proper treatment, diabetes can lead to serious compli and indirect cost of diabetes in the United States was recent data on diabetes for King County, …

Public Health Data Watch
Volume 9 Number 1

Public HealthSeattle King County

April 2007

Diabetes in King County
diabetes at a given time and the diabetes death rate have been increasing Diabetes is costly The American Diabetes Association estimates that the total direct and indirect cost of diabetes in the United States was 132 billion in 2002, up from 98 billion in 19971 This issue of Public Health Data Watch summarizes most recent data on diabetes for King County, updating a previous Data Watch issued in November 19992

iabetes is a chronic disease in which insulin deficiency or the bodys resistance to insulin leads to a high level of sugar in the blood Without proper treatment, diabetes can lead to serious complications such as heart attack, kidney failure, blindness, and lower extremity amputation In the United States, diabetes is the sixth leading cause of death During the past two decades, the diabetes prevalence rate defined a percent of people who have been diagnosed with

Highlights
The number of people in King County with diabetes doubled in the past decade Such a rapid increase in the occurrence of a chronic illness is very rare Diabetes now affects 84,000 adults
in King County or 58 of the adult population In King County, the diabetes death rate increased significantly from the mid-1980s to the mid-1990s and remains at a high level The age-adjusted death rate per 100,000 was 206 in 2005 Most cases of diabetes are potentially preventable through decreasing obesity and increasing physical activity in the population However, obesity is becoming increasingly common, suggesting that the diabetes prevalence will continue to increase in the future Diabetes complications, hospitalizations, and deaths are also potentially preventable through appropriate disease management Diabetes is costly to families, businesses and the health care system In King County, the total estimated annual cost attributable to diabetes is 1,025 million Total charges for hospitalizations alone are 245 million In King County, African Americans are 26 times more likely to be affected by diabetes than whites and have a death rate 33 times higher than whites The gap in the diabetes death rate between African Americans and whites increased during the 1990s and remains high Pacific Islanders have the highest diabetes prevalence of any racial/ethnic group in King County, 32
times higher than whites Asians and American Indians/Alaska Natives are also more likely to have diabetes than whites The age-adjusted diabetes death rate for African Americans in King County is 26 higher than the average rate for African Americans in the United States Diabetes disproportionately affects low income people People with lower incomes are more likely to have diabetes and die from it than higher income people There is significant neighborhood variation in the diabetes death rate Among the Health Planning Areas in King County, the death rate for Southeast Seattle with the highest rate is 41 times the rate for Mercer Island with the lowest rate Many people with diabetes do not receive health services that can control blood sugar levels and prevent complications

Public Health-Seattle King County

Current Data on Prevalence, Hospitalization, and Death

n 2006, 84,000 adults, or 58 of the adult population in King County have been diagnosed with diabetes by a doctor Another 09 approximately 13,400 have been told they have borderline diabetes In addition, many people who have diabetes are unaware of their condition Nationally, 30 of persons with diabetes are
undiagnosed3 The 2005 diabetes prevalence in the United States was 73i The King County prevalence in 2005 56 was significantly lower than the national rate and ranked 14th among the 15 largest counties in the US Each year, nearly 1,500 people are hospitalized for diabetes as primary diagnosis The aver-

age hospital stay was 42 days Almost all hospitalizations for diabetes in adults 957 are potentially preventable4 Of the 1,298 preventable diabetes hospitalizations in 2004, 354 were for short-term diabetes complications such as ketoacidosis and coma and 606 were for long-term complications such as renal, eye, neurological, or circulatory complications The remaining 40 were for unspecified complications In 2004, 278 hospitalizations were for diabetes-related lower-extremity amputation Diabetes is the 7th leading cause of death in King County, with 354 deaths in 2005i In addition, diabetes was a contributing cause in 712 additional

deaths The 1,066 diabetes-related deaths accounted for 93 of the total deaths in 2005 The age-adjustedii diabetes death rate per 100,000 in 2005 was 206 in King County and 253 in WA State The US 2004 death rate was 244 Compared to the 15 largest
counties in the US, the King County death rate ranked 10th Compared to the average death rate among similar counties in the US 221,iii the King County death rate was slightly lower The King County age-adjusted rate of diabetes-related deaths in 2005 was 627 per 100,000, 39 higher than the US 2010 objective of 450 per 100,000

