The Arkansas Diabetes Prevention and Control Program is funded by the Centers for Diabetes Advisory Council members, policy makers, researchers, and other …
The State of Diabetes in Arkansas
The State of Diabetes in Arkansas
January 2005
Published By Arkansas Diabetes Prevention and Control Program Arkansas Department of Health
Report Prepared By Appathurai Balamurugan MD, MPH Senior Epidemiologist, Arkansas Department of Health Assistant Professor, Department of Epidemiology UAMS College of Public Health
With Support From Arkansas Center for Health Statistics Arkansas Department of Health
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Executive Summary
The Arkansas Diabetes Prevention and Control Program is funded by the Centers for Disease Control and Prevention to reduce and prevent the burden of diabetes in Arkansas Information on the burden of diabetes in Arkansas is compiled every other year This report is intended to describe the impact of diabetes in Arkansas for program managers, Diabetes Advisory Council members, policy makers, researchers, and other interested parties It is hoped that this information will, provide assistance in determining where interventions are needed The Salient Findings Diabetes has reached epidemic proportions in Arkansas The prevalence of diabetes in Arkansas has been at or above the national average for the past 10 years There was a 35
percent increase in the diabetes prevalence from 1993 to 2002 An estimated 227,000 adult Arkansans had diabetes in 2003 Of those, 151,000 were diagnosed, but it remained undetected and untreated in the rest The prevalence of diabetes increases with age, with the prevalence among persons over the age of 45 being more than four times greater than the prevalence found among younger persons The diabetes prevalence among African Americans 97 is significantly higher than among whites 71 Diabetes is the 6th leading cause of death in Arkansas and the 4th leading cause of death among African Americans In 2003, 5619 hospitalizations were reported among people with diabetes in Arkansas An estimated 73 million was accrued in hospitalization costs for people with diabetes In 2002, 869 lower extremity amputations, 1576 hospitalizations for ketoacidosis, 372 incident cases of chronic end-stage renal disease, and 317 deaths among persons receiving dialysis were attributed to diabetes
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Table of Contents
Diabetes Mellitus Prevalence5 Mortality8 Hospitalizations9 Complications11 Risk Factors12 Access to Health Care14 Preventative Care Practices16 County Data18 Arkansas Demographics27
Healthy People 2010 Objectives28 American Diabetes Association Guidelines29 Glossary30 References31
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Diabetes Mellitus
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 life1 Diabetes can cause serious health complications including heart disease, blindness, kidney failure, and lower-extremity amputations2 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 roles1 An estimated 182 million Americans, or 63 percent of the US population, have diabetes About two-thirds of these individuals, or 13 million, have been diagnosed with diabetes The remaining third, or 52 million, are unaware that they have diabetes Types of Diabetes: Type 1 Failure of the body to produce insulin Accounts for 5 to10 percent of all cases Type 2 Insulin resistance combined with relative insulin deficiency Accounts for 90 to 95 percent of all cases Gestational diabetes Failure of the body to make and use all the insulin it needs for pregnancy Occurs in 2 to 5 percent of all
pregnant women
Prevalence of Diabetes in Arkansas
Approximately 227,000 Arkansans have diabetes An estimated 74 percent have been told that they have diabetes, which accounts for 151,000 people The other 75,500 remain undiagnosed
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Diabetes prevalence both in Arkansas and nationwide has increased over the past decade Diabetes prevalence in Arkansas has been above the national median throughout the past decade Diabetes prevalence in Arkansas rose from 58 percent in 1993 to 74 percent in 2003, a 28 percent increase over the 10-year period
Arkansas is in the second highest tier of diabetes prevalence in the nation
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Diabetes prevalence increases with age The prevalence increases fourfold after the age of 45 The highest prevalence of diabetes is found among people 65 years of age or older Like many other chronic diseases, diabetes can remain undetected for a long time before it is clinically diagnosed
Diabetes disproportionately affects minorities, primarily African Americans, and the prevalence varies by geographic region see Map 1 on page 19 The diabetes prevalence among African Americans is 37 percent higher than the prevalence among
whites
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Mortality
Diabetes is the sixth leading cause of death in Arkansas and in the US Every year, 300,000 deaths nationally are attributed to diabetes and its complications3
Diabetes mortality has increased both in Arkansas and nationwide over the past decade In 2001, the age-adjusted mortality rate for diabetes in Arkansas was the same as the national rate Diabetes may well be underreported on death certificates as the leading cause of death The CDC estimates that only 4 of 10 deaths among people with diabetes actually have diabetes listed as the cause of death
