of the Hawaii State Diabetes Prevention and Control Program, compiles The 2004 Hawaii Diabetes Report is intended to provide partners and stake …
2004
HAWAII DIABETES REPORT
MESSAGE FROM THE DIRECTOR
The Hawaii Department of Health is pleased to present the publication of the 2004 Hawaii Diabetes Report The report, produced under the direction of the Hawaii State Diabetes Prevention and Control Program, compiles surveillance information, vital statistics, and various other data sources into a comprehensive document The 2004 Hawaii Diabetes Report is intended to provide partners and stakeholders with information on the prevalence of diabetes and its effects on the people of Hawaii This report is a valuable resource for use in planning programs and initiatives targeting those people most impacted by the disease It is estimated that approximately 100,000 people in Hawaii have diabetes and more than 900 people die every year of related complications, making it the seventh leading cause of death in the state Diabetes is a serious, common, and costly disease, but by working together, we can create a healthier Hawaii I invite you to join us in that effort Kuikahi kakou i ka puuwai Let us work together from the heart
Chiyome Leinaala Fukino, MD Director, Department of Health
ACKNOWLEDGEMENTS
The Hawaii State Diabetes Prevention
and Control Program would like to thank the following individuals from the Hawaii Department of Health for their significant contributions in the analysis, writing, and editing of this report: Florentina Salvail, MSBehavioral Risk Factor Surveillance System Tianzhu Huang, MS Behavioral Risk Factor Surveillance System Hanh Dzung Nguyen, BS Behavioral Risk Factor Surveillance System Ann Pobutsky, PhDCommunity Health Division We would like to also thank the following organizations and agencies for providing their data for inclusion in this report: National Kidney Foundation of Hawaii Transpacific Renal Network ESRD Network 17 Office of Health Status Monitoring, Hawaii Department of Health
1
CONTENTS
HIGHLIGHTS
Directors Message Acknowledegments Highlights Introduction About the Data Charts
1 1 2 3 5 7
It is estimated that 72,000 to 100,000 people currently have diabetes in Hawaii, of which 25,000 or more remain undiagnosed
Native Hawaiians, Filipinos, and Japanese have higher rates of diabetes than Whites
Prevalence rates of diabetes are similar across all of Hawaiis counties
Native Hawaiians have the highest diabetes mortality rates when compared with the other
major ethnic groups Whites have the lowest diabetes mortality rates
Appendix 1 19 Glossary Data Definitions Appendix 2 Methodology 21
Lower educational attainment is associated with higher diabetes prevalence and mortality
Obesity rates are significantly higher among adults with diabetes when compared with adults without diabetes
Adults with diabetes are less likely to be current smokers and are more likely to be former smokers when compared with adults without diabetes
Adults with diabetes are more likely to eat at least 5 servings of fruits/vegetables when compared with adults without diabetes
Adults with diabetes are more likely to receive their immunization for flu and pneumonia when compared with adults without diabetes
Hawaii has a higher incidence and prevalence rate of patients with end-stage renal disease ESRD on kidney dialysis when compared with the national average
Almost 60 of patients receiving kidney dialysis for ESRD have a primary diagnosis of diabetes
2
2004
HAWAII DIABETES REPORT
INTRODUCTION
Diabetes mellitus is a group of metabolic diseases characterized by high levels of blood glucose blood sugar In a person with diabetes, the normal
use of food for energy is disrupted because of defects in insulin production, insulin action, or both Insulin is a hormone which assists with the uptake of glucose into the bodys cells When insulin defects are present, the normal pathway of energy production is disrupted and high blood glucose levels result The Centers for Disease Control and Prevention CDC estimates that 63 of the population, or 182 million people all ages, have diabetes in the United States Of these 182 million people, almost a third 52 million do not know they have diabetes Because uncontrolled, unmanaged diabetes is associated with the development of numerous complications, it is the 52 million undiagnosed individuals who are particularly at risk for experiencing these associated conditions Given that many diabetes complications are preventable, the monies spent to treat this disease are astounding Cost studies funded by the American Diabetes Association estimate the total direct and indirect costs of diabetes in this country to be as high as 132 billion 92 billion in direct medical costs Risk for diabetes is determined by certain factors, including genetic, physiological, and behavioral Certain ethnic groups