Economic Costs of Diabetes

he only local data on the cost of diabetes are hospitalization charges charges are what the hospital initially bills for its services but actual costs may be somewhat lower Other direct costs include costs for nursing home care, outpatient care, and outpatient medications Indirect costs attributable to diabetes include lost work days and premature mortality To provide a

more complete picture of the local economic burden of diabetes, we estimated the total costs of diabetes for King County based on per capita costs in the United States5 The total charges for hospitalizations in 2004 with diabetes as the primary diagnosis were 245 million, averaging 16,366 per hospitalization For the 1,298 hospitalizations

among adults that were potentially preventable, the average charge per hospitalization was 11,746 for those with shortterm
complications, 21,610 for long-term complications, and 7,634 for unspecified complications For hospitalizations with diabetes-related amputations, the average charge was 34,812

i ii iii

This is the median among 51 states and Washington DC based on BRFSS data As the underlying cause of death, which is a disease or condition which initiated the sequence of events leading directly to death The age-adjusted rate is a rate that mathematically removes the effect of age, by using a standard population For this report the rate is adjusted to the age distribution of the 2000 US population This is a selected group of US counties that are similar to King County in population size and demographic characteristics See King County Core Indicators for Public Health wwwmetrokcgov/health/reports/coreindicators

Public Health Data Watch: April 2007

Table 1 Estimated economic costs of diabetes in King County, 2006v
The total estimated direct and indirect annual cost attributable to diabetes in King County is 1,025 million Table 1 Hospitalizations are the largest direct cost contributor 44, followed by medications 19, nursing home care 16, and physician office visits 11
Total direct health
care cost Hospital inpatient Medications Nursing home/hospice Physicians office Hospital outpatient Emergency Home health Total Indirect cost Lost work days Restricted activity days Mortality Permanent disability Total Cost Millions 715 314 136 112 78 26 18 31 310 35 49 168 58 1,025

Time Trends
The prevalence of diabetes has been increasing locally, nationally, and worldwide In King County, the prevalence doubled from 28 in 1996 to 58 in 2006 The rise in diabetes prevalence occurred at a time when the prevalence of obesity also increased Figure 1 Other factors that are associated with diabetes and obesity include unhealthy eating and physical inactivity

Figure 1: Diabetes and obesity prevalence among adults ages 18, King County, 1987-2006
20

15 Percent

Obesity

5 Diabetes 0
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Based on adults age 18 with diabetes N84,000 in 2006, or 58 of the population The US 2002 per capita cost attributable to diabetes is from Table 10 of reference 1 The 2006 estimates are based on 2002 dollars adjusted for the 2006 US city average CPI for all items

Public
Health-Seattle King County The diabetes death rate in King County increased 47 and the number of deaths per year increased from 180 to 321 between 1987 and 1996 Since 1996, the death rate has stayed high Figure 2 The largest increase in the death rate was among African Americans during the 1990s Figure 3 The average number of deaths per year increased from 17 during 1987-1991 to 36 during 1995-1999 while the ageadjusted death rate increased 79, twice the rate of increase observed among whites The African American rate has remained high in recent years For Asians, the diabetes death rate increased in the late 1990s and reached its highest level in 2002 There was no significant change in the death rate among Hispanics Among whites, the diabetes death rate also increased significantly between the mid-1980s and the mid1990s and stayed stable since then

Figure 2: Diabetes deaths in King County and the US, 1980-2005
30 Age-Adjusted Rate Per 100,000 US

20 King County

0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
1998-2002 1999-2003 2000-2004

Figure 3: Diabetes death rate in King County by race/ethnicity, five year rolling averages, 1980-2005
70
Age-Adjusted Rate
Per 100,000
AA/W gap African American to White Gap

60 50 40 30 20 10 0
1980-1984 1981-1985 1982-1986 1983-1987 1984-1988 1985-1989 1986-1990 1987-1991 1988-1992 1989-1993 1990-1994 1991-1995 1992-1996 1993-1997 1994-1998 1995-1999 1996-2000 1997-2001 2001-2005

African American AA/W gap488 Hispanic/Latino

AA/W gap405 AA/W gap223

White

Asian/Paci c Islander

Age and Gender Distribution
The risk of diabetes increases with age Averaged over 20022006, 06 of 18-24 year olds, 22 of 25-44 year olds, 78 of 45-64 year olds, and 140 of those age 65 and older had diabetes The rates of hospitalization and death had a similar age pattern The percent of people with diabetes increased significantly during 1993 to 2006 Between 1993-1997 and 2002-2006, the prevalence increased from 10 to 22 for people ages 25-44,

