot exam Refer for dental/oral exam at least once a year Administer influenza vaccination Review need for other preventative care or treatment Administer pneumococcal vaccination repeat if over 64 years of age or immunocompromised and last vaccination was more than 5 years ago

Frequency
Every regular physician visit Every regular
physician visit Every regular physician visit Every regular physician visit Every regular physician visit Every regular physician visit Every regular physician visit Quarterly Annually Annually Annually Annually Annually Annually Annually Annually Lifetime

Self-Management Class Diabetes self-management classes are essential for helping those with diabetes understand their condition and how to care for themselves These courses are offered at health departments, clinics, and hospitals Topics include understanding diabetes and its effects on the body; monitoring blood glucose; nutrition; understanding the role of medications, exercising and the importance of maintaining a healthy weight; preventing complications by detecting problems early; proper foot, skin, and dental care; how to work with health care providers; and other topics18 Of adults with diabetes in Indiana, 61 reported that they have taken a course or class to help them manage their diabetes which was a slight increase from previous years Figure 626 There are 74 known diabetes education programs in Indiana that are recognized by the American Diabetes Association http://wwwingov/isdh/programs/diabetes/splashhtm18 ADA
recognition of an education program is required before Medicaid will reimburse a patient for attending the program There are many education programs offered at community health centers and hospitals in Indiana that are not included in these numbers3

Figure 62: Adults with Diabetes who have Taken a Diabetes Self-Management Class, Indiana, 2002-2006
70 60
Percentage

63 54

50 40 30 20 10 0 2002 2003 2004
Year

2005

2006

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Have you ever taken a course or class in how to manage your diabetes yourself? Source: Indiana 2002-2006 BRFSS Data

Regular Visits to Health Care Providers It is important for people with diabetes to see a health care provider regularly to monitor their disease and to detect and prevent complications According to the 2006 BRFSS, 89 of Indiana adults with diabetes saw a health care professional at least once in the previous year with the most common frequency being four times Figure 63 Unfortunately, 11 did not make a visit The frequency of visits has remained fairly consistent in recent years Figure 646

Figure 63: Frequency with
which Adults with Diabetes saw a Health Professional about Their Diabetes in the Past Year, Indiana, 2006
30 25
Percentage

20 15 10 5 0 None 1 15 11

18 16 12

Number of Visits per Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? Source: Indiana 2006 BRFSS Data

Figure 64: Frequency with which Adults with Diabetes saw a Health Professional about Their Diabetes in the Past 12 Months, Indiana, 2002-2006
30 25
Percentage
2002 2003 2004 2005 2006

20 15 10 5 0 None 1 2 3 4 5
Number of Visits Per Year

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes? Source: Indiana 2002-2006 BRFSS Data

Glucose Control Studies have shown that improved glucose control benefits people with type 1 and type 2 diabetes For every percentage point drop in A1C blood test results, the risk of microvascular
complications eye, kidney, and nerve disease is reduced by 402 Daily glucose checks and A1C testing twice a year at least three months apart if meeting treatment goals and quarterly if not meeting goals helps those with diabetes monitor their glucose levels so they know if and when adjustments are necessary18 According to the 2006 BRFSS, 26 of Indiana adults with diabetes reported that they checked their glucose level daily; however 8 never checked their levels Figure 64 In 2006, 72 of adults with diabetes reported getting the A1C test between one and four times and 6 reported getting the test five or more times in the previous year Figure 65 Around 10 did not get the test at all, and 7 had never heard of the test Test frequency has been similar in recent years Figure 66

Figure 64: Frequency with which Adults with Diabetes Checked Their Blood for Glucose or Sugar, Indiana, 2003-2006
60
Percentage

40 20 0
More than Daily Daily Less than Daily Never 2003 33 25 34 8 2004 42 23 25 10 2005 41 21 26 10 2006 40 26 24 8

Year
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how often do you check your blood for
glucose or sugar? Include times when checked by family member or friend, but do not include times when checked by a health professional Source: Indiana 2003-2006 BRFSS Data

Figure 65: Frequency with which Adults with Diabetes had an A1C Test in the Past 12 Months, Indiana, 2006
80 70
Percentage

60 50 40 30 20 10 0
1-4 5 Dont know None Never heard of

Number of Tests in the Past 12 Months
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how many times in the past 12 months has a doctor, nurse, or other health professional checked your for hemoglobin A one C? Source: Indiana 2006 BRFSS Data

