Diabetes Treatments

The Georgia Diabetes Advisory Council (DAC) is pleased to support the prevalence of diabetes and its effect on the health of Georgians. …

The Georgia Diabetes Advisory Council DAC is pleased to support the 2003 Georgia Diabetes ReportThe document contains information on the prevalence of diabetes and its effect on the health of Georgians The DAC was formed in 2000 to assist the Georgia Diabetes Prevention and Control Program in the strategic planning of programs and activities across the stateThe mission of the DAC is to reduce the prevalence of diabetes in Georgia and improve the well-being of those affected by diabetesThe Council is comprised of persons with diabetes, health care professionals, and other stakeholders who are interested in helping people with diabetes improve and maintain their health For more information about the Georgia Diabetes Advisory Council, please call 404 463-2748 We invite you to join us in our efforts to reduce the burden of diabetes in GeorgiaWorking together, we can create healthier communities Sincerely,

Rita Louard, MD Chair

Acknowledgments
Georgia Department of Human Resources Jim Martin, Commissioner Division of Public Health Kathleen EToomey, MD, MPH, Director Office of Health
Information and Policy Gordon R Freymann, MPH, Director Chronic Disease Prevention and Health Promotion Branch Carol B Steiner, RN, MN, Acting Director Epidemiology Branch Paul Blake, MD, MPH, Director Chronic Disease, Injury, and Environmental Epidemiology Section Kenneth E Powell, MD, MPH, Chief Centers for Disease Control Prevention This publication was supported by Cooperative Agreements U58/CCU400591 and U32/CCU400340-1 from the Centers for Disease Control and Prevention CDC Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC Suggested Citation: Jack, NH; Mbadugha, MM; Mertz, KJ;Wu, M: and Powell, KE 2003 Georgia Diabetes Report Georgia Department of Human Resources, Division of Public Health, Chronic Disease Prevention and Health Promotion Branch, June 2003 Publication number DPH03-113HW For more information on this report, contact: Georgia Department of Human Resources Division of Public Health Chronic Disease Prevention and Health Promotion Branch Diabetes Prevention and
Control Program 2 Peachtree Street, NW Atlanta, GA 30303-3142 404-463-2748 Internet: http://healthstategaus For more information on diabetes, contact: The American Diabetes Association Three Corporate Square, Suite 120 Atlanta, GA 30329 404-320-7100 1-888-DIABETES Internet: http://wwwdiabetesorg

CONTENTS
Highlights 3 Introduction 4
Leading Causes of Death in Georgia, 2000 Figure 1

About Diabetes 5 What is Diabetes? 5 Types of Diabetes 6 Complications of Diabetes 7 Diabetes in Children 8 State Statistics 9 The Number of People in Georgia with Diabetes 9
Prevalence of Diabetes by Year, Georgia and US, 1994-2001 Figure 2 Prevalence of Diabetes by Age Group, Georgia, 2000-2001 Figure 3 Prevalence of Diabetes by Race and Sex, Georgia Adults 18 years, 2000-2001 Figure 4

Hospitalizations for Diabetes

10 11

Diabetes
Prevalence, Deaths, and Hospitalizations, Georgia Table 1 Diabetes-Related Complications, Georgia, 2000 Table 2

Deaths from Diabetes in Georgia

Age-Adjusted Diabetes Death Rates, Georgia and US, 1980-2000 Figure 5 Age-Specific Death Rates from Diabetes, Georgia, 2000 Figure 6 Age-Adjusted Diabetes Death Rates by Race and Sex, Georgia, 2000 Figure 7 Number of Diabetes Deaths by Age Group, Georgia, 2000 Figure 8

County Statistics 12
Estimated Prevalence of Diabetes by County, 2000-2001 Figure 9 Diabetes Prevalence, Deaths, and Hospitalizations by County, Georgia Table 3

Risk Factors for Diabetes and Its Complications 16
Physical Inactivity Consumption of Less Than Five Fruits and Vegetables a Day Overweight/Obesity Smoking High Blood Pressure High Cholesterol Metabolic Syndrome
Percentage of Adults Who Report No Regular Physical Activity and Being Overweight / Obese, Georgia, 1984-2001 Figure 10 Prevalence of Risk Factors Among Adults With and Without Diabetes, Georgia, 2000-2001 Table 4 Percentage of Adults Who Report Being Told They Have High Cholesterol and High Blood Pressure, Georgia, 1984-2001 Figure
11

continued

CONTENTS
continued
Clinical Practice Recommendations for People with Diabetes

22

Percentage of Persons with Diabetes Who Receive Recommended Routine Care, Georgia, 2000-2001 Table 5 Annual Hemoglobin A1C Testing Rates for Medicare Beneficiaries Age 65 with Diabetes By Race, Georgia, 2000 Table 6 Annual Hemoglobin A1C Testing Rates for Medicare Beneficiaries Age 65 with Diabetes, Georgia, 2001 Figure 12

Conclusions 26 References 27 Appendices 30
Methods Glossary Abbreviations Guildelines for People with Diabetes

