Diabetes Treatments

temporary impotence, both in people who do, or do not, have diabetes. DIABETES is one of the leading physical causes of impotence in males. …

The Burden of

DIABETES
in South Dakota

South Dakota Department of Health Diabetes Prevention and Control Program 615 East Fourth Street, Pierre, SD 57501 Phone: 800 738-2301 Fax: 605 773-5942 http://diabetessdgov

OFFICE OF THE SECRETARY

600 East Capitol Avenue Pierre, South Dakota 57501-2536 605/773-3361 FAX: 605/773-5683

July 31, 2008

Dear South Dakotans: On behalf of the South Dakota Department of Health Diabetes Prevention Control Program, I am pleased to present The Burden of Diabetes in South Dakota This report quantifies the epidemic of diabetes in the state of South Dakota It presents information on the number of people with diabetes, their characteristics, the treatment they receive and the consequences of the disease It also describes the risk factors that increase the occurrence of diabetes and its complications The report indicates that diabetes is common, costly, and serious: Diabetes is common 2007 surveillance showed that approximately 40,000 South Dakota adults had been diagnosed with diabetes, more than 13,000 have the disease but do not know it, and almost 150,000 South Dakota adults have pre-diabetes Prediabetes places people at an increased risk of
developing type 2 diabetes, heart disease, and stroke Diabetes is costly the per capita annual cost of health care for people with diabetes is calculated at 11,744 a year, of which 6,649 57 is attributed to diabetes Diabetes is serious uncontrolled diabetes can lead to serious complications such as lower extremity amputations, blindness, end-stage renal disease, and significantly increased rates of heart disease and cardiovascular events In 2007 there were 246 deaths directly attributed to diabetes From 2003-2007 a total of 1,174 deaths were directly attributed to diabetes in South Dakota residents The Burden of Diabetes in South Dakota is part of a statewide initiative to improve the health care of people either at risk for or already with diabetes and is consistent with the South Dakota Diabetes State Plan 2007-2009, available at http://diabetessdgov We hope that you will find this report useful in your diabetes prevention and control efforts Sincerely,

Doneen B Hollingsworth Secretary of Health

The Burden of Diabetes in South Dakota

The Burden of Diabetes in South Dakota

Published July 2008

For additional information or copies of this report, contact: South Dakota
Department of Health 615 East 4th Street Pierre, South Dakota 57501-1700 800 738-2301 http://diabetessdgov

This publication was supported by Cooperative Agreement U32/CCU822730 from the Centers for Disease Control and Prevention Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention This document is in the public domain and may be downloaded, copied and/or reprinted The South Dakota Diabetes Prevention Control Program and its partners appreciate citation and notification of use

3

The Burden of Diabetes in South Dakota

Table of Contents
Letter from Secretary of Health Doneen Hollingsworth Table of Contents List of Figures Acknowledgements Executive Summary Introduction What is Diabetes? Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Gestational Diabetes Mellitus Pre-diabetes Demographics of South Dakota Prevalence of Diagnosed Diabetes Prevalence of Pre-diabetes Risk Factors for Development of Diabetes Overweight and Obesity Rates Physical Activity Rates Quality of Life Risk Reduction Glucose control Blood pressure control Control of blood lipids Preventive
care practices for eyes, feet, and kidneys Preventive Services Diabetes Self-Management Education DSME Self-Monitored Blood Glucose Testing SMBG Blood Pressure Blood Lipids Heart Disease Stroke Tobacco Use A1c Feet Eyes Vaccinations Oral Health Insurance Status Costs Preventive Services as Cost-Saving Tools Mortality Appendix A-Glossary Resources Appendix B-References 2 4 5 5 6-7 8 9 9 9 9 9 10 11 14 15 15 15 16 17 17 17 17 17 18 18 19 19 19 19 20 20 20 21 21 21 22 22 22 23 25 28

4

The Burden of Diabetes in South Dakota

List of Figures
Figure 1 Figure 2 Figure 3 South Dakota Medically Underserved Areas Nationally, BRFSS Respondents Who Were Told They Have Diabetes, 2007 Percent of BRFSS Respondents Who Were Told They Have Diabetes, 19882007 Figure 4 County Level Estimates of Diagnosed Diabetes - Percentage of Adults in South Dakota, 2005 Figure 5 Percent of South Dakota BRFSS Respondents Who Were Told They Have Diabetes, By Age, 2007 Figure 6 Percent of Race with Diagnosed Diabetes, South Dakota, 1999-2007 Figure 7 Percent of Obese Adult South Dakotans, 1993-2007 Figure 8 Quality of Life Indicators Figure 9 BRFSS Respondents Who Had Taken a DSME Course, 2007-2007 Figure
10 Ten South Dakota Counties with Highest Death Rates Due to Diabetes, 20032007

Acknowledgements
The Burden of Diabetes in South Dakota was developed thanks to the dedication of the following people: Linda Ahrendt, BS, Med - Administrator, Office of Health Promotion Barb Buhler - Department of Health Information Officer Kristin Biskeborn, RD, LN, MPH - State Nutritionist Kim Carlson - Policy Analyst Jacy Clarke, MPH - Chronic Disease Epidemiologist Jenna Everson - Intern, Office of Health Promotion Kathy Miller-Department of Health Office Supervisor Mark Gildemaster - Management Analyst Colette Hesla, RN, BSN - Diabetes Prevention Control Program Coordinator Melissa Magstadt, MS, CNP, CDE, BC-ADM, CTTS - SD Diabetes Coalition Coordinator Colleen Winter, RN - Director, SD Department of Health, Division of Health Medical Services