have higher rates of diabetes, suggesting a genetic predisposition to the disease Age also plays a major role in diabetes prevalence The CDC estimates that nearly 1 in 5 adults over the age of 65 years has diabetes Furthermore, nearly 80 of diabetes is diagnosed in overweight and obese individuals, suggesting a strong link between lifestyle behaviors and the development of diabetes Physical inactivity and poor diet are crucial factors then in the prevention of the disease While not all risk factors are modifiable, those that are contribute greatly to the high prevalence of diabetes and provide the key to public health efforts aimed at reducing diabetes prevalence Uncontrolled diabetes is associated with serious complications and premature death; however, much of this burden could be prevented with early detection, improved delivery of care, and better education on diabetes self-management The following are examples of diabetes-related complications that could be prevented or reduced: Cardiovascular disease Adults with diabetes are two to four times more likely to die of heart disease and stroke, which together cause about 65 of deaths among people with diabetes These deaths could
be reduced by 30 with improved care to control blood pressure, blood glucose, and blood cholesterol levels Eye disease and blindness Diabetes is the leading cause of new cases of blindness among adults aged 20 74 Diabetic retinopathy accounts for approximately
3
2004
HAWAII DIABETES REPORT
INTRODUCTION
12,00024,000 new cases of blindness each year Regular eye exams and timely treatment could prevent up to 90 of diabetes-related blindness; however, only 642 of people with diabetes received annual dilated eye exams in 2002 Kidney disease Diabetes is the leading cause of end-stage renal disease ESRD Each year, over 40,000 people with diabetes develop kidney failure, totaling more than 100,000 people treated for this condition Treatment to better control blood pressure and blood glucose levels could reduce diabetes-related kidney failure by about 50 Amputations Between 60 and 70 of people with diabetes have mild to severe forms of nervous system damage, contributing to lower-extremity amputation risk Vascular diseases associated with diabetes increases this risk further In fact, about 82,000 non-traumatic lower-extremity amputations of the leg, foot, or toe are performed annually
among people with diabetes Foot care programs that include regular examinations and patient education could prevent up to 85 of these amputations Pregnancy complications About 18,000 women with preexisting diabetes and about 135,000 women with gestational diabetes give birth each year These women and their babies have an increased risk for serious complications such as stillbirths, congenital malformations, and the need for cesarean sections Poorly controlled diabetes prior to conception and during the first trimester is associated with major birth defects in 5-10 of diabetic pregnancies Moreover, 15-20 of pregnancies in mothers with poorly controlled diabetes are spontaneously aborted Finally, poorly controlled diabetes during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to the mother and the child Women with gestational diabetes and their babies are also at higher risk of becoming obese and developing diabetes later in life These risks can be reduced with screenings and diabetes care before, during, and after pregnancy Flu- and pneumonia-related deaths Each year, 10,00030,000 people with diabetes die of complications from flu
or pneumonia They are roughly three times more likely to die of these complications than people without diabetes; however, only 55 of people with diabetes get an annual flu shot The aim of this document is straightforward: to provide insight on the burden and distribution of diabetes among Hawaiis residents, allowing local communities to focus their resources and attention where it is most needed To that end, this report provides pertinent and current information on the prevalence of diabetes; diabetes mortality; diabetes complications eye, foot, kidney; diabetes preventive care practices; and the relationship between diabetes and general health status, risk factors obesity, smoking, and health/lifestyle behaviors
4
2004
ABOUT THE DATA
The information presented in this report is based on these data sources: 1 Hawaii Behavioral Risk Factor Surveillance Survey BRFSS data averaged over three years 20002002, 2 mortality data from Hawaii vital statistics records averaged over three years 20002002, 3 end-stage renal disease ESRD data from the Transpacific Renal Network ESRD Network 17 for 2002, and 4 the Centers for Disease Control and Preventions CDC web publications Behavioral Risk
Factor Surveillance System The Behavioral Risk Factor Surveillance System BRFSS is the largest continuously conducted telephone health survey in the world Hawaii has been an active participant in the BRFSS since the early 1990s The BRFSS enables the Centers for Disease Control and Prevention CDC, state health departments, and other health and education agencies to monitor risk behaviors related to chronic diseases, injuries, and death State health departments use BRFSS data to create annual and periodic reports, fact sheets, press releases, or other publications, which are used to educate the public, the professional health community, and policymakers about the prevalence of modifiable behavioral risk factors and of preventive health screening practices Data collected through the BRFSS are routinely used to capture health information on demographically defined subgroups ethnicity, gender, age, educational level, income level, geographic location Tests of Statistical Significance Confidence intervals have been provided in the BRFSS section of this report as an efficient way to look for differences among subgroups on important health issues and serve as a useful tool to look for