44 to 78 among people indicates that 15 of the King ages 45-64, and 63 to 140 County students in grade 8, among people ages 65 and 10, and 12 report having been older The number of cases is diagnosed with diabetes too small for a reliable trend Men have higher diabetes evaluation for the 18-24 age prevalence and death rates than group women In King County, the Although most cases of
diaage-adjusted prevalence rate betes are among middle aged was 51 for men and 42 for and older adults, some studies women 2002-2006 average suggest that Type 2 diabetes is The age-adjusted death rate per increasingly being found among 100,000 was 260 for men and 5 children and adolescents The 175 for women 2001-2005 2004 Healthy Youth Survey average

2004

Public Health Data Watch: April 2007

Disparities by Race/Ethnicity, Income, and Geographic Area
Race/Ethnicity
African Americans have a higher percentage of people living with diabetes as well as a higher death rate In King County, African Americans were 26 times more likely to have diabetes and 33 times more likely to die from it than whites Table 2 and Table 3 If African Americans had the same diabetes death rate as whites, 71 of the deaths from diabetes would have been prevented The death rates for Asians/Pacific Islanders and American Indians/Alaska Natives were also significantly higher than the white rate The diabetes death rate for Hispanics was similar to the white rate Reliable death rates for Pacific Islanders alone are not yet available The percentages of the minority racial groups living with diabetes were all
significantly higher than that for whites Among Pacific Islanders, 133 were living with diabetes, followed by African Americans 105, American Indians/Alaska Natives 72, and Asians 68 For Hispanics, the rate was also

Table 2: Diabetes prevalence by race/ethnicity among adults age 18, King County, 2002-2006
Percent White African Am Asian Pacific Islander AI/AN Hispanic 41 105 68 133 72 60 95 CI 39 44 87 127 54 85 84 204 46 109 43 82 Rate Ratio 10 26 17 32 18 15 Estimated cases 61,600 5,000 5,100 1,200 1,200 2,700

The prevalence rate is age-adjusted to the 2000 US population For calculating the rate ratio, white is the reference group

higher than the white rate but County 9171 was lower than the difference was not statistithe national African American cally significant Table 2 average 11008 The gap in diabetes death rate The King County African between African Americans American-to-white death rate and whites narrowed from 405 ratio was substantially higher during 1980-1984 to 223 durthan the national ratio of 22 ing 1987-1991, but increased due to both a higher death rate again to 488 during 1995-1999, among African Americans and stayed above 400 since 622 in King County vs
494 then Figure 3 in the US and a lower death The age-adjusted diabetes death rate among whites 188 in King rate for African Americans in County vs 229 in the US The King County 622 during 2001lower white rate in King Coun2005 was 26 higher than the ty may be explained by the rate for African Americans in countys higher income level the United States 494 durHowever, we have not found a ing 1999-2003 Meanwhile, convincing explanation for the the death rate from all causes higher African American death for African Americans in King rate in King County
US, 1999-2003 Averages Excess deaths/ Year 0 29 6 2 1 Age-Adj Rate 229 494 Death/ Year 56980 12366 Rate Ratio 10 22 -

Table 3: Diabetes death rate by race/ethnicity, King County
King County, 2001-2005 Averages Age-Adj Rate White African Am Asian AI/AN Hispanic 188 622 251 424 222 95 CI 178, 198 537, 711 213, 293 236, 720 144, 330 Death/ Year 264 41 34 4 6 Rate Ratio 10 33 13 23 12

For calculating rate ratio and excess deaths, white is the reference group

Public Health-Seattle King County Many interrelated factors may have contributed to racial disparity in diabetes prevalence and death The higher death rate among African
Americans, for example, may be explained by racial discrimination, higher poverty, lower educational attainment, higher prevalence of diabetes and other heart disease risk factors, barriers to accessing medical care, and a lower likelihood of receiving optimal diabetes management once in care The 2004 BRFSS data, for example, indicate that African Americans, Hispanics, and American Indian/Alaska Natives are significantly more likely than whites to experience racial discrimination overall and in the health care setting They are also more likely to experience emotional upset and physical symptoms as a result of racial discrimination

Tables 4: Racial discrimination experience by race/ethnicity, King County, 2004 BRFSS
Overall Pct 31 298 87 95 159 95 CI 22, 44 185, 444 43, 167 35, 231 86, 274 Health Care Setting Pct 95 CI 11 06, 22 70 26, 176 01 00, 10 83 28, 220 77 30, 184 Emotional upset Pct 95 CI 30 21, 42 214 126, 341 104 40, 241 144 66, 288 156 81, 277 Physical symptoms Pct 95 CI 11 06, 21 156 85, 271 30 11, 78 126 50, 284 160 88, 273