5

The Burden of Diabetes in South Dakota

Executive Summary
Diabetes is a serious disease, requiring extensive medical monitoring, lifelong treatment and is a common cause of disability and death in South Dakota In 2007: Approximately 67-39,344 of South Dakota adults have been diagnosed with diabetes and the prevalence of diabetes has more than
doubled since 1998 Another estimated 13,115 South Dakotans are likely to not know they have diabetes A significant racial disparity exists as the prevalence of diagnosed diabetes in Native Americans was 110 compared to 64 in whites There are about 973 South Dakotans under 18 with diabetes Because type 2 diabetes rarely develops in those under 18, the vast majority of these 973 kids have type 1 diabetes South Dakotans aged 65 years or older were almost twice as likely to have been diagnosed with diabetes as persons aged 45 to 64 years Analysis by the Centers for Disease Prevention Control shows 259 of adults aged 20 years or older had pre-diabetes Extrapolating this analysis to South Dakota shows about 149,250 adult had pre-diabetes Of South Dakota women who gave birth between August 2006 and January 2007, 11 had pre-existing diabetes and 71 developed gestational diabetes during the pregnancy Being overweight or obese places South Dakotans at an increased risk for type 2 diabetes and other chronic diseases Among South Dakota adults, 383 were overweight and an additional 272 were obese Quality of life indicators among South Dakotans show people with diabetes were more likely to
report poor physical and mental health as well as significant limitations to their usual activities They also reported rates of disability with equipment needs three times higher than those without diabetes Dissatisfaction with life was higher for people with diabetes when compared to those without diabetes, 57 versus 34 664 of people with diabetes had taken a course to learn about diabetes self-care 666 of people with diabetes had been told by a health professional that they had high blood pressure 586 of people with diabetes had been told they had high cholesterol 141 of people with diabetes had heart disease Adults with diabetes were five times more likely to have suffered a stroke than those without diabetes, 103 versus 20 While South Dakota adults with diabetes are less likely than those without diabetes to be current smokers,175 versus 200 respectively, the incidence is still quite high The rate of adults with diabetes who use spit tobacco is 25

6

The Burden of Diabetes in South Dakota 906 of adults with diabetes reported their A1c had been checked one or more times in the previous year 734 of adults with diabetes stated a health professional had checked
their feet at least once in the previous year 744 of adults with diabetes stated theyd had a dilated eye exam in the previous 12 months and 194 had been told that diabetes had affected their eyes or they had retinopathy 802 of adults aged 65 and older with diabetes reported receiving a flu shot within the previous 12 months and 784 reported ever receiving a pneumococcal shot 727 of adults aged 18-64 with diabetes reported receiving a flu shot within the previous 12 months and 594 reported ever receiving a pneumococcal shot 57 of South Dakota adults with diabetes had no health insurance The per capita annual cost of health care for people with diabetes is calculated at 11,744 a year, of which 6,649 57 is attributed to diabetes Outpatient training to help people self-manage their diabetes prevents hospitalizations Every 1 invested in such training can cut health care costs by up to 876 Preconception care for women with diabetes leads to healthier mothers and babies Every 1 invested in such care can reduce health costs by up to 519 by preventing costly complications There were 246 deaths directly attributed to diabetes in 2007 compared to 201 in 2003 That is a 224 increase There have
been a total of 1,174 deaths attributed to diabetes in South Dakota residents from 2003-2007 Native Americans were more likely to die from diabetes as the primary cause than whites in 2007 86 versus 32 Also, there was a greater rate of potential life lost before the age of 75 per 100,000 for Native Americans than whites, 1,246 years versus 143 years Native Americans have a lower average age at death than whites, 66 years versus 80 years

The Burden of Diabetes in South Dakota was developed as part of a statewide initiative to improve the health care of people at risk for and with diabetes and is consistent with the South Dakota Diabetes State Plan 2007-2009, available at http:diabetessdgov We hope this document will be of benefit to you, your associates, and persons with diabetes The South Dakota Diabetes Prevention Control Program welcomes your comments and questions regarding the contents of this report Please contact Colette Hesla, DPCP coordinator at 605 773-7046 or Colettehesla@statesdus with your comments

7

The Burden of Diabetes in South Dakota

Introduction
Diabetes is a serious disease requiring extensive medical monitoring and lifelong treatment It is a
common cause of disability and death in South Dakota The purpose of this report is to quantify the epidemic of diabetes in the state of South Dakota It presents information on the number of people with diabetes, their characteristics, the treatment they receive and the consequences of the disease It also describes the risk factors that increase the occurrence of diabetes and its complications The Burden of Diabetes in South Dakota was developed as part of a statewide initiative to improve the health care of people at risk for and with diabetes and is consistent with the South Dakota Diabetes State Plan 2007-2009, available at http:diabetessdgov

8

The Burden of Diabetes in South Dakota

What is Diabetes?
Diabetes is a disease in which the body does not produce or properly use insulin Insulin is a hormone that is needed to convert sugar, starches and other food into energy needed for daily life The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play roles 1 Diabetes has 3 main categories: Type 1 Diabetes Mellitus Type 1 diabetes results from the bodys failure to produce insulin, the
hormone that unlocks the cells of the body, allowing glucose to enter cells and fuel them It is estimated that 5-10 of Americans who are diagnosed with diabetes have type 1 diabetes 1 Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes 36 Type 2 Diabetes Mellitus Type 2 diabetes results from insulin resistance a condition in which the body fails to properly use insulin, usually combined with the body not producing enough insulin 1 Insulin is necessary for the body to be able to use glucose for energy When glucose is not able to enter the cells and builds up in the blood it can cause two problems First, the cells may be starved for energy, and second, high blood glucose levels can damage the blood vessels, nerves, and other soft tissues Ninety to ninety-five percent of people with diabetes have type 2 While diabetes occurs in people of all ages and races, some groups have a higher risk for developing type 2 diabetes than others Type 2 diabetes is more common in Native Americans, Latinos, African Americans, and Asian Americans/Pacific Islanders, as well as the aged population 37 Gestational Diabetes Mellitus GDM GDM is
defined as any degree of glucose intolerance with onset or first recognition during pregnancy 10 Although this form of diabetes usually disappears after the babys birth, women who have had GDM have a 40 to 60 chance of developing type 2 diabetes within 5 to 10 years 17 GDM affects maternal-child health and is associated with a potential for preeclampsia, cesarean delivery for the mother, and with higher rates of perinatal mortality, macrosomia, birth trauma, hyperbilirubinemia, and neonatal hypoglycemia in the infant 11 Pre-diabetes Pre-diabetes is a general term for impaired fasting glucose IFG or impaired glucose tolerance IGT It occurs when a persons blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes 1 Progression to diabetes among those with pre-diabetes is not inevitable Studies have shown that people with pre-diabetes who lose weight and increase their physical activity can prevent or delay diabetes and return their blood glucose levels to normal In the Diabetes Prevention Program, a nationwide prevention study of people at high risk for diabetes, showed that lifestyle intervention reduced developing diabetes by 58 over 3 years
The reduction was even greater, 71, among adults aged 60 years or older 16