The diabetes mortality rate for blacks is approximately three times higher than that for whites Most of the deaths among blacks occur prematurely before 65 years of age 6 The diabetes mortality rate also varies by geographic location see Map 2 on page 20
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Hospitalizations
The Arkansas Hospital Discharge data system collects in-patient discharge information from all Arkansas hospitals Based on the data, the number of hospital discharges with primary diagnosis of diabetes has been increasing over the past 5 years
More than 5600 discharges were reported in 2003 There has been a 20 percent increase in
hospital discharges with primary diagnosis of diabetes in the 5-years since 1999
During the same period, the average length of diabetes-related hospital stays increased, reaching a high of 56 days in 2002 There was a subsequent decrease in 2003 to 53 days The reason for this pattern is not known
The costs due to diabetes include direct medical costs such as physician visits, hospitalizations, and pharmacy charges, as well as indirect costs, such as lost days of work, disability, and premature deaths Data are not available to estimate the indirect costs The direct medical costs due to hospitalizations are estimated from the Arkansas Hospital Discharge data system, although these estimates do not include outpatient costs 9
There has been a significant increase in total hospitalization charges due to diabetes in Arkansas These charges increased from 55 million in 2001 to 73 million in 2003, a 33 percent increase
The average hospitalization charges increased 55 percent from 1999 to 2003
The age-adjusted hospitalization rate for diabetes is significantly higher among blacks compared to whites This may be due to the higher diabetes prevalence and fewer preventive care
practices among blacks
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Complications
Diabetes can cause serious complications like heart disease, kidney disease, eye disease, foot problems, dental disease, pregnancy related complications and diabetic ketoacidosis
25 percent of the people admitted to Arkansas hospitals for ischemic heart disease also had a diagnosis of diabetes 72 percent of all lower extremity amputations performed during 2001 were performed on persons with diabetes
In 2002, diabetes accounted for: 869 lower extremity amputations 1576 hospitalizations for ketoacidosis 2939 hospitalizations for diabetic retinopathy see Map 5 on page 23 372 incident cases of chronic end-stage renal disease 317 deaths among persons receiving dialysis
Good glucose control has been shown to prevent many of these complications5
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Risk Factors
Prevention is the key to halting the unfolding diabetes epidemic Identification of the risk factors among the population and promotion of primary prevention measures are the first steps The risk factors associated with a person developing diabetes can be classified as either modifiable4 risk factors such as obesity and physical inactivity, or non-modifiable risk factors such as age,
race and family history of diabetes
Approximately one fourth of adults in Arkansas are obese, 29 percent are physically inactive and only 21 percent consume the recommended five servings of fruits and vegetables a day 25 percent of adults in Arkansas are current smokers Tobacco use increases cardiovascular complications for people with diabetes
14 percent of Arkansas youths are overweight; 34 percent of youths are involved in insufficient physical activity Only 1 in 5 of the Arkansas youths consume the recommended five servings of fruits and vegetables a day More than one third of them are current smokers
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Figure 16 shows the racial differences among factors that increase the likelihood of a person developing diabetes
The prevalence of obesity is 42 percent higher in blacks compared to whites The prevalence of physical inactivity is 21 percent higher in blacks compared to whites A lower proportion of black adults consume the recommended five or more fruits and vegetables a day compared to white adults The proportion of current smokers was about the same in blacks and whites
Research has shown that lifestyle changes can prevent or delay the onset of type 2
diabetes among high-risk adults The Centers for Disease Control and Prevention recommend the maintenance of a healthy diet 5 or more servings of fruits and vegetables a day, reduced fat and sugar intake and moderate physical activity 30 minutes a day, 5 days a week for all adults The Diabetes Prevention Program, a large prevention study of people at high risk for diabetes, showed that the risk of developing diabetes could be reduced by 58 percent over 3 years by following the recommended lifestyle modifications
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Access to Health Care
Lack of health care access is a problem faced not only by people with diabetes but also by many Arkansans generally Poor health consequences among people with diabetes can be secondary to limited availability of preventive services such as professional eye exams and foot exams
Barriers to health care access may include: Financial Barriers Structural Barriers Personal Barriers Financial Barriers Lack of health insurance is a major financial barrier It differs among different racial/ethnic groups in Arkansas
A greater proportion of minorities lack health insurance compared to whites
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S 
tructural Barriers Approximately 22 percent of the