Highlights
Diabetes is the sixth most common cause of death in Georgia For every death where diabetes is the primary cause of death, there are at least another two for which diabetes is a contributing cause Approximately 7 411,000 of adults in Georgia have been diagnosed with diabetes Approximately 205,000 adults in Georgia have diabetes but dont know it More than 15 of Georgians 60 years of age and older have diabetes Diabetes in Georgia is more common among blacks than whites In Georgia, diabetes is the primary
cause for approximately 13,000 hospitalizations annually, with hospital charges of nearly 138 million In Georgia, death rates from diabetes have been rising an average of 1 per year for nearly two decades Death rates from diabetes for black women in Georgia are more than two times higher than for white women Since the mid-1980s, more Georgians are becoming obese and continue to be physically inactive two fundamental risk factors for diabetes

3

Introduction
Diabetes is growing at an alarming rate Type 2 diabetes now affects more than 7 of adults in the United States1 There are over 17 million people in the US with diabetes and an estimated 6 million with undiagnosed diabetes The COMPLICATIONS OF DIABETES increasing prevalence of type 2 diabetes is presumably Heart disease due, all or in large part, to the increasing prevalence of Stroke obesity From 1991 to 2000, the prevalence of obesity in High blood pressure the United States increased 61; from 1990 to 2000, the Blindness retinopathy prevalence of diabetes increased 491 Diabetes is one of the most common, serious, and costly chronic diseases in Georgia and the United States It is the sixth most common underlying cause
of death in Georgia Figure 1 People with diabetes are more likely than people without diabetes to develop several other conditions, which are commonly referred to as complications of diabetes See text box Even more often, diabetes is a contributing cause to deaths from other causes2 Diabetes also results in hospitalizations and the need for other medical care services The health care costs for people with diabetes are estimated to be 13,200 per year compared to costs for people of comparable age without diabetes at 2,600 per year3 In 2000, there were more than 13,000 hospitalizations in Georgia for diabetes, resulting in approximately 68,000 days in the hospital and nearly 138 million in hospital charges
Figure 1 Leading Causes of Death in Georgia, 2000
Heart Disease Cancer Stroke Unintentional Injury Chronic Respiratory Disease Diabetes Influenza/Pneumonia Alzheimers Kidney Disease Sepricemia Other 1,483 1,426 1,280 1,279 1,139 14,702 3,141 3,043 4,534 13,628 18,002

Kidney disease Amputations Nerve damage neuropathy Dental disease Impotence Complications of pregnancy Susceptibility to
infection

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Number of Deaths

Source:Vital Statistics

4

This report provides highlights of the burden of diabetes in Georgia, including prevalence information, death rates, and hospitalization rates from diabetes The report also Minority groups have provides information about routine healthy behaviors that prevent the onset of type 2 diabetes, as well as behaviors and medical services that prevent complications a prevalence of diabetes that ranges of diabetes

About Diabetes
What is diabetes?
Diabetes, the common name for diabetes mellitus, is a chronic disorder of metabolism affecting the way the body uses digested food for growth and energy In people with diabetes, glucose the bodys main source of energy cannot get into the bodys cells and builds up in the blood To get glucose into cells, insulin a hormone produced in the pancreas must be present In people with diabetes, there is either too little insulin or the cells do not respond to the insulin that is present The exact cause of diabetes is not known There are, however, certain contributing factors that may lead to the development of diabetes,
including genetic factors, obesity, and physical inactivity Diabetes is more common in certain ethnic groups, such as African Americans, Hispanics, and Native Americans People who have diabetes need to take special care to keep the disease under control and to prevent complications Some individuals can manage their disease with meal planning, weight control, and regular physical activity Others need to routinely take prescription medications, such as insulin or oral agents, that either stimulate the body to produce more insulin or cause the cells to be more responsive to the insulin that is present It is important for people with diabetes to monitor the concentration of glucose in their blood and to be alert for the many complications of diabetes Therefore, routine visits to a health care professional for regular A1C tests, foot exams, eye exams, and immunizations are essential Minorities are likely to have higher rates of diabetes and diabetes related complications With the exception of Alaskan Natives, many minority groups - particularly African Americans, Puerto Ricans and Hispanic people living in the Southwest, American Indians, and Asians and Pacific Islander communities -
have a prevalence of diabetes that ranges from two to six

from two to six times higher than the white population

5

times higher than the white population Research has shown that many minorities often face economic barriers to treatment, are reluctant to put their own medical needs above needs of the family, and have fatalistic views about diabetes4 Therefore, intervention and education strategies must take into consideration cultures, traditions, and population-based barriers to reduce the severity of diabetes-related complications among minority populations

Types of diabetes
Type 1 diabetes once known as insulin-dependent diabetes mellitus or juvenile diabetes occurs when the insulin-producing cells in the pancreas are destroyed by the bodys own immune system The pancreas then produces little or no insulin Someone with type 1 diabetes needs daily injections of insulin to live Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States Type 1 diabetes develops most often in children and young adults, but the disorder can appear at any age Symptoms of type 1 diabetes usually develop over a short period of time Symptoms include increased thirst
and urination, constant hunger, weight loss, blurred vision, and extreme tiredness Type 2 diabetes is the most common form of diabetes once known as noninsulin-dependent diabetes mellitus About 90 to 95 percent of people with diabetes have type 2 diabetesThis form of diabetes usually develops in adults over the age of 40 and is most common among adults over age 55 In recent years, increasing numbers of children have been diagnosed with type 2 diabetes, presumably because of the elevated prevalence of obesity and physical inactivity In the United States, about 80 percent of people with type 2 diabetes are overweight5 In type 2 diabetes, the pancreas usually produces insulin, but for unknown reasons the body cannot use the insulin effectively The symptoms of type 2 diabetes usually develop gradually Symptoms include feeling tired or ill, frequent urination especially at night, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing of sores Some people with type 2 diabetes are treated with insulin Gestational diabetes develops or is discovered during pregnancy It usually disappears when the pregnancy is over Women who have had gestational diabetes have a
greater risk of developing type 2 diabetes later in their lives