Figure 66: Frequency with which Adults with Diabetes had an A1C Test in the Past 12 Months, Indiana, 2002-2006
90 80 70 60 50 40 30 20 10 0
1-4 5 Dont know None Never heard of

Percentage

2002 2003 2004 2005 2006

Blood Pressure and Blood Lipid Control Controlling blood pressure among individuals with diabetes helps to reduce the risk of heart disease and stroke by 33-50 It also reduces the risk of microvascular complications eye, kidney, and nerve diseases by about 33 For every 10 mmHg reduction in systolic blood pressure, the risk of complications is reduced by 12 Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30-70 ACE inhibitors and angiotensin receptor blockers are more effective in reducing kidney function decline than other blood pressure lowering medications2 Ninety-one percent of Indiana adults with diabetes reported taking medication for high blood pressure in 20056 Improving cholesterol or blood lipids can reduce cardiovascular complications by 20-502 In 2005, 96 of Indiana adults with diabetes reported that they had their cholesterol checked in the previous year, and 67 reported they were told they had high cholesterol6 Eye Exams Detecting and treating diabetic eye disease with laser therapy can reduce development of severe vision loss by about 50-602 Of adults with diabetes in Indiana, 63
reported having a dilated eye exam in the previous year; however 6 had never had one Figure 67 There has been little change in these percentages from prior years Figure 686

Figure 67: Last Time Adults with Diabetes had an Eye Exam, Indiana, 2006
50 45 40 35 30 25 20 15 10 5 0 46

Percentage

15 6

1 Month

1 12 Months

12 Years

2 Years

Never

Time Since Last Eye Exam
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light Source: Indiana 2006 BRFSS Data

Figure 68: Last Time Adults with Diabetes had an Eye Exam, Indiana, 2002-2006
60 50
Percentage
2002 2003 2004 2005 2006

40 30 20 10 0 1 1 12 Month Months 12 Years 2 Years Never

Foot Exams Regular
comprehensive foot exams can reduce amputation rates by 45-852 In 2006, the majority of adults in Indiana with diabetes reported that they had at least one foot exam by a health professional in the previous year Figure 69 However, 27 of adults with diabetes did not Figure 70 shows the frequency for foot exams in the past five years In addition to seeing a doctor for a yearly foot exam, individuals with diabetes need to check their own feet daily In 2006, the majority 63 of Indiana adults with diabetes did so Figure 71 Unfortunately, some adults 11 never checked their feet Figure 72 shows the frequency of self foot exams for the past five years6

Figure 69: Times in the Past 12 Months that Adults with Diabetes had Their Feet Checked by a Health Professional, Indiana, 2006
30 25
Percentage

27 22 19 18

20 15 10 5 0 1

None

Number of Foot Exams in the Last 12 Months
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? Source: Indiana 2006 BRFSS Data

Figure 70: Times in the Past 12
Months that Adults with Diabetes had Their Feet Checked by a Health Professional, Indiana, 2002-2006
35 30
Percentage

25 20 15 10 5 0
1 2 3 4 5 None
Number of Foot Exams in the Last 12 Months

2002 2003 2004 2005 2006

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how many times in the past 12 months has a health professional checked your feet for any sores or irritations? Source: Indiana 2002-2006 BRFSS Data

Figure 71: Frequency with which Adults with Diabetes Checked Their Feet for Sores or Irritations, Indiana, 2006
70 60
Percentage

50 40 30 20 10 0
Daily Weekly Monthly Yearly Never No feet

19 11 5 2 1

Frequency
Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: About how often do you check your feet for any sores or irritations? Include times when checked by family member or friend, but do not include times when checked by a health professional Source: Indiana 2006 BRFSS Data

Figure 72: Frequency with which Adults with Diabetes Checked Their Feet for Sores or Irritations, Indiana, 2002-2006
70 60
Percentage

50 40 30 20 10
0
Daily Weekly Monthly Yearly Never No feet

2002 2003 2004 2005 2006

Dental Exams Regular dental exams are important to detect and prevent periodontal disease2 Although people with diabetes are at a higher risk of having dental disease, they are less likely to receive regular dental care In 2006, only 55 of Indiana adults with diabetes reported that they had a dental exam in the previous year Figure 736