states population lives in areas designated as Health Profession Shortage Areas HPSAs by the federal government More than half of the states population live in areas designated as Medically Underserved Areas MUAs
In Arkansas, the Southeast and Southwest Public Health Regions have fewer health care professionals compared to other public health regions However this is not adjusted for population size
Personal Barriers Even in the presence of health care infrastructure, personal barriers, such as lack of knowledge or trust in the system, could pose barriers to health care access Promoting awareness and education among the general public regarding access to health care services is the key to eliminating this barrier
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Preventive Care Practices
The Centers for Disease Control and Prevention and the American Diabetes Association have set national objectives for preventive care practices among people with diabetes Following the recommended guidelines, which address receiving annual eye exams, foot exams, HbA1c checks, and flu and pneumonia vaccinations, has been shown to reduce the costs associated with complications of diabetes and also improves the quality of life among people
with diabetes 1,2
Only 56 percent of people with diabetes report having received a flu shot in the past year Only 43 percent report having ever received a pneumonia vaccination 63 percent reported they had received a dilated eye examination and fewer still 58 reported receiving a foot examination by a health care provider
The guidelines also recommend daily blood glucose checks and foot checks for the people with diabetes
Only 78 percent reported checking their feet daily for any sores or irritations Less than three-fourths checking their blood glucose daily
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There were racial differences in preventive care practices among people with diabetes According to the Behavioral Risk Factor Surveillance Survey BRFSS:
Fewer blacks 69 received HbA1c tests in the past year than whites 88 Fewer whites 57 received foot exams by a professional than blacks 69 Fewer blacks 58 received dilated eye exam in the past year than whites 62 Fewer blacks 23 received flu shot in the past year than whites 40 Fewer blacks 18 ever received pneumonia vaccination than whites 21
There were racial differences even among the patient-completed preventive care practices
Fewer whites 77
checked their feet everyday than blacks 86 No difference was found between blacks and whites in daily blood glucose check
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County Data
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Map 1
The prevalence of diabetes appears to be disproportionately high in certain parts of the state Counties in the Southeastern part of the state along the Mississippi delta, shaded blue have the highest estimated diabetes prevalence
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Map 2
Mortality rates for diabetes are higher in some counties than in others Counties shaded red are those with the highest age-adjusted mortality rates for diabetes
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Map 3
Diabetes can damage both the nerves and the blood vessels to the feet, leading to numbness, burning sensation, poor circulation and possibly lower extremity amputation Counties shaded blue have higher hospital discharge rates for lower extremity amputations per 1000 people with diabetes
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Map 4
Diabetes causes heart disease, especially in people with high blood pressure and high cholesterol Heart disease is the leading cause of death among people with diabetes Counties shaded blue have higher hospital discharge rates for heart disease per 1000 people with diabetes
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Map 5
Poorly controlled diabetes can
result in diabetic retinopathy, and subsequent blindness Counties shaded blue have higher hospital discharge rates for diabetic retinopathy
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Map 6
The disproportionate burden of diabetic retinopathy in some counties may be associated in part with the differential distribution of the eye care providers Eye care providers tend to be clustered in counties within the central and northwest regions of the state and to be less common, in the remainder of the state
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Map 7
More than half of the counties do not have an American Diabetes Association ADA recognized diabetes self-management education program Arkansas Diabetes Prevention and Control Program along with its advisory council members are working together to establish ADA-recognized programs in all Arkansas counties
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Map 8
The Arkansas Diabetes Prevention and Control Program formed the Arkansas Diabetes Advisory Council, along with its partners, to work toward reducing the diabetes burden in Arkansas Although most of the Diabetes Advisory Council members are located centrally in Pulaski County, it has members representing each of the public health regions within the state
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Arkansas
Demographics
Arkansas, the Natural State, is home to 26 million citizens Arkansas is blessed with an abundance of clean air, clean water, and a great outdoors Some general information about Arkansas: The following facts were obtained from the 2000 US Census: Total population Females Males Age distribution Persons under 18 years Persons 18-64 years Persons 65 years and over Racial/Ethnic distribution Whites Blacks or African Americans Hispanic Asian American Indian and Alaskan native Native Hawaiian and Pacific Islander Median household income Persons below poverty 2,673,400 512 488 254 600 14 80 157 32 08 07 01 32,182 158