6

Complications of diabetes
Diabetes is a very complex, serious, and costly disease because it can affect nearly every organ of the body People with diabetes are more likely to develop other health problems, such as heart disease, stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations, dental diseases, complications of pregnancy, impotence, and infections These types of complications, when not fatal, can cause disability, financial devastation, and social dependency Cardiovascular disease CVD is the primary cause of morbidity and mortality among people with diabetes and the leading cause of death nationwide6,7,8 Up to 80 of deaths in people with diabetes are due to CVD6 The risk of CVD is two to four times greater in people with diabetes than in people without diabetes It has been estimated that 27 of people with diabetes have cardiovascular disease, and 71 have risk factors for cardiovascular disease Among people with diabetes, the age-adjusted prevalence of people who have been told they have had a heart attack is 71; among people without diabetes, it is 36 For coronary heart
disease, the age-adjusted prevalence is 83 among people with diabetes versus 33 among people without diabetes; for stroke, 80 versus 18 The prevalence of CVD risk factors obesity, physical inactivity, poor nutrition, high blood pressure, and elevated blood lipid levels is higher among people with diabetes than among the general population7 Over two-thirds of all morbidity, mortality, and health care costs among people with diabetes is attributed to CVD9 Diabetes is the leading cause of end-stage renal disease ESRD, ie, kidney failure requiring dialysis or transplantation10,11,12 In the United States, diabetes accounts for approximately 40 of all new cases of ESRD The Southeastern Kidney Council 2000 Annual Report indicated that 1,302 of 3,075 42 of newly diagnosed chronic ESRD patients in Georgia had diabetes Approximately 37 of all ESRD dialysis patients at the end of 2000 had diabetes14 Persons with diabetes are the fastestgrowing population receiving kidney dialysis or transplantation In patients with established kidney problems eg elevated microalbuminuria or nephropathy, hypertension and uncontrolled blood glucose were found to be the most important factors contributing to
disease progression10 Lower extremity complications such as amputation, ulcers, and infection are very common in people with diabetes More than 60 of all nontraumatic lower extremity amputations LEAs occur in persons with diagnosed diabetes13 After undergoing limb amputation, as many as 50 of these patients will have another amputation within two to five years15

7

The risk factors for ulceration and amputation are peripheral vascular disease, peripheral sensory neuropathy, foot deformity, poor blood sugar control, and poorly fitting shoes Diabetes is the leading cause of new cases of blindness in adults aged 20-74, responsible for 8 of new blindness cases in the US15 People with diabetes are also at increased risk for developing glaucoma, cataracts, and corneal disease Nearly all people with type 1 and more than 60 of people with type 2 diabetes will develop some degree of retinopathy16 Because the diagnosis of diabetes is often delayed, up to 21 of people with type 2 diabetes have retinopathy by the time of diagnosis15,16 Diabetic ketoacidosis DKA is the most serious, acute metabolic complication of diabetes The condition results from a deficiency in insulin or poorly controlled
diabetes The symptoms of DKA ie frequent urination, weight loss, vomiting, weakness, abdominal pain may be present for several days, but they often develop within less than 24 hours DKA may require hospitalization for treatment and increases the use of health care services and the cost of diabetes If not properly treated, DKA can result in coma or death Most cases of DKA can be prevented by appropriate access to medical care and proper diabetes education

Diabetes in Children
In recent years, the number of children with type 2 diabetes has increased substantially, and has been recognized as an emerging public health problem Among children in the United States with diabetes, the percentage who have type 2 diabetes the type which is associated with being overweight and inactive ranges from 8 to 4517 Many children diagnosed with type 2 diabetes are girls between the ages of 10 to 19, who belong to ethnic groups at high risk for diabetes, have a family history of type 2 diabetes, are overweight and/or physically inactive, or have acanthosis nigricians18 Acanthosis nigricians AN is a darkening of pigmentation and thickening of the skin that can occur on any area of the body,
particularly on the neck This skin abnormality is often associated with metabolic disorders, such as diabetes Many studies have indicated that AN is strongly associated with insulin resistance,19,20 and can be used as an easy, inexpensive screening method for minorities at risk for diabetes19

8

Percentage

In Georgia, the current statewide prevalence of type 2 diabetes in children is unknownThe development of diabetes during childhood increases the likelihood of developing complications as a young adult, as well as the likelihood of premature mortality

Figure 2 Prevalence of Diabetes by Year, Georgia and US, Adults 18 years, 1994-2001
8 7 6 5 4 3 2 1 0 1994 1995 1996 1997 1998 1999 2000 2001
Source: BRFSS