9

The Burden of Diabetes in South Dakota

Demographics of South Dakota
South Dakota is one of the least densely populated states in the nation with 781,919 people living within its 75,955 square miles for an average population density of 103 people per square mile Nearly 60 of South Dakotas total population lives in small, rural communities of 5,000 or fewer people, with communities of less than 500 people comprising a large portion of this population group The population of South Dakota is predominantly non-Hispanic White with Native American being the largest minority, 884 and 85, respectively The remaining 31 are classified as another race Adults age 65 and older comprise 142 of the population which is higher than the national average of 124 A total of 129 of South Dakotans live below 100 of the federal poverty level 31 and five of the 10 counties in the United States with the lowest per capita income are on South Dakota Indian reservations 32 Access to primary care providers, diabetes educators and specialists is limited in the state with over two-thirds of the state designated by the federal
government as Medically Underserved Figure 1 27 Figure 1

As of July 2008, there are 1,675 physicians practicing in South Dakota Over half 553 currently practice in an urban community defined as having a population center of 50,000 or more Of the remaining physicians, 41 practice in frontier communities defined as having a population density of six or less persons per square mile and 406 practice in a rural community defined as a population density of more than six persons per square mile but no population centers of 50,000 or more 23 South Dakota has 49 general community hospitals, of which 37 are critical access hospitals, and three Veterans Administration hospitals There are also 39 federally qualified health center FQHC sites, 60 licensed rural health clinics 24, a multitude of clinics associated with the Avera McKennan, Rapid City Regional, and Sanford health systems as well as some private clinics There are four Indian Health Service hospitals, seven Service Units 35, and 10

The Burden of Diabetes in South Dakota three Urban Indian Health Clinics There are 25 Diabetes Self-Management Education DSME programs recognized by the American Diabetes Association, the Indian Health
Service or the South Dakota Department of Health 26 Prevalence of Diagnosed Diabetes According to the Centers for Disease Control and Prevention CDC, nearly 8 of the population in the United States 24 million people has diabetes Of this number, about 179 million have been diagnosed and another 25-57 million people have not been diagnosed and are unaware that they have the disease 18 The 2007 Behavioral Risk Factor Surveillance System BRFSS shows that 67 of South Dakotans 18 and older have been diagnosed with diabetes, about 39,344 adults Using the national estimate that about 25 of people with diabetes are undiagnosed, an additional 13,115 South Dakotans are likely to not know they have diabetes 18 Nationally, Colorado had the lowest prevalence rate at 53 while Tennessee had the highest rate at 119 The national median was 80 2 Figure 2 Figure 2 Nationally, BRFSS Respondents Who Were Told They Have Diabetes, 2007

71 78 57 79 67 70 68 71 80 76 95 58 53 73 80 99 91 119 102 84 78 92 103 96 111 103
61

66 69

63 70 72 65 88 87 82

88

85 108 80

CT-73 DE-87 DC-81 MD-84 MA-74 NJ-92 RI-72

101

102

87

Less than or equal to 72 73-87 Greater than or equal to 88

77

Diabetes prevalence
rates in South Dakota, as in the United States, have increased gradually since the late 1980s The number of people with diagnosed diabetes in South Dakota has increased 24 percentage points since 1988; however, the prevalence has more than doubled since 1998 Figure 3

11

The Burden of Diabetes in South Dakota Figure 3 Percent of BRFSS Respondents Who Were Told They Have Diabetes, 1988-2007
8 71 7 61 6 5 4 3 2 1 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 49 43 39 38 34 36 29 43 43 38 31 49 57 63 66 64 65 67

Source: The Behavioral Risk Factor Surveillance System, South Dakota Department of Health, 2007

In June 2008, the CDC released estimates of diagnosed diabetes for all counties in the United States Derived from BRFSS and census data, the estimates provide a clearer picture of areas within the state that have higher diabetes rates 5 See Figure 4 Figure 4 County Level Estimates of Diagnosed Diabetes - Percentage of Adults in SD, 2005

Diabetes incidence generally increases with age Data from the 2007 BRFSS indicate that South Dakotans aged 65 years or older were almost twice as likely to have been diagnosed with diabetes
as persons aged 45 to 64 years See Figure 5 In recent years, the incidence is occurring at a younger age 22 12

The Burden of Diabetes in South Dakota Figure 5 Percent of SD BRFSS Respondents Who Were Told They Have Diabetes, By Age, 2007
20 162 15 108 10 60 5 11 0 18-24 25-34 35-44 45-54 Age 55-64 65-74 75 37 20 149

The prevalence of diabetes is significantly higher among persons of lower income levels In 2007, of those earning less than 25,000, 109 had diabetes versus 48 of those earning more than 50,000 per year 22 Racial and ethnic sub-populations in the United States suffer from diabetes at disproportionately higher rates than the majority population South Dakotas 2007 BRFSS data reflects this racial disparity The prevalence of diagnosed diabetes among Whites was 64 compared to Native Americans at 110 nearly twice the prevalence among Whites 22 See Figure 6 Native American females have a significantly higher prevalence of diabetes than those of White females, 114 versus 62 in 2007 22 Figure 6 Percent of Race with Diagnosed Diabetes, South Dakota, 1999-2007
20 15
113 190 161 156 132 134 110 186