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Healthy People 2010 Objectives
1 Increase the proportion of persons with diabetes who receive formal diabetes education from 45 to 60 2 Prevent Diabetes Decrease new cases of diabetes from 35 cases per 1000 population to 25 cases per 1000 population 3 Reduce the overall rate of diabetes that is clinically diagnosed from 40 cases per 1000 population to 25 cases per 1000 population 4 Increase the proportion of adults with diabetes whose condition has been diagnosed from 68 percent to 80 percent 5 Reduce the diabetes death rate from 75 deaths per
100,000 population to 45 deaths per 100,000 population 6 Reduce diabetes-related deaths among persons with diabetes from 88 deaths per 1000 people with diabetes to 78 deaths per 1000 people with diabetes 7 Reduce deaths from cardiovascular disease in persons with diabetes from 343 deaths from cardiovascular disease per 100,000 persons with diabetes to 309 deaths per 100,000 persons with diabetes 8 Developmental Decrease the proportion of pregnant women with gestational diabetes 9 Developmental Reduce the frequency of foot ulcers in persons with diabetes 10 Reduce the rate of lower extremity amputations in persons with diabetes from 41 lower extremity amputations per 1,000 persons with diabetes to 18 lower extremity amputations per 1,000 persons with diabetes per year 11 Developmental Increase the proportion of persons with diabetes who obtain an annual urinary microalbumin measurement 12 Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least once a year from 24 percent to 50 percent 13 Increase the proportion of adults with diabetes who have an annual dilated eye examination from 47 percent to 75 percent 14 Increase the proportion of
adults with diabetes who have at least an annual foot examination from 55 percent to 75 percent 15 Increase the proportion of persons with diabetes who have at least an annual dental examination from 58 percent to 75 percent 16 Increase the proportion of adults with diabetes who take aspirin at least 15 times per month from 20 percent to 30 percent 17 Increase the proportion of adults with diabetes who perform self-blood-glucosemonitoring at least once daily from 42 percent to 60 percent
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American Diabetes Association Guidelines
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Glossary
Age-adjusted rate: A rate calculated in a manner that allows for the comparison of populations with different age structures Insufficient physical activity: Percentage of students who did not participate in at least 20 minutes of vigorous physical activity on three or more of the past seven days and did not do at least 30 minutes of moderate physical activity on five or more of the past seven days Ischemic Heart Disease: Disease of the heart characterized by local and temporary deficiency of blood supply due to obstruction of circulation Prevalence: The percent proportion of a population that has a disease or a risk factor at a given point
in time Risk factor: A characteristic or behavior that is consistently associated with increased probability of disease or event BMI: A surrogate measure of body fatness expressed as weight measured in kilograms divided by height measured in meters squared Normal weight: Neither overweight nor obese BMI 250 but more than 185 Overweight: BMI greater than or equal to 250 but less than 300 Obese: BMI greater than or equal to 300 Mortality rate: Death rate No physical activity: People who reported not being involved in any kind of physical activity or exercise in the past 30 days besides their regular job
Limitations of the data presented in the report It must be noted that in 1999, a new cause-of-death tabulation was developed in the form of ICD-10 International Classification of Diseases codes Before 1999, the ICD-9 classification was used There are differences in mortality rates between the two codes In this document, however, no adjustments have been made in mortality rates with respect to ICD-9 and ICD-10 codes
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References
1 American Diabetes Association http://wwwdiabetesorg/homejsp 2 Centers for Disease Control and Prevention, Division of Diabetes Translation
http://wwwcdcgov/nccdphp/bb_diabetes/indexhtm 3 National Institute of Diabetes Digestive Kidney Diseases http://wwwniddknihgov/ 4 Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, Marks JS Prevalence of Obesity, Diabetes, and Obesity-Related Health Risk Factors, 2001 JAMA 2003 Jan 1;2891:76-9 5 UK Prospective Diabetes Study Group: Tight Blood Pressure Control and Risk of Macrovascular and Microvascular Complications in Type 2 Diabetes BMJ 317:703-7131998 6 Phillips, M Balamurugan, A 2002 The Burden of Diabetes in Arkansas AR Diabetes Control Program, Arkansas Department of Health, Little Rock 7 2002 Annual Report End Stage Renal Disease Network 13, INC 8 US Census wwwcensusgov
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Requests for additional copies should be directed to: Arkansas Diabetes Prevention and Control Program Arkansas Department of Health 4815, W Markham, Slot 11 Little Rock, AR 72205 501 661-2964, 501 661-2093, 501 661-2070Fax Or visit the Web site at www Healthyarkansascom/services/services_diabeteshtml
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Source:sandia.gov