White African Am Asian/PI AI/AN Hispanic

The four racial discrimination indicators are based on the following questions in the BRFSS:
Overall experienced being treated worse than people of other races/past 12 months; Health Care Setting experienced being treated worse than people of other races when seeking health care/past 12 months; Emotional upset - felt emotionally upset as a result of how you were treated based on your race/past 30 days; Physical symptoms experienced physical symptoms as a result of how you were treated based on your race/past 30 days Data for AI/AN are for Washington State because the sample size for King County is too small Statewide AI/AN rates are significantly higher than statewide rates for whites

Income
Averaged over 2002-2006, 92 of adults with a household annual income less than 20,000 had diabetes, compared to 49 among those with higher incomes Among adults age 45 and older, 181 of those living below 200 poverty had diabetes, compared to 79 of those living above 200 poverty The gap in diabetes prevalence between those living below and above 200 poverty more than doubled since the late 1990s Figure 4 The diabetes death rate is strongly related to neighborhood poverty levelvi The age-adjusted death

Figure 4: Diabetes prevalence among adults age 45 by household poverty level,
King County five year rolling averages, 1993-2006
20

200 Poverty

15 Percent

200 Poverty

0 93-97 94-98 95-99 96-00 97-01 98-02 99-03 00-04 01-05 02-06

rates per 100,000 in high, medium, and low poverty neighborhoods, averaged over 1995-2004,

were 309, 211, and 162 respectively Figure 5

Public Health Data Watch: April 2007 The association between neighborhood poverty and the diabetes death rate is not the same among all racial groups For whites, there was a strong association similar to what was observed in the total population Among African Americans, the death rate was similar across neighborhoods regardless of neighborhood poverty level For the other minority groups, the diabetes death rate appeared to be higher among those living in high poverty neighborhoods, although the differences were not statistically significant Figure 5 The death rate for African Americans living in low poverty areas 703 was 26 times the rate for whites living in high poverty areas 273

Figure 5: Race-specific age-adjusted death rate by neighborhood poverty level, King County, 1995-2004
100
Age-Adjusted Rate Per 100,000

80 60
703

628

635

40
309

490

273

263

244

263

231

240

20
0

397

211

162

196

156

High Medium Low

145

Total

White

African Am

AI/AN

Asian

Based on percent of population living below the 200 Federal Poverty Level at the census tract level 30, 15-29, 15

Figure 6: Diabetes prevalence among adults age 40, King County, by Health Planning Areas, 2001-2005 averages
Southeast King County Auburn Kent

2800 3300 6800 5100 3000 5400 2600 3900 1300 5700 500 2900 1300 2000 2100 2600 2100 2600 1200 3800 1400 1700 1300 500 1000
5 10 15 20 25

Geographic Area
By Health Planning Areas, among adults age 40 and older, the highest diabetes prevalence rates were in Southeast King County, Auburn, Kent, Renton, Beacon Hill/Southeast Seattle, and Federal Way while the lowest rates were in Issaquah/Sammamish, Mercer Island/Point Cities, Burien/Des Moines, Kirkland, and Queen Anne/Magnolia Figure 6 The age-adjusted diabetes death rate per 100,000 had a somewhat similar pattern as the prevalence rate The death rate was the highest in Southeast Seattle 397 and the lowest on Mercer Island 97 See a map in the age-adjusted death rate by Health Planning Area at http://wwwmetrokc
gov/gis/vmc/images/Mapimages/05070_DiabetesD_586gif

Renton Beacon SE Seattle Federal Way White Center/Boulevard P Downtown Central Tukwila/SeaTac N Seattle/Shoreline Vashon Island

KING COUNTY
Bothell/Woodinville Lower Valley Upper Sno Cascade Covington Redmond/Union Hill W Seattle/Delridge NE Seattle Ball-Fremt-Greenlk Capitol Hill/Eastlake Bellevue Queen Anne/Magnolia Kirkland Burien/Des Moines Mercer Isle/Point Cities Issaquah/Sammamish

Numbers in the boxes are estimated numbers of adults with diabetes based on ve-year average prevalence rate

Poverty neighborhoods are based on percent population living below the 200 Federal Poverty Level high poverty: 30 living below 200 poverty, medium poverty: 15 29, low poverty: 15