10
51 57 60 65 59 61 61 64

White Native American

5 0 2000 2001 2002 2003 2004
2005 2006 2007

Year

13

The Burden of Diabetes in South Dakota Additional consideration needs to be given to overweight women of childbearing age as excess weight increases the risk of gestational diabetes mellitus GDM Approximately 7 of all pregnancies ranging from 1 to 14 depending on the population studied and the diagnostic tests used are complicated by GDM 30 According to a survey of South Dakota women who gave birth between August 2006 and January 2007, 11 had pre-existing diabetes and 71 developed diabetes during the pregnancy 28 The CDC calculates about 186,300 people younger than 20 years have diabetes type 1 or type 2 in the United States In South Dakota in 2007, the prevalence of type 1 and type 2 diabetes in South Dakotans 17 years and younger was 05 22 In 2006 the prevalence rate was 03 7 and in 2005 it was 05 33 The US Census 2006 population estimate indicates there were 194,698 South Dakotans under 18 31 Therefore, there are approximately 973 South Dakota youth with diabetes Because type 2 diabetes rarely develops in those under 18, the vast majority of these 973 kids have type 1 diabetes Prevalence of Pre-diabetes Pre-diabetes is a condition in which individuals
have blood glucose levels higher than normal but not high enough to be classified as diabetes According to analysis by CDC, 259 of US adults aged 20 years or older, 57 million Americans, had pre-diabetes in 2007 16 Extrapolating this analysis to South Dakota suggests about 149,250 South Dakotans had prediabetes in 2007 People with pre-diabetes have an increased risk of developing type 2 diabetes, heart disease, and stroke

14

The Burden of Diabetes in South Dakota

Risk Factors for Development of Diabetes
For type 1 diabetes, there are no known modifiable risk factors that can lower a persons probability of developing the disease For type 2 diabetes however, both obesity and lack of physical activity are significant risk factors, making lifestyle changes such as improved nutrition, weight control, and regular physical activity highly advisable The Diabetes Prevention Program, a study which was ended and the results released a year early because of the profound findings, proved that type 2 diabetes can be prevented or delayed with modest weight loss and increased physical activity for many people at risk for the disease 8 Overweight and Obesity Rates For the past few decades, the
prevalence of overweight and obesity has steadily increased which puts South Dakotans at an increased risk for type 2 diabetes South Dakotas percentage of overweight but not obese defined as a body mass index of 250 to 299 has increased from 378 in 1993 to 383 in 2007 The percent of obese adults defined as a body mass index of 300 and over has increased from 152 in 1993 to 272 in 2007 22 See Figure 7 Overweight and obese adults were most prevalent among the 55-64 year old age group In 2007, 848 of South Dakotans with diabetes were overweight or obese 22 Figure 7 Percent of Obese Adult South Dakotans, 1993-2007
30 25 20 15 10 5 0

212 212 229 152
144

238

255

254

272

170 139 147

196 198 158

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Overweight and obese children are at risk for developing type 2 diabetes later on in life 15 The 2006-2007 School Height and Weight Report shows that 329 of South Dakota children and adolescents aged 5-19 are overweight or obese Native American students have a higher rate of overweight and obese than Whites, 468 and 307 respectively 20 Physical Activity Rates To achieve and maintain good health and
reduce the risk for chronic disease, able adults are recommended to get moderate-intensity aerobic physical activity, at least 30 minutes a day, five days a week and/or vigorous-intensity aerobic physical activity for at least 20 minutes on three days a week Physical activity can be acquired in 10 minute bouts throughout the day to achieve the recommended amounts of physical activity 14

15

The Burden of Diabetes in South Dakota In 2007, 321 of persons with diabetes engaged in moderate physical activity compared to 490 of persons without diabetes Also In 2007, 129 of persons with diabetes engaged in vigorous physical activity compared to 263 of persons without diabetes

Quality of Life
Diabetes can cause emotional distress and impair self-care It is not uncommon for persons with diabetes to feel overwhelmed from their care regimens Depression, anxiety, and other psychological disorders are more prevalent among persons with diabetes Quality of life indicators among South Dakotans as reported in the 2007 BRFSS show people with diabetes were more likely to report poor physical and mental health as well as significant limitations to their usual activities South Dakotans with diabetes
also reported rates of disability with equipment needs three times higher than those without diabetes Dissatisfaction with life was higher for people with diabetes when compared to those without diabetes, 57 versus 34 22 See Figure 8 Figure 8 South Dakota Adult Quality of Life Indicators 18 16 14 12 10 8 6 4 2 0
168 153 138

92 54 57 34

Adults without Diabetes
51

48

Adults with Diabetes

47

Poor Physical Health

Usual Activities Unattainable

Poor Mental Health

Disabled with Equipment Needs

Dissatisfied with Life

16

The Burden of Diabetes in South Dakota

Risk Reduction
People who have diabetes suffer an increased risk of developing a number of disabling and life-threatening complications including heart disease, stroke, kidney failure, blindness, and lower-limb amputations Working together, people with diabetes, their support network, and their health care providers can reduce the occurrence of these and other diabetes complications by controlling the levels of blood glucose, blood pressure, and blood lipids, by receiving other preventive care practices in a timely manner 16 Glucose control Studies in the United States and abroad have found that improved glycemic control
benefits people with either type 1 or type 2 diabetes In general, every percentage point drop in A1c blood test results eg, from 80 to 70 can reduce the risk of microvascular complications eye, kidney, and nerve diseases by 40 In patients with type 1 diabetes, intensive insulin therapy has long-term beneficial effects on the risk of cardiovascular disease 16 Blood pressure control Blood pressure control reduces the risk of cardiovascular disease heart disease or stroke among persons with diabetes by 33 to 50, and the risk of microvascular complications eye, kidney, and nerve diseases by approximately 33 In general, for every 10 mm Hg reduction in systolic blood pressure, the risk for any complication related to diabetes is reduced by 12 16 Control of blood lipids Improved control of LDL cholesterol can reduce cardiovascular complications by 20 to 50 16 Preventive care practices for eyes, feet, and kidneys Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50 to 60 Comprehensive foot care programs can reduce amputation rates by 45 to 85 Detecting and treating early diabetic kidney disease by lowering
blood pressure can reduce the decline in kidney function by 30 to 70 Treatment with angiotensinconverting enzyme ACE inhibitors and angiotensin receptor blockers ARBs are more effective in reducing the decline in kidney function than other blood pressure lowering drugs In addition to lowering blood pressure, ARBs reduce proteinuria, a risk factor for developing kidney disease, by 35, similar to the reduction achieved by ACE inhibitors 16