GA US

State Statistics
The Number of People in Georgia with Diabetes
Among adults 18 years and older in Georgia, 68 approximately 411,000 know they have diabetes For every two people who know they have diabetes, a third person has it but does not know it This is because the early symptoms of diabetes may be mild Therefore, the total number of adults with diabetes, including the 205,000 individuals who are unaware they have diabetes, is about 616,000, or 102 of the adult
population in Georgia The prevalence of diabetes has increased substantially over the last decade From 1994 through 2001, the prevalence of diabetes in Georgia has increased at an average annual rate of 8 per year Figure 2 Diabetes is more common among older people Approximately 1 of Georgians from 18 through 29 years of age have the disease, but more than 15 of those greater than 60 years of age are afflicted Figure 3

Year

20 18 16
Percentage with Diabetes

Figure 3 Prevalence of Diabetes by Age Group, Georgia, 2000-2001

173

163

14 12 10 8 6 4 2 0

127

59 26 12
18-29 30-39 40-49 50-59 60-69 70
Source: BRFSS

Age group in years

12

Figure 4 Prevalence of Diabetes by Race and Sex, Georgia, Adults 18 years, 2000-2001

111

10
Percentage with Diabetes

8

The prevalence of diabetes is higher in women 74 than men 62, and higher among blacks 94 than whites 60 The prevalence of diabetes among black women is almost twice as high as any other race/sex group Figure 4

72 61 60 50 44

6

4

2 0

White Males

White Females

Black Males

Black Females

Other Males

Other Females
Source: BRFSS

Groups

9

Hospitalizations for Diabetes
People with diabetes are more likely to be
hospitalized than people without diabetes In 2000, diabetes was the primary cause of more than 13,300 hospitalizations in Georgia Table 1, totaling an estimated 68,000 hospital days equivalent to 186 years Diabetes is a huge financial burden on people with diabetes, their families, and society In 2000, hospital charges for persons hospitalized in Georgia for a primary diagnosis of diabetes was approximately 138 million Table 1 National data indicates that hospitalization costs for diabetes have more than doubled from 1997 44 billion to 2002 918 billion3 Even after adjusting for age, sex, and race/ethnicity, persons with diabetes incur medical expenses at a rate of five times higher than persons without diabetes

Table 1 Diabetes Prevalence, Deaths, and Hospitalizations, Georgia
Prevalence 2000-2001
Number Percent

Deaths 1996-2000
Number Rate

Hospitalizations 2000
Number Rate Total Charges

410,790

68

6,935

226

13,356

2000

137,866,000

Age-adjusted death and hospitalization rates are per 100,000

Hospital discharge data was also used to estimate the number of hospitalizations for certain diabetes-related complications In 2000, 295 of Georgia residents hospitalized with CVD,
274 of those hospitalized with end-stage renal disease, and 495 of those with a lower extremity amputation had diabetes Table 2 All hospitalizations for persons with the complication diabetic ketoacidosis, of course, occurred among people with diabetes

Table 2 Diabetes-Related Complications, Georgia, 2000
Number of Hospitalizations with Secondary Diagnosis of Diabetes
39,242 295 215 274 2,009 495 3,702 100
Source: Office of Health Information and Policy 10

Primary Diagnosis
Cardiovascular Disease End-Stage Renal Disease Lower Extremity Amputation Diabetic Ketoacidosis

Number of Hospitalizations
133,075 765 4,060 3,702

Deaths from Diabetes in Georgia
Diabetes is the sixth most common cause of death in Georgia In 2000, there were almost 1,500 people for whom diabetes was the primary cause of death Figure 1 Diabetes, however, contributes to many more deaths For every one death where diabetes is the primary cause of death, there are two more where diabetes is a contributing cause In Georgia and in the rest of the United States, death rates from diabetes have been increasing Figure 5 From 1980 to 2000, the age-adjusted death rate from diabetes in Georgia increased from 185 to 226
per 100,000 per year, an average annual increase of 1 per The death rate from year The increase cannot be diabetes for black attributed to an aging population, females in 2000 was because the age-adjusted rate takes more than twice that of white into account the changes in the age females distribution of the population Death rates where diabetes is the primary cause of death increase dramatically with age among all race and ethnic groups In Georgia the rate increases significantly from 17 per 100,000 adults aged 25-34 to 2846 per 100,000 adults aged 85 and older Figure 6 Death rates from diabetes are higher for blacks than for whites The Georgia death rate in 2000 for black males was about one and a half times that for white males, and the death rate for black females was more than twice that for white females Figure 7
Black Females
Source:Vital Statistics

Figure 5 Age-Adjusted Diabetes Death Rates, Georgia and US, 1980-2000
30
Age-adjusted death rate per 100,000 US

25 20 15 10 5 0
19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00
Year
NOTE: The dotted line indicates a change in coding systems used for cause of death ICD-9 codes were used for 1980-1998 death
records; ICD-10 codes were used for 1999-2000 death records

GA

Source:Vital Statistics

Figure 6 Age-Specific Death Rates from Diabetes, Georgia, 2000
300

2846

250

Deaths per 100,000

200

1570
150

100

808 373 00 05
15-24

50

17
25-34

41
35-44

130
45-54 55-64 65-74 75-84 85

0

0-14

Age Group in Years

Source:Vital Statistics

45 40
Age-Adjusted Deaths per 100,000

Figure 7 Age-Adjusted Diabetes Death Rates by Race and Sex,Georgia, 2000

389 335

35 30 25 20 15 10 5 0 White Males White Females
Groups

234 167

Black Males

11

Figure 8 Number of Diabetes Deaths by Age Group in Georgia, 2000
500 450 400 350
Number of Deaths 33 of Deaths 65 Years of Age