Figure 73: Last Time Adults with Diabetes Visited a Dentist or Dental Clinic, Indiana, 2006
80
Percentage

60 40 20 0
With Diabetes Without Diabetes 12 Months 55 67 12 Years 13 11 25 Years 11 10 5 Years 21 11

Never 0 1

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: How long has it been since you last visited a dentist or a dental clinic for any reason? Include
visits to dental specialists, such as orthodontists Source: Indiana 2006 BRFSS Data

Other Preventive Measures People with diabetes have worse outcomes when they become ill with influenza and/or pneumonia compared to the general population Yearly influenza vaccinations and a pneumonia vaccination can help to prevent illness Of adults with diabetes, 58 reported in 2006 that they had a flu vaccination in the past 12 months, and 53 have had a pneumonia vaccination at some point in their lives Figures 74 and 75 Quitting smoking, exercising regularly, eating healthy foods, and maintaining a healthy weight are also important for reducing complications Smoking doubles the risk for heart disease in those with diabetes2 In 2006, 17 of Indiana adults with diabetes were currently smoking Figure 76 Of adults with diabetes, 31 were overweight, and 51 were obese Figure 77 Nearly 43 of adults with diabetes reported not participating in any physical activities in the past 30 days Figure 786

Figure 74: Adults with and without Diabetes who had a Flu Vaccination in Past 12 Months, Indiana, 2006
70 60
Percentage

50 40 30 20 10 0 With Diabetes Without Diabetes 29

Percentages are weighted to
population characteristics Survey was asked of individuals 18 years or older Question: A flu shot is an influenza vaccine injected into your arm During the past 12 months, have you had a flu shot? Source: Indiana 2006 BRFSS Data

Figure 75: Adults with and without Diabetes who have had a Pneumonia Vaccination in Their Lifetime, Indiana, 2006
60 50
Percentage

40 30 21 20 10 0 With Diabetes Without Diabetes

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a persons lifetime and is different from the flu shot Have you ever had a pneumonia shot? Source: Indiana 2006 BRFSS Data

Figure 76: Adults with and without Diabetes who Currently Smoke, Indiana, 2006
30 25
Percentage

20 15 10 5 0

With Diabetes

Without Diabetes

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: Do you now smoke cigarettes every day, some days, or not at all? Source: Indiana 2006 BRFSS Data

Figure 77: Overweight or Obese Adults by Diabetes Status, Indiana, 2006
60 50
Percentage

40 30 20
10 0
With Diabetes Without Diabetes Overweight 31 34 Obese 51 24

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Overweight as BMI 25 299, and obese as BMI 30 Question: About how much do you weigh without shoes? and About how tall are you without shoes? BMI Formula weight in kilograms / height in meters2 Source: Indiana 2006 BRFSS Data

Figure 78: Adults with and without Diabetes who Engaged in Physical Activity in the Past Month, Indiana, 2006
90 80
Percentage

77 57

70 60 50 40 30 20 10 0

With Diabetes

Without Diabetes

Percentages are weighted to population characteristics Survey was asked of individuals 18 years or older Question: During the past month, did you participate in any physical activities? Source: Indiana 2006 BRFSS Data

Gaps and Barriers to Diabetes Care
While Indiana has many resources in diabetes research and education, a gap remains between these programs and the diabetes education and management received by most patients in a clinical setting Barriers include cost of disease management and services, geographic location, access to and quality of care, and cultural barriers such as language
and lack of minority physicians Cost Diabetes is an expensive chronic disease to manage Costs include regular physician visits, medications, supplies, treatment and hospitalizations for complications, and some educational programs In 2007, the total annual economic cost of diabetes in the United States was estimated to be 174 billion, comprising 116 billion in excess medical expenditures and 58 billion in reduced national productivity Twenty-seven billion dollars was spent on direct care, 58 billion was spent on complications due to diabetes, and 31 billion was associated with excess general medical care The largest components were for inpatient hospital care 50 of total cost, medication and supplies 12, retail medications to treat complications 11, and physician office visits 9 Individuals with diabetes incurred an average expenditure of 11,744 per year 6,649 attributed to diabetes, which is about 23 times higher than what expenditures would be in the absence of diabetes One out of every five health care dollars spent in the United States is spent on caring for an individual with diabetes while one in every ten dollars is attributed to diabetes This cost data does not include
social costs such as pain and suffering, care provided by nonpaid caregivers, or excess medical costs associated with undiagnosed diabetes, therefore the cost is likely to be much greater18 Geographic Location Individuals with diabetes who live in urban areas and rural areas have unique challenges The majority of Blacks and other minorities are located in urban areas Minorities in the urban areas often have limited access to primary care This limited access is due to lack of health insurance as well as cities having a heavy concentration of subspecialty physicians in large, tertiary-care hospitals and centers Many times those living in urban environments receive primary care in overcrowded, resource-consuming emergency departments20 Approximately one-third of Indianas population lives in rural counties10 Individuals in rural areas have a poorer perception of overall health, lower income, and a higher proportion of elderly and children compared to those in urban settings Other challenges of rural residents include access to public or reliable transportation and time away from work or family to access quality care These issues pose serious problems for individuals with a chronic
disease such as diabetes, because constant monitoring and contact with a physician or health care provider are essential20 Access to and Quality of Care Access to medical care and coverage of care is also a challenge in Indiana In 2005, an estimated 839,702 individuals 14 were uninsured Another 24 of individuals 1,431,046 had either Medicaid 12 or Medicare 12 as their primary form of health insurance coverage21 In