17

The Burden of Diabetes in South Dakota

Preventive Services
Self-management of diabetes, combined with medical treatment for metabolic abnormalities, and early detection and treatment of complications, can alleviate the problems and lessen the severity of complications arising from the condition Data from the BRFSS provide an indication of the level of self-care and medical care attained by South Dakotans with diabetes Diabetes Self-Management Education Diabetes Self-Management Education DSME is a key step in improving health outc omes and quality of life for people with diabetes DSME focuses on self-care behaviors such as healthy eating, being active, and monitoring blood sugar It is a collaborative process in which diabetes educators help
people with diabetes gain the knowledge and problem-solving and coping skills needed to successfully self-manage the disease and its related conditions 16 DSME prevents complications and hospitalizations Every 1 invested in such training can cut health care costs by up to 876 19 In 2007, 664 of BRFSS respondents stated they had taken a course to learn about diabetes self care 22 Participation in a course is up from 2000, when 587 had done so See Figure 9

Healthy People 2010 objective: Increase the proportion of persons with diabetes who receive formal diabetes education 13

Figure 9 BRFSS Respondents Who Had Taken a DSME Course, 2000-2007
80 70
587 654 559 613 684 637 662 664

60 50 40 30 20 10 0 2000

2001

2002

2003 Year

2004

2005

2006

2007

18

The Burden of Diabetes in South Dakota Self-Monitored Blood Glucose Testing SMBG Self-monitoring of blood glucose allows people with diabetes to achieve specific glycemic goals Maintenance of normal or near-normal blood glucose levels has major health benefits for persons with diabetes Results of major studies indicate that there is a direct relationship between blood glucose level and the risk of future diabetes related
complications diabetic retinopathy, nephropathy, and neuropathy Both the development and the progression of microvascular complications are slowed with improved glucose control 21 Selfmonitoring of blood glucose can also be used as a proxy measure for overall diabetes selfcare Data from the 2007 BRFSS indicates that 673 of South Dakotans with diabetes check their blood glucose one or more times per day This percentage is 9 percentage points higher than in 2000 However, those reporting never checking their blood glucose increased 35 percentage points from 2004 to 2007 22 Blood Pressure High blood pressure contributes to the development and progression of diabetes complications Control of high blood pressure reduces the rate of progression of diabetes nephropathy and reduces complications of hypertensive nephropathy, cerebrovascular and cardiovascular disease 3 Awareness of the existence of high blood pressure is the base upon which treatment and control can be built In 2007, 666 of BRFSS respondents with diagnosed diabetes had been told by a health professional that they hade high blood pressure 22 Blood Lipids In type 2 diabetes there is an increased risk for obesity and lipid
abnormalities that is independent of blood glucose control Because of the two to four fold increase in the prevalence of blood vessel disease in persons with diabetes, it is important to identify and manage all modifiable cardiovascular risk factors 25 Awareness of abnormalities in blood lipids such as LDL low-density lipoprotein and HDL high-density lipoprotein cholesterols is the base upon which treatment and control can be built In 2007, 586 of BRFSS respondents with diabetes had been told that they had high cholesterol 22 Heart Disease Stroke Adults with diabetes have heart disease death rates 2 to 4 times higher than adults without diabetes and death records note that more than 65 of people with diabetes die from heart disease 16 In 2007, 141 of BRFSS respondents with diabetes had heart disease as compared to

19

The Burden of Diabetes in South Dakota 33 of respondents without diabetes 22 Adults with diabetes were five times more likely to have suffered a stroke than those without diabetes, 103 versus 20 22 People with diabetes were nearly three times more likely to report having high blood pressure than those without diabetes-666 compared to 226 22

Tobacco Use Tobacco
use is the leading cause of preventable death in the United States and is responsible for the deaths of more than 1,000 South Dakotans each year including many with diabetes 25 People with diabetes who use tobacco are at increased risk of complications to blood vessels 34 While South Dakota adults with diabetes are less likely than those without diabetes to be current smokers, 175 versus 200, the incidence is still quite high The rate of adults with diabetes who use spit tobacco is 25 while 52 of adults without diabetes use spit tobacco 22 A1c A1c, also known as Hemoglobin A1c and HbA1c, is a blood test that measures the amount of glycosylated hemoglobin in blood Glycosylated hemoglobin is a molecule in red blood cells that attaches to glucose blood sugar The more glucose in blood, the more glycosylated hemoglobin is present The test gives an estimated average blood glucose level over the previous 2 to 3 months and is reported as a percentage with less than 7 generally considered to be good control A1c has a strong predictive value for diabetes complications and is used to assess therapy efficacy 12 In 2007, 906 of BRFSS respondents with diabetes stated their A1c had been
checked one or more times in the previous year This percentage is up from 2000, when 884 reported it had been checked one or more times in the past year 22

Healthy People 2010 objective: Increase the proportion of adults with diabetes who have an A1c measurement at least once a year 13

Feet Due to the caustic nature of high blood glucose on nerves and blood vessels, especially on the lower extremities, diabetes is the leading cause lower limb amputations In 2007, 734 of BRFSS respondents with diabetes stated a health professional had checked their feet at least once in the previous year The rate was 738 in 2000 22

Healthy People 2010 objective: Increase the proportion of adults with diabetes who have at least one annual foot examination each year 13