patterns in BRFSS reports A confidence interval is a range that contains the true population prevalence estimate with a certain degree of assurance when repeated sampling of the population is performed The degree of assurance commonly used is 95 For example, if we set our confidence interval at 95, then we can expect that 5 out of 100 times the estimates coming from our samples will fall outside the range that contains the true population value However, 95 of the time our estimates will fall within the range This is known as a 95 confidence interval Confidence intervals are used to assess if there are differences in prevalence among defined subgroups It is a quick and simple way to determine if such differences are potentially significant statistically For example, the analysis of diabetes prevalence by ethnicity shows that Native Hawaiians have a higher diabetes prevalence rate when compared with Whites 79 versus 34 and the confidence intervals around these prevalence estimates do not overlap page 10, figure 7 Based on this finding, it is reasonable to say that likely significant differences of diabetes prevalence does exist between Native Hawaiians and Whites in this state
However, in order to say that there are statistically significant differences of diabetes prevalence between these ethnic groups Native Hawaiians, Whites, a formal test of significance would have to be conducted eg, t-test, chi-square test Where feasible, formal tests of significance were also performed to more accurately assess differences between sub-groups on important diabetes-related health issues
ABOUT THE DATA
5
2004
ABOUT THE DATA
Mortality Data Vital Statistics The Office of Health Status Monitoring OHSM of the Hawaii Department of Health collects, processes, analyzes and disseminates relevant, population-based data in a timely fashion in order to assess the health status of Hawaiis population and to fulfill health statistics legal requirements OHSM also provides the Department with vital statistics and demographic and health data for use in identifying state and community health trends, identifying population groups at risk for serious health problems, and evaluating program effectiveness Other OHSM activities include: maintaining health surveys for the purpose of collecting data on health conditions not otherwise monitored within the state yet needed to analyze
health status; disseminating information through published reports and through visual presentations such as charts, graphs and maps; and coordinating the integration and linkage of departmental databases with external databases OHSM also provides a repository for vital event records with the State such as births, deaths, and marriages and provides copies to the general public on a timely basis OHSM issues marriage licenses as well as marriage, birth, and death certificates End-Stage Renal Disease The TransPacific Renal Network also known as ESRD Network 17 is a private nonprofit corporation, located in the state of California It is one of 18 organizations established by the US Department of Health, Education, and Welfare DHEW in 1977 to implement a regional system of health care for patients with end-stage renal disease ESRD The Renal Disease Amendments of June 3, 1976, Subpart U, Conditions of Coverage, commonly known as the ESRD Regulations, is the enabling legislation for Networks The purpose of the TransPacific Renal Network is to provide leadership for chronic dialysis and transplantation professionals to promote delivery of the highest quality renal care to people with
endstage renal disease This is accomplished through education of renal care professionals and consumers; data collection, validation and analysis; information development and dissemination; review, evaluation and improvement of provider performance; and acting as a liaison with federal and state policy makers The Network 17 consists of the 45 northernmost counties in California roughly stretching from the Oregon border southward to Fresno, the state of Hawaii, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands Saipan The Network 17 dialysis centers serve approximately 5 of the United States dialysis population, and its transplant centers perform about 5 of kidney transplants annually As of December 31, 2002, the Network 17 had 153 Medicare certified dialysis facilities and two Veterans Administration facilities as well as eight transplant centers Hawaii has eighteen dialysis facilities and one transplant center The dialysis facilities are located on six islands: nine on Oahu, three on the Big Island, two on Maui, two on Kauai, one on Molokai, and one on Lanai In 2002, the Network served 1870 dialysis patients in the state of Hawaii The transplant center is
located on the island of Oahu
ABOUT THE DATA
6
STATE/COUNTY ADULT DIABETES PREVALENCE AND MORTALITY, 2000-2002
FIGURE 1: Prevalence of adults diagnosed with diabetes statewide and by county, BRFSS, 2000-2002
7 6 5 4 3 2 1 0 State 56 Honolulu County 58 Hawaii County 54 Kauai County 54 Maui County 52