431

Although death from diabetes is more common among older people, it can be fatal even among younger populations In 2000, 33 of all Georgians who died from diabetes were younger than 65 years of age Figure 8

317 251 238

County Statistics

300 250 200 150 100 50 0

Table 3 shows the estimated number column 1 and percentage column 2 of adults in each county who know they have diabetes The actual number of 125 people who have diabetes is likely to be higher, 79 because about one-third of people with diabetes 24 4 1 do
not know that they have it The prevalence of 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85 Source:Vital Statistics Age Group in Years adults who know they have diabetes is higher in the southern half and northwestern corner of Georgia Figure 9 Column 4 shows Figure 9 Estimated Prevalence of Diabetes by County, the age-adjusted death rate for diabetes Georgia, 2000-2001 from 1996 until 2000 for each county The 21 counties with rates in bold print have rates that are statistically higher than the state rate of 226 per 100,000 Diabetes Prevalence persons
11 9-11 7-9 7

County-by-County Statistics for Diabetes
Also shown are the number of hospitalizations column 5 in 2000 for county residents, the hospitalization rate per 100,000 persons column 6, and the hospital charges column 7 Caution should be used when making comparisons among county hospitalization statistics because Georgia residents hospitalized outside of the state or in federal hospitals are not included in Table 3

The state prevalence is 68
Source: BRFSS

12

Table 3 Diabetes Prevalence, Deaths, and Hospitalization by County, Georgia
Prevalence 2000-2001
Number Percent

Deaths 1996-2000
Number Rate

Hospitalizations
2000
Number Rate Total Charges

GEORGIA APPLING ATKINSON BACON BAKER BALDWIN BANKS BARROW BARTOW BEN-HILL BERRIEN BIBB BLECKLEY BRANTLEY BROOKS BRYAN BULLOCH BURKE BUTTS CALHOUN CAMDEN CANDLER CARROLL CATOOSA CHARLTON CHATHAM CHATTAHOOCHEE CHATTOOGA CHEROKEE CLARKE CLAY CLAYTON CLINCH COBB COFFEE COLQUITT COLUMBIA COOK COWETA CRAWFORD CRISP DADE DAWSON DEKALB DECATUR DODGE DOOLEY DOUGHERTY DOUGLAS EARLY ECHOLS EFFINGHAM ELBERT

410,790 1,140 640 760 220 2,530 820 1,870 3,580 1,670 1,810 8,310 620 680 1,460 1,080 3,920 1,430 780 480 1,610 700 3,840 2,980 600 11,310 930 1,770 4,910 5,840 190 8,920 580 18,230 3,780 3,500 3,850 1,390 3,020 700 1,350 930 760 29,600 1,800 1,400 640 6,380 3,150 710 400 1,970 940

68 90 120 102 75 72 77 56 65 132 154 74 72 65 122 67 90 93 53 97 54 99 59 75 81 65 87 90 48 70 77 54 117 41 141 115 61 123 47 77 87 81 63 59 89 98 74 92 47 81 149 75 62

6,935 25 7 9 2 27 18 26 45 23 18 207 8 12 15 21 42 18 25 12 23 13 70 66 7 205 4 21 71 81 9 136 7 291 61 33 48 17 55 11 44 12 11 522 46 27 16 77 61 28 2 24 31

226 322 147 316 161 146 262 223 269 231 166 286 220 191 305 453 268 258 205 292 188 154 180 252 218 176 435 166 178 224 169 263 404 169 172 241 355 282 297
182 213 375 229 264

13,356 20 22 42 5 85 22 74 106 43 52 369 35 26 42 37 70 51 42 26 34 31 184 22 22 413 1 46 87 209 8 298 15 545 122 69 69 65 141 14 83 12 22 828 87 61 30 220 129 13 1 57 76

2000 1096 3495 4210 1857 1672 1858 1511 2426 3124 2434 3067 1831 2421 1728 1519 2466 2216 3900 1179 3313 2264 419 2220 1795 1683 784 2671 1685 2152 996 3719 1671 850 4145 1817 1216 3846 805 1772 1378 3149 3102 2601 2402 1518 1033 1763 3491

137,866,000 272,000 207,000 269,000 55,000 619,000 218,000 710,000 1,151,000 273,000 384,000 4,025,000 263,000 249,000 280,000 407,000 928,000 363,000 310,000 171,000 392,000 167,000 1,619,000 147,000 159,000 5,376,000 3,000 557,000 798,000 2,257,000 617,000 3,749,000 140,000 5,593,000 986,000 391,000 1,019,000 500,000 1,521,000 116,000 401,000 144,000 237,000 9,156,000 528,000 440,000 250,000 2,271,000 1,390,000 54,000 3,000 737,000 678,000 13

Note: Counties with rates in bold print are statistically higher than the state rate

Age-adjusted death and hospitalization rates are per 100,000 Rates are not reported for counties where the number of deaths or hospitalizations is less than 10