20

The Burden of Diabetes in South Dakota Eyes High blood glucose is caustic to the nerves and blood vessels of the eye and can lead to development of diabetic retinopathy Diabetes is the leading cause of new cases of blindness in adults 20-74 years of age 4 If retinopathy is untreated, it can lead to blindness If diagnosed and treated promptly blindness is usually preventable A dilated eye exam completed by an optometrist or
ophthalmologist can detect the signs of retinopathy In 2007, 744 of BRFSS respondents with diabetes stated theyd had a dilated eye exam in the previous 12 months, compared to 771 in 2000 22 Also in 2007, 194 of BRFSS respondents with diabetes had been told that diabetes had affected their eyes or they had retinopathy, compared to 237 in 2000 22

Healthy People 2010 objective: Increase the proportion of adults with diabetes who have an annual dilated eye examination 13

Vaccinations Influenza flu and pneumococcal pneumonia vaccinations can prevent flu and pneumonia in people with diabetes, who are at greater risk of hospitalizations and death than those without diabetes The flu shot is recommended annually and a pneumonia shot is generally given once in a lifetime South Dakotans with diabetes historically have had higher rates for flu and pneumonia shots than the general population of South Dakota In 2007, 802 of adults aged 65 and older with diabetes reported receiving a flu shot within the past 12 months and 784 reported ever receiving a pneumococcal shot 22 Healthy People 2010 objective: Increase the proportion of adults with diabetes aged 65 and older who are vaccinated
annually against influenza and ever vaccination against pneumococcal disease to 90 13 Also in 2007, 727 of adults aged 18-64 with diabetes reported receiving a flu shot within the past 12 months and 594 reported ever receiving a pneumococcal shot 22 Healthy People 2010 objective: Increase the proportion of adults with diabetes aged 18-64 who are vaccinated annually against influenza and ever vaccinated against pneumococcal disease to 60 13 Oral Health People with diabetes get periodontal disease more often than people who do not have the disease Gum infections can make it hard to control blood sugar and once an infection starts, it can take longer to heal Good blood sugar control and regular dental exams are the best defense against periodontal disease 6 South Dakota BRFSS data indicate that in 2006, adults with diabetes are less likely to go to the dentist than those without diabetes, 609 versus 701 7

21

The Burden of Diabetes in South Dakota Insurance Status Access to health care is necessary for successful treatment of diabetes People without health insurance are less likely than others to have a usual source of care and to receive preventive health care services and
appropriate medical management of diabetes 57 of South Dakota adults with diabetes had no health insurance in 2007 22 compared to almost 15 of adults nationwide

Costs
Costs for the preventive services detailed above plus treatment of complications if they arise the direct cost of diabetes combined with the indirect costs of decreased productivity, contribute to diabetes staggering cost, which was estimated in 2007 by the American Diabetes Association ADA to be 174 billion Medical expenditures totaled 116 billion and were comprised of 27 billion for diabetes care, 58 billion for chronic diabetes-related complications, and 31 billion for excess general medical costs Indirect costs resulting from increased absenteeism, reduced productivity, disease-related unemployment disability, and loss of productive capacity due to early mortality totaled 58 billion The actual national burden of diabetes likely exceeds the 174 billion estimate because it omits the social cost of intangibles such as pain and suffering, care provided by non-paid caregivers, excess medical costs associated with undiagnosed diabetes, and diabetesattributed costs for health care expenditures categories not studied
The 2007 per capita annual cost of health care for people with diabetes is 11,744 a year, of which 6,649 57 is attributed to diabetes One out of every five health care dollars is spent caring for someone with diagnosed diabetes, while one in 10 health care dollars is attributed to diabetes 9

Preventive Services as Cost-Saving Tools

Outpatient training to help people self-manage their diabetes prevents hospitalizations Every 1 invested in such training can cut health care costs by up to 876 19 Preconception care for women with diabetes leads to healthier mothers and babies Every 1 invested in such care can reduce health costs by up to 519 by preventing costly complications 19 Intensified blood pressure control can cut health care costs by 900 2000 US dollars over the lifetime of a person with type 2 diabetes It can also extend life by 6 months 19 In just 5 years, a foot care program can save 900 2000 US dollars in health care costs for a person with diabetes who has had foot ulcers Such care prevents amputations 19

22

The Burden of Diabetes in South Dakota

Mortality
Diabetes is widely recognized as one of the leading causes of death In South Dakota, diabetes is currently
the seventh leading cause of death by disease 23 The number of deaths directly caused by diabetes continues to increase Unpublished data from the SD Office of Data, Statistics and Vital Records show that in 2003 there were 201 deaths from diabetes and in 2007 there were 246 That is a 224 increase There have been a total of 1,174 deaths attributed to diabetes in South Dakota residents from 2003-2007 23 Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age 16 Although diabetes is listed as the underlying cause of 1,174 deaths 36 of all deaths reported in 2007 23, diabetes is likely to be underreported as a cause of death Studies have found that only about 35 to 40 of decedents with diabetes have it listed anywhere on the death certificate and only about 10 to 15 have it listed as the underlying cause of death 16 Because diabetes is not mentioned at all on the death certificate of many people whose death is diabetes-related, mortality statistics alone underestimate the impact of the disease The statistics reflect the fact that people with diabetes are more likely to die from the complications of the disease rather than the
disease itself and die at an earlier age than their non-diabetic counterparts The disparity noted in the prevalence of diabetes between Native Americans and Whites is also present in the death rates South Dakota death records indicate that Native Americans were more likely to die from diabetes as the primary cause than Whites in 2007 86 vs 32 23 Also, there was a greater rate of potential life lost before the age of 75 per 100,000 for Native Americans than Whites, 1,246 years versus 143 years Native Americans also have a lower average age at death than Whites, 66 years versus 80 years respectively 23 The 10 South Dakota counties with the highest death rates due to diabetes, 2003-2007 are plotted on the map in Figure 10 29

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The Burden of Diabetes in South Dakota Figure 10

Age-adjusted mortality rates per 100,000 population for counties noted above 18: Shannon - 2054 Buffalo - 1308 Ziebach - 1297 Todd - 1054 Dewey - 989 Corson - 730 Bennett - 725 Jackson - 603 Mellette - 489 Bon Homme - 477