3-year average, age-adjusted
Confidence Interval
FINDING: Using averaged data 2000-2002 from the Hawaii Behavioral Risk Factor Surveillance Survey BRFSS, an estimated 48,000 to 57,000 adults know they have diabetes excludes gestational diabetes An additional 25,000 or more adults may have diabetes but remain undiagnosed
FIGURE 2: Diabetes mortality rates per 100,000 population statewide and by county, 2000-2002
FINDING: In Hawaii, diabetes accounts for approximately 116 of all deaths The average 2000-2002 annual number of deaths due to diabetes include 191 cases as an underlying cause and 761 cases as a contributory cause
120 100 80 60 40 20 0 State Honolulu County 20 81 101 Hawaii County 25 86 111 Kauai County Maui County 20 90 110 20 86 106
3-year average, age-adjusted Source: OHSM Analysis: BRFSS
Diabetes as an underlying cause of death per 100,000 population Diabetes as a
contributing cause of death per 100,000 population Diabetes as an underlying and contributing cause of death per 100,000 population
21 82 103
7
COUNTY/SUB-COUNTY ADULT DIABETES PREVALENCE, 2000-2002
FIGURE 3: Prevalence of adults diagnosed with diabetes — Honolulu County, BRFSS, 2000-2002
16 14 12 10 8 6 4 2 0
A B C D E F G H I J K L M
North Shore/Laie Kaaawa/Kahuluu/Kaneohe Kailua/Waimanalo Hawaii Kai/Kahala/Waialae Kaimuki/Palolo/Waikiki Upper Makiki/Manoa Lower Makiki/Ala Moana Moanalua/Kalihi/Nuuanu Salt Lake/Foster Village Aiea/Pearl City Mililani/Wahiawa Waipahu/Waipio/Kapolei Nanakuli/Waianae
Hon State Co A
58 93
B
75
C
47
D
E
F
34
G
H
I
46
J
82
K
7
L
M
56
28 63
57 59
48 71
3-year average, age-adjusted
FINDING: The estimated prevalence rate of diabetes in Honolulu County using BRFSS data averaged over three years is 58 This equates to approximately 39,000 adults with known diabetes residing in Honolulu County alone An additional 21,000 adults approximate may also have diabetes but remain undiagnosed Likely significant differences of age-adjusted diabetes prevalence rates exist between the Hawaii Kai/Kahala/Waialae region D and communities A, B, E,
H, J, K; Honolulu County; and the State
FIGURE 4: Prevalence of adults diagnosed with diabetes — Hawaii County, BRFSS, 2000-2002
9 8 7 6 5 4 3 2 1 0
State
A B C D
North Hawaii Hilo Puna/Kau Kona
Hawaii County
54
A
58
B
66
C
43
D
49
56
3-year average, age-adjusted
FINDING: The estimated prevalence rate of diabetes in Hawaii County using BRFSS data averaged over three years is 54 This equates to approximately 6,400 adults with known diabetes residing in Hawaii County An additional 3,500 adults approximate may also have diabetes but remain undiagnosed
8
COUNTY/SUB-COUNTY ADULT DIABETES PREVALENCE, 2000-2002
FIGURE 5: Prevalence of adults diagnosed with diabetes — Kauai County, BRFSS, 2000-2002
9 8 7 6 5 4 3 2 1 0
State
56
Kauai County
54
A
33
B
66
3-year average, age-adjusted
A Hanalei/Kapaa B Lihue/Waimea
FINDING: The estimated prevalence rate of diabetes in Kauai County using BRFSS data averaged over three years is 54 This equates to approximately 2,500 adults with known diabetes residing in Kauai County An additional 1,400 adults approximate may also have diabetes but remain undiagnosed
FIGURE 6: Prevalence of adults diagnosed with diabetes — Maui
County, BRFSS, 2000-2002
14 12 10 8 6 4 2 0 State
A B C D E Lahaina/Wailuku Kahului/Kihei Upcountry/Hana Molokai Lanai
Maui County
52
A
54
B
84
C
45
D
6
E
77
56
3-year average, age-adjusted
FINDING: The estimated prevalence rate of diabetes in Maui County using BRFSS data averaged over three years is 52 This equates to approximately 5,100 adults with known diabetes residing in Maui County An additional 2,800 adults approximate may also have diabetes but remain undiagnosed
9
ADULT DIABETES PREVALENCE, MEAN AGE OF ONSET AND MORTALITY BY ETHNICITY, 2000-2002
FIGURE 7: Prevalence of adults diagnosed with diabetes by ethnicity, BRFSS, 2000-2002
FINDING: Whites have significantly lower age-adjusted prevalence rates when compared with the other major groups: Native Hawaiians, Filipinos, and Japanese
10 8 6 4 2
p05
0
Hawaiian
79
Filipino
75
Japanese
66
White
34
3-year average, age-adjusted
FIGURE 8: Mean age when diagnosed with diabetes by ethnicity, BRFSS, 2000-2002
FINDING: Likely significant differences of mean age of diabetes diagnosis exists between Native Hawaiians and the other major ethnic groups as well as the State average Native Hawaiians have the
youngest mean age of diabetes diagnosis 446 years of age among the major ethnic groups
60 50 40 30 20 10 0
Mean age of diagnosis
State
493
Hawaiian
446
Filipino
481
Japanese
522
White
512
3-year average
FIGURE 9: Diabetes m 
ortality rates per 100,000 population by ethnicity, 2000-2002
FINDING: Native Hawaiians have the highest age-adjusted diabetes mortality rates, either as an underlying cause or contributing cause when compared with the other major ethnic groups Whites have the lowest age-adjusted diabetes mortality rates
250 200 150 100 50 0 Diabetes as an undenying cause of death per 100,000 population Diabetes as a contributing cause of death per 100,000 population Diabetes as an underlying and contributing cause of death per 100,000 population
Hawaiian Others Filipino Japanese White
47 169 216
32 116 148
22 94 116
19 81 100
7 31 38