Prevalence 2000-2001
Number Percent

Deaths 1996-2000
Number
Rate

Hospitalizations 2000
Number Rate Total Charges

EMANUEL EVANS FANNIN FAYETTE FLOYD FORSYTH FRANKLIN FULTON GILMER GLASCOCK GLYNN GORDON GRADY GREENE GWINNETT HABERSHAM HALL HANCOCK HARALSON HARRIS HART HEARD HENRY HOUSTON IRWIN JACKSON JASPER JEFF-DAVIS JEFFERSON JENKINS JOHNSON JONES LAMAR LANIER LAURENS LEE LIBERTY LINCOLN LONG LOWNDES LUMPKIN MACON MADISON MARION MCDUFFIE MCINTOSH MERIWETHER MILLER MITCHELL MONROE MONTGOMERY MORGAN MURRAY MUSCOGEE

1,480 470 1,070 3,190 6,850 3,420 1,170 25,940 1,180 150 2,890 3,010 1,480 630 20,440 2,160 5,510 390 1,600 1,190 1,420 620 5,250 5,650 1,040 2,340 540 1,240 1,030 580 470 1,250 680 790 2,410 1,750 1,920 420 260 9,560 1,010 700 1,410 450 970 460 1,340 360 1,450 1,320 650 400 2,020 10,170

94 61 68 49 100 48 76 42 66 76 57 92 86 58 48 79 54 51 84 67 81 79 62 71 147 77 65 134 83 94 79 73 57 150 73 102 46 67 37 141 63 69 74 88 63 59 81 77 83 82 105 35 77 75

10 9 39 51 82 34 21 733 13 13 59 28 34 36 280 30 125 12 34 23 27 11 68 84 19 39 7 19 31 10 9 24 20 11 26 9 20 13 4 66 33 36 22 17 22 8 25 11 16 31 8 9 29 239

96 310 179 177 133 187 252 112 765 165 160 295 514 224 170 245 254 267 222 211 228 200 218 364 238 351 346 231 249 270
366 118 185 290 198 434 559 203 634 233 219 269 155 345 263 291

70 36 37 77 167 52 84 1751 40 6 115 78 42 58 369 55 164 36 53 24 36 19 134 149 34 85 15 18 48 34 12 22 31 24 95 21 60 19 9 191 29 48 19 44 57 10 67 13 44 33 8 33 62 401

3244 3497 1550 979 1806 656 3912 2385 1570 1658 1808 1775 3867 825 1513 1313 3512 1982 940 1392 1695 1350 1499 3203 2155 1358 1442 2726 3940 1332 944 1859 3623 2091 1045 1853 2110 2459 1469 2298 1557 3122 2284 1524 2929 1790 1881 1608 2144 1904 2283

517,000 213,000 271,000 892,000 1,913,000 630,000 604,000 19,737,000 309,000 78,000 1,275,000 1,116,000 297,000 601,000 4,445,000 605,000 2,835,000 257,000 431,000 158,000 298,000 252,000 1,524,000 1,285,000 225,000 936,000 375,000 93,000 471,000 195,000 153,000 172,000 166,000 229,000 703,000 140,000 599,000 124,000 216,000 1,548,000 327,000 524,000 821,000 108,000 315,000 214,000 659,000 53,000 527,000 186,000 152,000 384,000 589,000 4,441,000

14 Note: Counties with rates in bold print are statistically higher than the state rate

Age-adjusted death and hospitalization rates are per 100,000 Rates are not reported for counties where the number of deaths or hospitalizations is less than 10

Prevalence
2000-2001
Number Percent

Deaths 1996-2000
Number Rate

Hospitalizations 2000
Number Rate Total Charges

NEWTON OCONEE OGLETHORPE PAULDING PEACH PICKENS PIERCE PIKE POLK PULASKI PUTNAM QUITMAN RABUN RANDOLPH RICHMOND ROCKDALE SCHLEY SCREVEN SEMINOLE SPAULDING STEPHENS STEWART SUMTER TALBOT TALIAFERRO TATTNALL TAYLOR TELFAIR TERRELL THOMAS TIFT TOOMBS TOWNS TREUTLEN TROUP TURNER TWIGGS UNION UPSON WALKER WALTON WARE WARREN WASHINGTON WAYNE WEBSTER WHEELER WHITE WHITFIELD WILCOX WILKES WILKINSON WORTH

2,930 940 520 3,470 1,260 1,410 960 610 3,700 480 850 180 810 560 12,160 2,890 230 1,150 640 2,510 1,440 410 2,310 370 80 1,210 470 1,250 790 3,310 3,980 1,670 540 540 2,240 1,040 620 890 1,630 4,160 2,380 2,440 310 1,240 1,310 160 540 820 4,400 750 540 510 1,660

65 51 56 61 72 80 84 62 131 65 58 92 69 98 83 57 87 104 93 59 74 103 96 75 52 71 73 137 100 106 142 89 69 107 53 154 80 64 79 91 55 91 67 80 67 90 113 54 72 114 66 69 106

47 17 15 44 32 18 26 6 29 6 15 1 19 14 208 65 14 14 10 34 26 22 39 11 5 14 18 34 11 48 59 18 10 11 40 18 9 11 48 102 58 44 11 20 17 2 19 16 103 12 21 7 19