High Medium Low
Hispanic

228

Public Health-Seattle King County

Diabetes Risk Factors

Figure 7: Diabetes prevalence by weight status among King County adults 2002-2006 average
25
197

ype 2 diabetes occurs more commonly among people with the following characteristics:6 Age 45 or older Overweight BMI25 Family history of diabetes Physical inactivity Race/ethnicity African American, American Indian, Asian, Pacific Islander and Hispanic
Previous tests for diabetes indicating borderline abnormal result History of diabetes during pregnancy or delivery of a baby weighing more than 9 pounds Metabolic syndrome: hypertension, increased lipids, and cardiovascular disease Polycystic ovary syndrome The modifiable risk factors are overweight and physical inactivity

20
109

Percent

10
54

Not Overweight BMI25

Overweight BMI 25-29

Obese BMI 30-34

Severely Obese BMI 35

Figure 8: Diabetes prevalence by physical activity level and weight status among King County adults 2001, 2003, and 2005 average
30 237 20 73 10 16 22 0
ity ity ity ity ity tiv ac No ity ity tiv tiv tiv tiv ity tiv tiv ac ac ac ac tiv ac ac nt ac No nt No nt nt nt nt ac tiv ity

104 43 50

129 113

Obesityvii
Overweight and obese people are more likely to have diabetes Among adults age 18 and older during 2002-2006, 23 of those who were not overweight BMI25, 54 of those overweight BMI 25-29, 109 of those obese BMI 30-34, and 197 of those severely obese BMI 35 had diabetes Figure 7
vii

cie

Not overweight

Overweight

Obese

Suf cient activity: physical activity met the recommended
level of moderate or vigorous activity Insuf cient activity: did not meet the recommended level of physical activity

The prevalence of obesity more than doubled during the past two decades among King County adults, from 73 during 1988-1990 to 187 during 2004-2006 Figure 1 Diabetes prevalence doubled between 1996 and 2005

Physical inactivity
Physical inactivity not only contributes to obesity but also independently increases the risk of diabetes Regardless of weight, being physically active substantially reduces the risk of diabetes Figure 8

Obesity can be determined by a measure called the BMI Body Mass Index The BMI is a ratio of weight to height weight in kilograms /height in meters2 An adult who is 55 tall is considered overweight if he/she weighs 150 pounds or more, is considered obese if he/she weighs 180 pounds or more, and is considered severely obese if he/she weights more than 210 pounds For a person who is 510 tall, the cut-off points are 174 pounds, 209 pounds, and 244 pounds respectively

Public Health Data Watch: April 2007

Diabetes Prevention and Control
Preventing the development of diabetes
For Type 2 diabetes,viii effective strategies for preventing or
delaying the onset of diabetes among high risk adults include weight reduction, dietary changes, and increased physical activity7 8 have uniformly demonstrated low yield and poor follow-up Such screening usually does not represent a good use of resources Periodic screening of high-risk individuals as part of ongoing medical care may be warranted, understanding that evidence in support of this is incomplete Questions remain about the optimal screening methods, best cutpoint measurements for a positive test to use to identify those with diabetes, and how often to screen people not at high risk for diabetes11 Improving patient care can be best accomplished by setting up diabetes management systems at sources of medical care and integrating these with community resources These systems can track patient care to assure that all components of a comprehensive care plan are provided for each individual Recent studies show that good control of blood sugar can prevent many of the diabetes complications10 Averaged over 2002-2006, among adult diabetics in King County, the frequency of checking blood sugar was associated with insulin use Among current insulin users, 93 checked their blood sugar
daily, 5 weekly, 1 less than weekly, and 1 never Among patients who were not using insulin, the percentages were 58, 20, 8, and 14 respectively Also, 8 of the diabetics had not seen a health professional for their diabetes during the previous year Among diabetics who had seen a health care professional at least once during the previous year, 19 did not receive a foot exam and 28 did not receive an eye exam Among all people with diabetes, the proportions were 22 and 29 respectively

Screening and early detection
Type 2 diabetes usually has no obvious symptoms in its early stages About 30 of the individuals who have diabetes are undiagnosed Some of these individuals may have already developed diabetic complications at the time of diagnosis However, there is no consensus about who to screen for diabetes The US Preventive Services Task Force states that the evidence is insufficient to recommend for or against routinely screening all asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose and screening should be limited to high-risk individuals such as those with hypertension and hyperlipidemia9 The American Diabetes Association recommends that
screening should be considered in individuals 45 years of age at three year intervals, particularly in those with a BMI 2510 The Centers for Disease Control and Prevention CDC concluded that population-based and selective screening programs in community settings, such as outreach programs, health fairs, and shopping malls,
viii