2004, approximately 86,968 Medicaid patients had one of the following four chronic diseases: diabetes, congestive heart failure, asthma, or AIDS Of these patients, 21 18,030 individuals had diabetes Fifty-seven percent of the all Medicaid patients and 60 of the diabetes Medicaid patients with diabetes visited public health clinics for their care22 Medicare and Medicaid reimbursement for diabetes have been hindered because of physicians lack of knowledge of Centers for Medicare and Medicaid Services guidelines and because many physicians believe reimbursement levels are unrealistically low23 In addition, Indiana law does not require insurance plans to cover the cost of diabetes medications and supplies if the company is self-insured24 Fifty-one of the 92 Indiana
counties were classified as medically underserved areas and populations and 36 of the 92 counties had health professional shortages25, 26 Indiana has one of the lowest numbers of physicians for its population size with only 215 physicians per 100,000 resident population, ranking Indiana 38th in the nation for physician-to-population ratio27 Throughout rural and urban Indiana, there are 42 community health centers CHC which receive funds from ISDH to provide services to uninsured and under-insured Indiana residents Sixteen of these community health centers also receive funding from the Bureau of Primary Health Care through the Federal 330 grant program Receiving this funding designates the centers as Federally Qualified Health Centers FQHC In 2006, 39 of the 42 CHCs reported they served 331,010 people with 113,046 enrolled in Medicaid and 118,017 with no insurance28 The FQHCs participating in the Bureau of Primary Health Cares Health Disparities Collaborative HDC have begun tracking and following their diabetic population through health center registries The HDC program encourages health centers to embed the evidence-based guidelines from the American Diabetes Association into their
processes so that they can assist their partners to reach the goal of 70 for the average hemoglobin A1C The August 2007 aggregate data from 14 of Indiana FQHCs participating in the HDC reported that 6,690 people with diabetes are being served and their average hemoglobin A1C is 78 the national average is 77628 Cultural Barriers Indianas Hispanic/Latino population has increased and is concentrated in several rural counties and in close-knit urban communities Many rural communities have more than the state average Hispanic/Latino population with some having twice the state average10 In rural areas, there are few bilingual health services available with the exception of those offered by the Migrant Health Program In Indianapolis, there is a Hispanic Center and the Wishard Hospital Hispanic Health Project with branches in other urban areas However, the Hispanic Center and Wishard mainly serve the Indianapolis area There are cultural barriers and some language barriers, especially with newly immigrated Hispanic/Latino residents in the rural areas where there have been few Hispanic/Latinos in the past29 There are few bilingual health professionals and even fewer resources in some rural
communities that are experiencing the growth Research consistently demonstrates patients treated by a

physician of similar culture and ethnicity have better clinical outcomes and greater satisfaction In Indiana, less than 4 of physicians are Black and less than 3 are Hispanic/Latino At Wishard Health Services, for example, more than 46 of the patients cared for were Black and at several of Wishards community health centers, more than 30 of patients were Hispanic/Latino30