3-year average, age-adjusted Source: OHSM Analysis: BRFSS
10
ADULT DIABETES PREVALENCE AND MORTALITY BY GENDER AND EDUCATIONAL ATTAINMENT, 2000-2002
FIGURE 10: Prevalence of adults diagnosed with diabetes by gender and educational attainment, BRFSS, 2000-2002
9 8 7 6 5 4 3 2 1 0 Male Female 53 High School 61 High School 66 Some
College 55 College 44
FINDING: Diabetes prevalence rates are slightly higher in males than females, but this relationship is not significant Diabetes prevalence rates are inversely associated with educational attainment For example, adults with diabetes are significantly more likely to report having a high school education as opposed to a college education
p05
6
3-year average, age-adjusted
FIGURE 11: Diabetes mortality rates per 100,000 population by gender and educational level, 2000-2002
FINDING: Age-adjusted diabetes mortality rates are slightly higher for males when compared with females and decreases as educational level increases The inverse relationship between diabetes and educational attainment exists for both prevalence and mortality
250 250 200 150 100 50 0
Male Female
High School
High School
Some College
College
Diabetes as an undenying cause of death per 100,000 population Diabetes as a contributing cause of death per 100,000 population Diabetes as an underlying and contributing cause of death per 100,000 population
23 98 121
19 69 88
60 219 279
23 88 111
8 40 48
9 33 42
3-year average, age-adjusted
11
Source: OHSM Analysis: BRFSS
ADULT
PREVALENCE OF DIABETES COMPLICATIONS BY ETHNICITY, GENDER, AND EDUCATIONAL ATTAINMENT, 2000-2002
FIGURE 12: Prevalance of retinopathy among adults with diabetes by ethnicity, gender, educational level, and age, BRFSS, 2000-2002
FINDING: The prevalence rate of retinopathy among adults with diabetes is approximately 22 Diabetic retinopathy is significantly higher among Native Hawaiians when compared with Whites, and among those between the ages of 45 to 64 when compared to those between the ages 18 to 44
60 40 20 0
State 219 Hawaiian 287 Filipino 183 Japanese 198 White 165 Male 24 Female 197
40 30 20 10 0
State 219 High School 249 High School 243 Some College 195 65 older 202
College 194
18-44 137
45-64 266
p05
3-year average, crude
FIGURE 13: Prevalance of foot sores among adults with diabetes by ethnicity, gender, educational attainment, and age, BRFSS, 2000-2002
20 15 10 5 0
State 86 Hawaiian 65 Filipino 78 Japanese 33 White 96 Male 111 11 Female 6
FINDING: The prevalence rate of foot sores among adults with diabetes is approximately 9 Foot sore rates are significantly lower among Japanese when compared with Whites, and among those between the ages of 18 to 44
when compared to those between the ages 45 to 64
25 20 15 10 5 0
State 86 High School 51 High School 87 Some College 127 College 57 18-44 3 45-64 11 65 older 82
p05
3-year average, crude
12
HEALTH STATUS AND HEALTH/LIFESTYLE BEHAVIORS OF ADULTS WITH AND WITHOUT DIABETES, 2000-2002
FIGURE 14: General health status of adults with and without diabetes, BRFSS, 2000-2002
FINDING: When compared to adults without diabetes, a significantly lower percentage of adults with diabetes report excellent health Furthermore, a significantly higher percentage of adults with diabetes report fair to poor health when compared to adults without diabetes
50 45 40 35 30 25 20 15 10 5 0
Excellent Health 31 227 Very Good Health 147 345 Good Health 353 325 Fair Health 387 86 Poor Health 82 18 Avg of Unhealthy Days 66 38
p05
of adults with diabetes of adults without diabetes
Average Number of Unhealthy Days is number of days, not percentages 3-year average, age-adjusted
FIGURE 15: Weight status of adults with and without diabetes, BRFSS, 2000-2002
FINDING: The obesity rate among adults with diabetes 51 is significantly higher when compared with the obesity rate among adults without diabetes
155
60 50 40 30 20 10 0
of adults with diabetes Normal Weight 171 499 Overweight 315 346 Obese 514 155 3-year average, age-adjusted
p05
of adults without diabetes
13
HEALTH STATUS AND HEALTH/LIFESTYLE BEHAVIORS OF ADULTS WITH AND WITHOUT DIABETES, 2000-2002
FIGURE 16: Smoking status of adults with and without diabetes, BRFSS, 2000-2002
60 50 40 30 20 10 0
of adults with diabetes of adults without diabetes
State 144 207
Former Smoker 398 235
Never Smoked 458 558
3-year average, age-adjusted
FINDING: A significantly lower percentage of adults with diabetes are current smokers A significantly higher percentage of adults with diabetes are former smokers Finally, a significantly lower percentage of adults with diabetes never smoked when compared with adults without diabetes
p05
FIGURE 17: Immunization, Physical Activity, and Fruit/Vegetable consumption of adults with and without diabetes, BRFSS, 2000-2002
FINDING: A significantly higher percentage of adults with diabetes received both their flu vaccine and pneumonia vaccine when compared with adults without diabetes A higher percentage of adults with diabetes report no leisure time physical activity than adults
without diabetes; however, this finding is not significant A significantly higher percentage of adults with diabetes report that they are eating at least 5 servings of fruits/vegetables a day when compared with adults without diabetes
80 70 60 50 40 30 20 10 0