202 196 281 237 329 173 371 155 166 201 302 258 245 819 180 193 127 182 682 250 307 147 420 526 190
216 353 148 121 342 137 370 90 310 313 248 214 274 194 147 667 153 309 286 315 207

99 35 9 69 68 32 26 26 97 27 35 5 38 25 393 80 4 62 19 129 58 21 97 15 7 32 11 56 35 84 91 73 19 10 199 24 17 31 81 78 82 102 18 39 63 8 14 31 132 26 23 31 43

1700 1555 1152 3111 1363 1632 2013 2518 2717 1903 2430 3179 2105 1229 4067 1836 2243 2199 3699 3106 2252 1547 1213 4539 3272 1914 2512 2871 1583 1410 3445 2583 1592 1344 2789 1225 1449 2777 2805 1860 2426 2228 1464 1683 2903 1837 3092 1943

935,000 403,000 81,000 620,000 457,000 420,000 243,000 163,000 1,084,000 199,000 219,000 47,000 186,000 248,000 4,893,000 650,000 77,000 571,000 96,000 1,634,000 477,000 86,000 701,000 192,000 31,000 323,000 99,000 483,000 289,000 642,000 649,000 819,000 180,000 66,000 1,553,000 257,000 217,000 178,000 451,000 1,099,000 844,000 1,012,000 201,000 609,000 653,000 87,000 106,000 388,000 1,422,000 189,000 325,000 355,000 315,000 15

Note: Counties with rates in bold print are statistically higher than the state rate

Age-adjusted death and hospitalization rates are per 100,000 Rates are not reported for counties where the number of deaths or hospitalizations is less than 10

Risk Factors for Diabetes and Its
Complications
Many people can avoid developing type 2 diabetes by maintaining normal body weight and getting regular physical activity The Diabetes Prevention Program Study found a 58 reduction in the incidence of diabetes in the test Figure 10 Percentage of Adults Who Report No Regular Physical Activity group that made lifestyle modifications4 Lifestyle and Being Overweight/Obese, Georgia, 1984-2001 90 intervention showed positive effects in individuals 80 No regular physical activity 70 regardless of age, sex, race, or ethnicity4 Since the 60 mid-1980s, the percent of Georgia adults who are 50 40 not regularly active has remained elevated, and the Overweight or obese 30 20 percent who are overweight or obese has been 10 increasing Figure 10 These trends are likely to 0 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 98 198 198 198 198 198 199 199 199 199 199 199 199 199 199 199 200 200 1 influence the rising prevalence of diabetes and the Year Source: BRFSS rising rate of death from diabetes People with diabetes who are overweight or do not get enough regular physical activity can improve control of their diabetes and lower their risk of complications by reducing weight and being physically
active Other behaviors that reduce the likelihood of developing complications include controlling blood pressure and blood cholesterol, not smoking, and eating a healthy diet Keeping blood glucose as close to normal as possible is one of the most important things people with diabetes can do to prevent complications

Percentage of Adult Georgians

The Diabetes Prevention Program Study found a 58 reduction in the incidence of diabetes in the test group that made lifestyle modifications through diet and exercise

Physical Inactivity
Regular physical activity is bodily movement that is produced by the contraction of skeletal muscle and results in the expenditure of energy The current recommended amount of physical activity for good health is thirty minutes of moderate activity — such as brisk walking, gardening, or vacuuming — at least five days per week, or twenty minutes of vigorous physical activity — such as jogging, bicycling, or swimming — at least three times per week22,23 Regular physical activity can also reduce blood sugar levels; improve cardiovascular health; reduce feelings of depression and anxiety; help to build and maintain healthy bones, muscles and joints;
maintain proper body weight; and enhance overall quality of life 22,23 In 2000-2001, 32 of Georgians with diabetes reported they did not get any non-occupational physical activity compared to 28 of those without diabetes Table 4

16

In 1993, a research study indicated that approximately 14-23 deaths in the Unites States were attributed to activity patterns and diet24 Physical inactivity and unhealthy eating contribute to obesity, cancer, cardiovascular diseases, and diabetes, which are the most common chronic diseases in the United States Although virtually anyone can benefit from regular physical activity, more than 73 of Georgians reported getting no regular physical activity Figure 10

Consumption of Less Than Five Fruits and Vegetables a Day
The 5-A-Day for Better Health campaign is an initiative of the National Cancer Institute, which encourages Americans to consume five or more servings of fruits and vegetables per day Additionally, the campaign works to inform Americans that eating fruits and vegetables can improve their health and may reduce the risk for cancer and other chronic diseases such as diabetes and heart disease25,26 Fruits and vegetables are high in fiber, which
slows the rate of glucose absorption in the body, providing better blood sugar control in persons with diabetes Also, fiber provided by these products can lower blood cholesterol levels and reduce the risk for heart disease25,26,27 This combined effect ultimately leads to a reduction in diabetes-related complications and improves quality of life for persons with diabetes In 2000-2001, only 19 of Georgians with diabetes reported eating five or more servings of fruits and vegetables daily compared to 23 of those without diabetes Table 4