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The Burden of Diabetes in South Dakota

Appendix A: Glossary and Resources
A1c: Hemoglobin A1c or HbA1c A blood test that measures a persons average blood glucose sugar level
for the 2-3 month period before the test Because it provides an indication of blood glucose management over time, this test is very valuable in determining overall diabetes management effectiveness Age-adjusted rate: Adjusted rate with allowances made for the age distribution of the population such that rates of two or more populations can be compared to each other as though the populations had the same age distributions Body Mass Index BMI: BMI is a tool for measuring weight status in both youth and adults BMI is the commonly accepted index for the classification of overweight and obesity in adults and is recommended to identify children and adolescents who are underweight, overweight, or obese when compared to the same age and gender BMI formula: BMI Weight in Pounds x 703 Height in inches x Height in inches Stated another way, BMI body weight in pounds divided by height in inches squared multiplied by 703 Behavioral Risk Factor Surveillance System BRFSS: The BRFSS is a random digitdialed telephone survey of a sample of non-institutionalized adults age 18 years and older conducted annually in all 50 states, the District of Columbia, Puerto Rico, Guam, and the US Virgin Islands,
in collaboration with the Centers for Disease Control and Prevention CDC In South Dakota, the 2007 BRFSS survey was administered to 6871 adults between January 1, 2007 and December 31, 2007 The BRFSS survey includes questions on a wide variety of health-related topics, including diabetes, tobacco and alcohol use, physical activity, diet, weight control, health insurance, and the use of preventive and other health care services For this report, a person was assumed to have diabetes if they answered yes to the question: Have you ever been told by a doctor that you have diabetes? Responses to this question were used to develop the state and county specific estimates of the prevalence of diabetes presented elsewhere in this report Responses of dont know, not sure or refusals were excluded from the analysis of all BRFSS questions included in this report Cholesterol: A fat-like substance found in the body The body makes and needs some cholesterol Too much cholesterol, however, may cause fat to build up in the artery walls and cause disease that slows or stops the flow of blood Death Certificates: The diabetes mortality data presented in this report were obtained from death certificates
on file with Data, Statistics, and Vital Records within the Department of Health Mortality data are available for every deceased South Dakota resident, whether death occurs in South Dakota or out of state Information collected on the death certificate include personal identifiers, demographics age at death, gender, race, date and place of death, and the underlying ie, primary and contributing causes of death For deaths occurring in or before 1998, causes of death are coded according to the Ninth Edition of the World Health Organizations International Classification of Disease ICD-9 For deaths occurring in 1999

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The Burden of Diabetes in South Dakota or later, causes of death are coded according to the Tenth Edition of the World Health Organizations International Classification of Disease ICD-10 Diabetic retinopathy : Progressive weakening and leaking of blood vessels in the eyes retina, caused by long-term uncontrolled diabetes Diabetic retinopathy can result in loss of vision Dilated eye pupil exam : An eye examination in which eye drops are administered to enlarge the pupils enabling the doctor to examine the retina, located at the back of the eye, for signs of deterioration
End stage renal disease ESRD: The final stage of kidney disease treated by dialysis or kidney transplantation Incidence: The number of newly diagnosed cases over a certain period of time Insulin: A hormone produced by the pancreas that helps the body use glucose sugar for energy Morbidity: A descriptive measurement of sickness Morbidity rates are generally given in one of two ways see corresponding definitions: incidence or prevalence Mortality: A descriptive measurement of death A mortality rate is the number of deaths per unit of population over a specified period of time Nephropathy: A disease or abnormality of the kidney In diabetes, high glucose sugar concentrations damage the blood vessels in the kidney that remove wastes from the blood If uncontrolled, leads to progressive weakening of the kidneys and end stage renal disease see corresponding definition Neuropathy: Damage to nerves In diabetes it is caused by high glucose sugar concentrations in the blood Usually seen in the peripheral nerves and results in pain, numbness, and sometimes muscle weakness Obesity: In Body Mass Index measurements, obesity is defined as a BMI equal to or greater than 300 in adults and equal to or
greater than 95th percentile in children and adolescents Overweight: In Body Mass Index measurements, overweight is defined as a BMI between 250 and 299 in adults For children two to twenty years, overweight is defined as BMI-forage equal to or greater than the 85th percentile and less than the 95th percentile Prevalence: The number of known cases at any given time Diabetes prevalence is expressed as a percentage Rate: A proportion of the number of specific events per a stated number in the population The persons or events represented in the numerator must be from the population in the denominator Prevalence rates are sometimes written as percentages since they represent the number of cases per 100 population Mortality rates are calculated per 100,000 population 26

The Burden of Diabetes in South Dakota Risk Factor: A habit, characteristic, or finding on clinical examination that is consistently associated with increased probability of a disease or complication from that disease South Dakota School Height and Weight Report: A summary of South Dakota student height and weight data collected by the South Dakota Department of Health in cooperation with the South Dakota Department of
Education More information is available online at http://wwwstatesdus/doh/SchoolWeight/ Years of Potential Life Lost YPLL: A widely-used estimate of premature mortality, defined as the number of years of life lost among persons who die before age 75 YPLL is the sum of the differences between age 75 and the age at death for everyone who died before age 75

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The Burden of Diabetes in South Dakota