p05
Had Flu Shot in Had Pneumonia No Leisure Time Eat at Least 5 Servings of Past 12 Months Shot Before Physical Activity Fruits/Vegetables of adults with diabetes 642 455 228 31 189 213 of adults without diabetes 352 169
3-year average, age-adjusted
14
PREVENTIVE CARE PRACTICES OF ADULTS WITH DIABETES, 2000-2002
FIGURE 18: Percentage of adults with diabetes receiving diabetes management education by ethnicity, gender, educational attainment, and age, BRFSS 2000-2002
80 70 60 50 40 30 20 10 0 80 60 40 20 0 State 53 High School 323 High School 464 Some College 638 State 53 Hawaiian 585 Filipino 539 Japanese 425 White 56 Male 517 Female 543
FINDING: Approximately 53 of adults with diabetes report that they have taken a course on how to manage their diabetes A significantly lower percentage of Japanese report receiving diabetes management education when compared with Native Hawaiians and Whites Furthermore, less
educated high school or less or older adults 65 years and older are significantly less likely to report receiving diabetes management education when compared with college educated or younger adults 45 to 64 years
College 619
18-44 556
45-64 632
65 older 42
3-year average, crude
p05
FIGURE 19: Percentage of adults with diabetes who check their feet daily by ethnicity, gender, educational attainment, and age, BRFSS 2000-2002
100
FINDING: About 69 of adults with diabetes report that they check their feet on a daily basis This finding did not differ significantly by gender, educational level, or age group; however, a significantly higher percentage of Whites report that they check their feet on a daily basis when compared with Japanese and Filipinos
80 60 40 20 0
State 694 Hawaiian 651 Filipino 687 Japanese 636 White 794 Male 669 Female 72
100 80 60 40 20 0
State High School 695 High School 665 Some College 762
p05
College 668
18-44 657
45-64 701
65 older 701
694
15
3-year average, crude
PREVENTIVE CARE PRACTICES OF ADULTS WITH DIABETES, 2000-2002
FIGURE 20: Percentage of adults with diabetes who check their blood glucose levels daily by ethnicity, gender,
educational attainment, and age, BRFSS 2000-2002 80 60 40 20 0
State 454 Hawaiian 548 Filipino 435 Japanese 328 White 586 Male 462 Female 445
FINDING: About 45 of adults with diabetes report that they check their blood glucose levels on a daily basis Likely significant differences exist when comparing Japanese 328 to Native Hawaiians 548 and Whites 586 regarding the percentage of adults who check their blood glucose levels on a daily basis However, a formal test of signicance did not confirm this finding A significantly lower percentage of adults 65 years and older report that they check their blood glucose levels daily when compared with adults between the ages of 45 to 64 years and when compared to adults between the ages of 18 to 44 years
80 60 40 20 0
State 454 High School 379 High School 44 Some College 485
College 484
18-44 548
45-64 486
65 older 388
3-year average, crude
p05
16
END-STAGE RENAL DISEASE ESRD
FIGURE 21: Crude incidence rate of newly diagnosed ESRD patients who are receiving chronic ESRD therapy per million population by region, Transpacific Renal Network, 2002 ESRD Network 17
FINDING: Hawaiis incidence rate of 3936 per million population is higher
than the national average
600 500 400 300 200 100 0
United States
2925
Guam
5597
Hawaii
3936
California
2727
Saipan
2458
American Samoa
1747
Incidence rate per million population
FIGURE 22: Crude ESRD dialysis prevalence rate per million population by region, Transpacific Renal Network, 2002 ESRD Network 17
FINDING: Hawaiis prevalence rate of 15021 per million population is higher than the national average of 10397 per million population
2500 2000 1500 1000 500 0
Prevalence rate per million population
United States
10397
Guam
19528
Hawaii
15021
Saipan
11512
American Samoa
10628
California
10455
FIGURE 23: Percent contribution of primary diagnoses to ESRD dialysis prevalence, Transpacific Renal Network, 2002 ESRD Network 17
FINDING: Diabetes is the primary cause of the majority of ESRD dialysis cases in Hawaii Nearly 60 of all ESRD dialysis cases are directly attributable to diabetes as a primary cause 2002
70 60 50 40 30 20 10 0
Diabetes
in 2000 in 2001 in 2002 552 576 588
Glomerulonephritis
183 166 149
Hypertension
133 131 14
Polycystic Kidney Disease
19 2 19
Other
65 61 61
17
END-STAGE RENAL DISEASE ESRD
FIGURE 24: Mean age and percent contribution of
primary diagnoses to ESRD dialysis prevalence by ethnicity, Transpacific Renal Network, 2002 ESRD Network 17
80 70 60 50 40 30 20 10 0
Mean Age Native Hawaiian Filipino Japanese 583 604 666 ESRD caused by diabetes 699 511 58 ESRD caused by glomerulo-nephritis 142 189 135 ESRD caused by hypertension 66 164 158 ESRD caused by other diseases 93 136 126
FINDING: Nearly 70 of all ESRD dialysis cases among Native Hawaiians are directly attributable to diabetes as a primary cause 2002
FIGURE 25: Deaths among dialysis patients by diagnoses, Transpacific Renal Network, 2002 ESRD Network 17
Diabetes 19 4 Hypertension 31 Glomerulonephritis
4 10
In 2002, there were 332 deaths among patients on dialysis in Hawaii Two hundred seven, or 623 of those who died had a primary diagnosis of diabetes