Preventing diabetic complications among persons with diabetes
Diabetes is a chronic disease that requires lifelong medical care and active patient involvement In addition to prescribing medication and proper counseling on nutrition, weight reduction, physical activity, and tobacco cessation, health providers can reduce the risk of diabetes complications by improving self-management skills of those with diabetes such as self-monitoring of blood sugar levels, checking their blood pressure at every visit and controlling high blood pressure, conducting annual eye exams to detect diabetic eye damage, treating early signs of diabetic kidney damage, conducting foot exams, prescribing a low dose of aspirin, and checking cholesterol annually and treating elevated cholesterol aggressively

There are two types of diabetes Type 2 diabetes is caused by resistance to
insulin often develops during middle age and it accounts for 90-95 of all cases Type 1 diabetes is caused by lack of insulin and usually develops during childhood

Public Health-Seattle King County

Public Health-Community partnerships that address diabetes
The REACH Racial and Ethnic Approaches to Community Health Project
The REACH Coalition is a partnership of community based agencies, community groups, educational and research institutions, public health agencies, hospitals and health care providers, and people living with diabetes working together to reduce diabetes-related health disparities in King County The coalition partners provide culturally tailored diabetes education and self management classes, along with support groups to African Americans, Asian/Pacific Islanders, and Latinos/Hispanics For more details, please visit http://wwwmetrokcgov/health/reach/ indexhtm

Steps to a Healthier US
Steps to a Healthier US in Seattle and King County is a federally-funded program lead by community partners and Public Health - Seattle King County that focuses on asthma, diabetes, obesity, nutrition, physical activity and tobacco Steps supports activities and policy changes in
schools, health care settings, and communities to prevent obesity and improve the care of diabetes Steps emphasizes reducing diabetes disparities The intervention area includes South Seattle and adjacent South King County See http://www metrokcgov/health/steps/ for more details

References
1 2 3 4 5 6 7

American Diabetes Association Economic Costs of Diabetes in the US in 2002 Diabetes Care 26:917-932, March 2003 Public Health Seattle King County Public Health Data Watch Diabetes in King County November 1999 http://wwwmetrokcgov/health/datawatch/diabetespdf CDC National Diabetes Fact Sheet United States, 2005 National Estimates on Diabetes http://wwwcdcgov/diabetes/pubs/pdf/ndfs_2005pdf Department of Health and Human Services Agency for Health Care Research and Quality Guide to Prevention Quality Indicators http://wwwqualityindicatorsahrqgov National Diabetes Information Clearinghouse NDIC Prevalence of Diagnosed Diabetes in People Aged 20 Years or Younger, United States, 2005 http://diabetesniddknihgov/dm/pubs/statistics/8 American Diabetes Association Screening for Type 2 Diabetes Diabetes Care 27, Supplement 1, January 2004 Centers for Disease Control and Prevention Primary
Prevention Working Group Primary Prevention of Type 2 Diabetes Mellitus by Lifestyle Intervention: Implications for Health Policy Annals of Internal Medicine 2004;140:951-957 Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Ilanne-Parikka P, et al Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance N Engl J Med 2001;344:1343-50 USPSTForce Screening Diabetes Mellitus, Adult Type 2 http://wwwahcprgov/clinic/uspstf/uspsdiabhtm

10 American Diabetes Association Standards of Medical Care in Diabetes-2006 Diabetes Care 29, Supplement 1, January 2006 11 CDC CDC Statements on Diabetes Issues http://wwwcdcgov/diabetes/news/docs/screeninghtm

Public Health Data Watch: April 2007

Public Health Data Watch
Public Health Data Watch monitors trends in key health indicators for King County It is produced several times a year by the Epidemiology, Planning, and Evaluation Unit EPE of Public Health - Seattle King County with assistance from other staff of Public Health This issue is prepared by Lin Song, James Krieger, and David Solet For additional copies of this Data Watch please contact or visit:

Public Health - Seattle King
County Epidemiology, Planning, and Evaluation Wells Fargo Center, Suite 1200 999 Third Avenue, Seattle, WA 98104-4039 Phone: 206 296-6817 Fax: 206 205-5314 Email: data request@kingcountygov Web: http://wwwmetrokcgov/health/datawatch/
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