Appendix B References
1 All About Diabetes American Diabetes Association 26 June 2008 http://wwwdiabetesorg/about-diabetesjsp 2 Behavioral Risk Factor Surveillance System Prevalence Data 17 Apr 2007 Centers for Disease Control and Prevention 26 June 2008 http://appsnccdcdcgov/brfss/listasp?catDByr2007qkey1363stateAll 3 Blood Pressure South Dakota Department of Health 22 June 2008 http://dohsdgov/Diabetes/Guidelines/BloodPressurepdf 4 Complications of Diabetes in the United States American Diabetes Association 2 June 2008 http://wwwdiabetesorg/diabetes-statistics/complicationsjsp 5 County Level Estimates of Diagnosed Diabetes — Percentage of Adults in Alabama by Natural Breaks, 2005 Department of Health and Human Services Centers for Disease Control and Prevention 24 June 2008
http://appsnccdcdcgov/DDT_STRS2/CountyPrevalence Dataaspx 6 Dental and Periodontal Disease South Dakota Department of Health 22 June 2008 http://dohsdgov/diabetes/guidelines/dentalpdf 7 Diabetes 2006 South Dakota Department of Health 24 June 2008 http://dohsdgov/Statistics/2006BRFSS/Diabetespdf 8 Diabetes Prevention Program National Diabetes Information Clearinghouse Aug 2006 National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Health 24 June 2008 http://diabetesniddknihgov/dm/pubs/preventionprogram/ 9 Direct and Indirect Costs of Diabetes in the United States American Diabetes Association 24 June 2008 http://wwwdiabetesorg/diabetes-statistics/cost-of-diabetes-in-usjsp 10 Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the diagnosis and classification of diabetes mellitus Diabetes Care, 1997 20:11831197 11 Gestational Diabetes Mellitus GDM South Dakota Department of Health 24 June 2008 http://dohsdgov/Diabetes/Guidelines/GDMpdf 12 HbA1c Medline Plus 26 Apr 2007 United States National Library of Medicine, National Institutes of Health 24 June 2008
http://wwwnlmnihgov/medlineplus/ency/article/003640htm

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The Burden of Diabetes in South Dakota 13 Healthy People Healthy People 2010 Office of Disease Prevention and Health Promotion, United States Department of Health and Human Services 26 June 2008 http://healthypeoplegov/ 14 Lowest-Income Counties in the United States Wikipedia 15 Apr 2008 24 June 2008 http://enwikipediaorg/wiki/Lowest_income_counties_in_the_United_States 15 Many Obese Youth Have Condition That Precedes Type 2 Diabetes 13 Mar 2002 National Institutes of Health 25 Feb 2008 http://wwwnihgov/news/pr/mar2002/nichd-13htm 16 National Diabetes Fact Sheet United States Department of Health and Human Services, Centers for Disease Control and Prevention 26 June 2008 http://wwwcdcgov/diabetes/pubs/pdf/ndfs_2007pdf 17 National Diabetes Fact Sheet, 2007 2007 Centers for Disease Control 24 June 2008 http://wwwcdcgov/diabetes/pubs/pdf/ndfs_2007pdf 18 Number of People with Diabetes Continues to Increase 25 June 2008 Centers for Disease Control and Prevention 28 June 2008 http://wwwcdcgov/Features/DiabetesFactSheet/ 19 Preventing Diabetes and Its Complications 25 Nov 2005 Centers for Disease Control and Prevention 24 June
2008 http://wwwcdcgov/nccdphp/publications/factsheets/prevention/diabeteshtm 20 School Height and Weight Report for South Dakota Students, 2006-2007 School Year Feb 2008 South Dakota Department of Health 24 June 2008 http://dohsdgov/SchoolWeight/06-07summarypdf 21 Self-Monitored Blood Glucose Testing SMBG South Dakota Department of Health 24 June 2008 http://dohsdgov/Diabetes/Guidelines/SMBGpdf 22 South Dakota Department of Health, Behavioral Risk Factor Surveillance System BRFSS Program 2007 2003-2007 BRFSS Survey data Unpublished tables 23 South Dakota Department of Health, Office of Data, Statistics and Vital Records 2007 Unpublished data 24 South Dakota Department of Health, Office of Rural Health 25 South Dakota Department of Health, Tobacco Control Program 26 South Dakota Diabetes Education Recognition Program July 7, 2008 South Dakota Department of Health, Diabetes Prevention Control Program Accessed July 7, 2008

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The Burden of Diabetes in South Dakota 27 South Dakota Medically Underserved Areas 12 May 2008 South Dakota Department of Health 24 June 2008 http://dohsdgov/ruralhealth/documents/muapdf 28 South Dakota Perinatal Health Risk Assessment Report 2007 South Dakota
Department of Health 24 June 2008 http://dohsdgov/Statistics/PDF/2007Perinatalpdf 29 South Dakota Vital Statistics: State and County Comparison of Leading Health Indicators 2006 Report South Dakota Department of Health 24 June 2008 http://dohsdgov/statistics/2006vital/healthstatuspdf 30 Standards of Medical Care in Diabetes–2008 Diabetes Care Oct 2007 American Diabetes Association 26 June 2008 31 State and County Quick Facts, South Dakota 2 Jan 2008 United States Census Bureau 25 Feb 2008 http://quickfactscensusgov/qfd/states/46000html 32 Statistics derived from US Census Bureau data; US Department of Commerce, Bureau of Economic Analysis, Survey of Current Business; and DataQuick Information Systems, a public records database company located in La Jolla, San Diego, CA Retrieved from http://enwikipediaorg/wiki/Lowestincome_counties_in_the_United_States 33 The Health Behaviors of South Dakotans 2005 2005 South Dakota Department of Health 24 June 2008 http://dohsdgov/Statistics/2005BRFSS/defaultaspx 34 Tobacco South Dakota Department of Health 22 June 2008 http://dohsdgov/Diabetes/Guidelines/Tobaccopdf 35 Tribes and Facilities Today Aberdeen Area Indian Health Service 14 June 2007
United States Department of Health and Human Services Indian Health Service 24 June 2008 http://wwwihsgov/facilitiesServices/areaoffices/aberdeen/aberdeen-tribesfacilities-todayasp 36 Type 1 Diabetes American Diabetes Association 26 June 2008 http://wwwdiabetesorg/type-1-diabetesjsp 37 Type 2 Diabetes American Diabetes Association 26 June 2008 http://wwwdiabetesorg/type-2-diabetesjsp

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The Burden of Diabetes in South Dakota

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250 copies were printed by the South Dakota Department of Health for 448 per copy

Source:bddiabetes.com