Polycystic kidney disease Other disease Other urologic condition Etiology unknown
Source: Transpacific Renal Network, Selected Demographics, 2002
57 207
18
APPENDIX 1: GLOSSARY DATA DEFINITIONS
Behavioral Risk Factor Surveillance System
The Behavioral Risk Factor Surveillance System BRFSS is the worlds largest telephone survey The BRFSS tracks health risks throughout the entire United States
Information from the survey is used to improve the health of the American people Hawaiis Behavioral Risk Factor Surveillance System BRFSS is conducted and administrated by the Hawaii Department of Health in collaboration with the Centers for Disease Control and Prevention CDC The results from the BRFSS are used by the state to help formulate public health policies, prevention and health promotion programs http://wwwhawaiigov/health/statistics/brfss/indexhtml Age-adjusted prevalence rate It is often necessary to compare diabetes rates of different populations and/or years However, since diabetes rates increase with age, a higher diabetes rate in one population compared with another may simply reflect differing age distributions within the populations Statistical techniques are used to adjust or standardize the rates in the populations to be compared, eliminating the effect of different age distributions in the different populations Prevalence rates computed with these techniques are called age-adjusted or age-standardized prevalence rates An age-adjusted prevalence rate is not a real measure of condition within a given population, but rather an artificial measure that is used for
comparison purposes In this report, prevalence rates with age adjustment employed the age distribution 9 of the Year 2000 Projected US Population DHHS/CDC/NCHS, 2001
Community
Communities sub-county geographic regions in this report are defined by the aggregation of adjacent zip codes with at least one school complex in the area A list of community zip codes can be found at: http://wwwstatehius/doh/stats/surveys/2001/subareahtml
End-stage Renal Disease ESRD
Incidence rate The crude ESRD incidence rate is equal to the number of newly diagnosed persons receiving chronic ESRD therapy dialysis per million population during 2002 Prevalence rate The crude ESRD dialysis prevalence rate is equal to the total number of persons presently on dialysis per million population during 2002
Diabetes
Adult respondents are asked, Have you ever been told by a doctor that you have diabetes? If the respondent is a female and her answer to that question is Yes, then she is further asked, Was this only when you were pregnant? Gestational diabetes is excluded from diabetes in this report
Diabetes Prevalence
Prevalence rate Diabetes prevalence rate is defined as the estimated number of adults with
diabetes divided by the estimated total adult population All percentages or prevalence rates presented in all the tables except the mortality tables are weighted percentages
Ethnicity
Respondents are asked to choose one race from the race list to answer the question: What is your race? The race list includes Caucasian, Hawaiian, Chinese, Filipino, Japanese, Korean, Samoan, Black, American Indian/Alaska native/Eskimo/Inuit, Vietnamese, Asian Indian, Portuguese, Guamanian/Chamorro, Puerto Rican,
19
APPENDIX 1: GLOSSARY DATA DEFINITIONS
Mexican, Tongan, Laotian, Cambodian, Malaysian, Fijian, Micronesian, and other Asian In addition, a respondent can specify their own ethnicity if it is not listed, or they can say they dont know, they are not sure, or they refuse to answer For simplicity, this report re-categorizes ethnicity into White includes Portuguese, Hawaiian, Filipino, Japanese, and Others includes Chinese Diabetes-related eye condition The BRFSS uses the following question to define diabetes-related eye complications: Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy? Diabetes-related foot complication The BRFSS uses the following
question to define foot complications related to diabetes: Have you ever had any sores or irritations on your feet that took more than four weeks to heal? General health status The BRFSS uses the following question to define and quantify general health status: Would you say that in general your health is: 1 Excellent, 2 Very Good, 3 Good, 4 Fair, or 5 Poor? Physical activity leisure time activity The BRFSS defines no leisure time activity as those responding no to the question, During the past month, other than your regular job, did you participate in any physical activities or exercise such as running, calisthenics, golf, gardening, or walking for exercise? Smoking status The BRFSS defines a current smoker as a person who responds yes to the question Have you smoked at least 100 cigarettes in your life time, and still smokes everyday or some days A former smoker is a person who smoked a least 100 cigarettes before, but does not smoke anymore Vegetable/fruit consumption The BRFSS estimates the number of daily servings of fruit/vegetable by asking the following series of questions Not counting juice, how often do you eat fruit? How often do you eat green? How often do you eat
potatoes not including French fries, fried potatoes, or potato chips? How often do you eat carrots? Not counting carrots, potatoes, or salad, how many serving of vegetables do you usually eat?