Looking to the Future
Diabetes presents a tremendous challenge in Indiana and the United States The World Health Organization estimates that the number of adults in the United States with diabetes will double by the year 203031 The rates of obesity and diabetes are on the rise in Indiana as well as the rate of persons developing complications due to diabetes Diabetes-related mortality and morbidity, amputations, blindness, and kidney disease cause needless suffering and unnecessary financial burden on individuals and Indianas economy The Indiana Diabetes Prevention and Control Program DPCP works to overcome the various barriers where it will have an impact and to reach more individuals with diabetes and
those at risk for diabetes3 The DPCPs mission is to reduce the burden of diabetes in Indiana through data surveillance, health communications, health systems development, and development and implementation of community interventions and programs To achieve its mission, the DPCP works closely with the Diabetes Advisory Council DAC, a group of diabetes experts and clinicians, who guide and support the activities of the DPCP The focus of the DAC is to increase public awareness of the impact of diabetes, to improve the quality of life for those who are affected by diabetes, to improve the quality of care for patients with diabetes, and to reduce the burdens imposed by diabetes in Indiana3

References
1 American Diabetes Association 67th Annual Scientific Sessions, Chicago, June 22-26, 2007 Linda S Geiss, MA, chief, Diabetes Surveillance, CDC, Atlanta Ann Albright, PhD, RD, director, Division of Diabetes Translation, CDC 2 Centers for Disease Control and Prevention, http://wwwcdcgov 3 Indiana State Department of Health Diabetes Prevention and Control Program, http://wwwstateinus/isdh/programs/diabetes/resources/group_educationhtm 4 WebMD,
http://diabeteswebmdcom/tc/Prediabetes-What-Happens 5 K G M M Alberti, P Zimmet, and J Shaw International Diabetes Federation: A Consensus on Type 2 Diabetes Prevention Diabetic Medicine 24: 451-463, 2007 6 Indiana State Department of Health Behavior Risk Factor Surveillance Survey, 1995-2006 Data 7 United States Behavior Risk Factor Surveillance Survey, 2006 Data 8 Cowie, Catherine C, et al Prevalence of Diabetes and Impaired Fasting Glucose in Adults in the United States Population Diabetes Care 29: 1263-1268, 2006 9 Indiana State Department of Health Vital Records, 1995-2005 Birth Data 10 US Census Bureau American Community Survey, 2006, http://quickfactscensusgov/qfd/states/18000html 11 Trust for Americas Health F as in Fat: How Obesity Policies are Failing in America 2004, wwwhealthyamericansorg 12 Indiana State Department of Heath, Youth Risk Behavior Survey, 2003 and 2005 Data 13 Indiana Blind Registry, 2000-2005 Data 14 The Renal Network, 1995-2005 Data, wwwtherenalnetworkorg 15 Indiana State Department of Health Indiana Hospital Discharge, 2005 Data 16 Emedicine, http://emedicinecom 17 Indiana State Department of Health Vital Records, 2005 Mortality Data 18 American
Diabetes Association, http://wwwdiabetesorg 19 National Diabetes Education Program, http://ndepnihgov/ 20 Zgibor JC, Songer TJ: External Barriers to Diabetes Care: Addressing Personal and Health Systems Issues Diabetes Spectrum 14:23-28, 2001 21 Kaiser Family Foundation State Health Facts, 2004, wwwstatehealthfactsorg/cgibin/healthfactscgi 22 Indiana Family and Social Services Administration, 2005, http://wwwingov/fssa/ 23 Larme AC, Pugh JA Evidence-Based Guidelines Meet the Real World Diabetes Care 24: 1728-1733, 2001 24 Indiana Code, IC 27-8-145 25 Indiana State Department of Health Medically Underserved Areas, May 2006, http://wwwingov/isdh/publications/llo/shortages/pdf/MUA_details_table5-06pdf 26 Indiana State Department of Health Primary Care Health Professional Shortage Areas, May 2006, http://wwwingov/isdh/publications/llo/shortages/pdf/HPSA_PC_details_table5-06pdf 27 US Census Bureau Statistical Abstract: State Rankings, 2006, http://wwwcensusgov/compendia/statab/rankingshtml 28 Wishard, http://wwwwishardedu/Hispanic/ 29 Indiana Primary Health Care Association, 2006, http://wwwindianapcaorg/

30 Inside Indiana Business IU Medical Group Contributes to Minority
Scholarship Fund May 31, 2005, wwwinsideindianabusinesscom 31 World Health Organization, http://wwwwhoint/diabetes/en/

Source:in.gov

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