Mortality
Diabetes mortality rate The mortality rate is the frequency of occurrence of death diabetes-related in a defined population Population denominators 916,580 adults were estimated from the Hawaii Behavioral Risk Factor Surveillance System, 20002002 Contributory cause of death CCD Contributory cause of death is defined as conditions that did not initiate the chain of events leading to death, but resulted in death directly or indirectly; or any other significant conditions that unfavorably influenced the course of the morbid process and thus contributed to the fatal outcome Underlying cause of death UCD Underlying cause of death is defined as the disease/condition that initiated the chain of events leading to death
Survey BRFSS Definitions
Bodyweight status The BRFSS uses Body Mass Index BMI as a measure of bodyweight Cutoffs for weight status are defined as follows: normal weight BMI 25, overweight BMI 25 and 30, and obese BMI 30 Diabetes management education The BRFSS uses
the following question to define diabetes management education: Have you ever taken a course or class in how to manage your diabetes yourself?
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APPENDIX II: METHODOLOGY
Survey Methods
The Hawaii Behavioral Risk Factor Surveillance System BRFSS follows the Centers for Disease Control and Preventions CDC guidelines and standards by using a Disproportionate Stratified Sample DSS method to randomly select landbased telephone numbers throughout the state of Hawaii Business and nonworking numbers are excluded; residential numbers are retained Individuals, aged 18 years and older, are randomly selected from each household called To ensure maximum data quality, interviewers are specially trained to ask questions exactly the same way for every call Interviewers use the Computer Assisted Telephone Interview CATI program to dial telephone numbers and enter data directly into their computers Once the survey data are edited, imputed, and weighted by CDC, the processed data set is sent back to Hawaii BRFSS staff for analytical purposes ated in this report: crude prevalence rates and ageadjusted prevalence rates Crude prevalence rates estimate the true rate, reflecting the real burden of
disease in a population Age-adjusted prevalence rates are synthetic and are used for rate comparison between two populations or for rate comparisons within a single population over time SUDAAN proc descript feature was used to calculate prevalence rates and age-adjusted prevalence rates and standard errors SE
Data Sources
1 Survey data, 2000 through 2002, Hawaii Behavioral Risk Factor Surveillance System BRFSS, Hawaii Department of Health 2 Mortality data, 2000 through 2002, Office of Health Status Monitoring OHSM, Hawaii Department of Health 3 Transpacific Renal Network, Selected Demographics, 2002 4 Centers for Disease Control and Prevention http://wwwcdcgov/brfss/indexhtm
Surveyed Population
The survey population for the Hawaii BRFSS includes all non-institutionalized residents aged 18 years or older in the state of Hawaii Persons in households without telephones, or people who live in non-traditional homes, are not included in the telephone survey
Data Analysis
Hawaii residents who died at age 18 years or older are included in the analysis of mortality data SAS Proc FREQ was used to generate diabetes mortality frequencies for the following: 1 diabetes as the underlying cause
of death UCD; 2 diabetes as a contributory cause of death CCD; and 3 UCD and CCD combined UCDCCD Excel was used to calculate mortality rates based upon the estimated average adult populations from 2000 to 2002 Two types of diabetes prevalence rates were gener-
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CITATION
Suggested Citation
Hirokawa, R, Huang, T, Pobutsky, A, Noguès, M, Salvail, F, Nguyen, HD 2004 Hawaii Diabetes Report, 2004 Hawaii State Department of Health Honolulu, Hawaii
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