Overweight / Obesity
The National Research Council NRC defines overweight as excess body weight in relation to height, when compared to a standard of desirable weight28 Obesity is defined as an excessively Table 4 Prevalence of Risk Factors Among Adults With and Without Diabetes, Georgia, 2000-2001 high amount of body fat in relation to lean body Percent of those Percent of those mass In obesity, the concern is not only for the WITH Diabetes WITHOUT Diabetes amount of fat, but its distribution throughout the Ever told blood pressure high 50 26 body28,29 Fat distributed in the mid-trunk area, Ever told cholesterol high 43 30 which is classified as
central obesity, has been Smoke 28 23 linked to diabetes and other chronic diseases28,29,30,31 Dont eat 5 fruits or vegetables daily 81 77 In both Georgia and the US, there has been a Get no non-occupational physical activity 32 28 steady increase in the prevalence of overweight Overweight or obese 82 58 body mass index 250-299 and obese body mass Age-adjusted to 2000 US standard population Source: BRFSS index 30 individuals
17

Normal

Overweight

Obese

Among th e US population, the prevalence of overweight individuals has increased from 33 in 1990 to 37 in 2001, and obesity prevalence has nearly doubled from 12 in 1990 to 21 in 2001 In Georgia, the prevalence of overweight or obesity has increased from 457 348 overweight, 108 obese in 1990 to 594 444 overweight, 15 obese in 2001 Figure 10 Eighty-two percent of people in Georgia with diabetes are overweight or obese compared to 58 of those without diabetes Table 4 Overweight trends among children are disheartening The National Health Interview Survey found that 15 of children and adolescents aged 6-19 years of age are overweight33 Another 10 of preschool aged children 2 to 5 were found to be overweight34 In 2001, the Georgia
Youth Tobacco Survey collected height and weight data from a sample of middle and high school students The survey found that 134 of middle school students 9 girls, 175 boys and 112 of high school students 76 girls, 149 boys were overweight Data were obtained through self-report and therefore may underestimate the prevalence of overweight

18

Smoking
Tobacco use contributes to hundreds of deaths each year Smoking has long been associated with cancer, but it also causes cardiovascular disease CVD People with diabetes who smoke have an increased risk for heart and blood vessel problems Diabetes increases the risk for CVD, but this risk triples among those who smoke6,35,36 Twenty-eight percent of Georgians with diabetes report that they smoke Table 4, and this places them at an increased risk for cardiovascular complications Nationally, CDC reports that the prevalence of smoking appears to be higher in young people less than 21 years old with diabetes than in young people without diabetes36

High Blood Pressure
High blood pressure is a major risk factor for both heart disease and stroke and is more common in individuals with type 2 diabetes than in the general population High blood
pressure is defined as blood pressure 140/9037 Blood pressure above this level in people with diabetes has been associated with an increased risk for damage to the blood vessels, eyes, and kidneys 6,37,38 In Georgia, there has been a slight increase in the prevalence of persons who report ever being told they have high blood pressure Figure 11 The percentage of Georgians with diabetes who report having been told they have high blood pressure was 50 compared to 26 of Georgians without diabetes Table 4 Individuals with diabetes and high blood pressure are strongly encouraged to get their blood pressure checked often, stop smoking, manage body weight, exercise regularly, and take prescribed medications as directed by a health professional to bring their blood pressure under control The recommended blood pressure for people with diabetes is 130/80 to prevent diabetes-related complications, which is lower than the national standard for blood pressure control6

High Cholesterol
High cholesterol has been long associated with an increased risk for cardiovascular disease CVD When blood sugar remains high for an extended period, the circulating glucose is stored as fats, causing an increase
in blood lipids such as cholesterol and triglycerides over time When there is too much cholesterol in the blood, the excess can become trapped in the artery wall Cholesterol buildup is a gradual process, but is the cause of many heart attacks

19

Percentage of Adult Georgians

35 30 25 20 15

Cholesterol is transported through the body by lipoproteins There are two major types of lipoproteins Low-density lipoprotein LDL, commonly called the bad cholesterol, tends to stick to the walls of arteries increasing the risk for heart disease High-density lipoprotein HDL, or good cholesterol, carries cholesterol away from the heart and other parts of the body A high HDL level is therefore preferred because it decreases the risk for heart disease The percentage of persons who report ever being told they have high cholesterol has increased from 153 in 1987 to 318 in 2001 Figure 11 Forty-three percent of Georgians with diabetes report being told they have Figure 11 Percentage of Adults Who Report Being Told They Have High Cholesterol and High Blood Pressure, Georgia, 1984-2001 high cholesterol level compared with 30 of Georgians without High cholesterol diabetes Table 4
High blood
pressure

People with diabetes are encouraged to maintain total cholesterol 10 levels less than 200 mg/dl, triglyc5 0 erides levels less than 150 mg/dl, 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 low-density lipoprotein LDL Year Source: BRFSS less than 100 mg/dl, and highdensity cholesterol HDL 39 over 40 mg for men and 50 mg for women Cholesterol can be controlled by making modifications to diet and level of physical activity For those who cannot control cholesterol with this method, the use of cholesterol-lowering medications might be beneficial

Metabolic Syndrome
Metabolic Syndrome, or Syndrome X, is a collection of symptoms associated with a high risk for heart disease, diabetes, and stroke Metabolic Syndrome patients exhibit a cluster of medical conditions characterized by insulin resistance, obesity, abdominal fat, high blood pressure, high blood sugar, high triglycerides, and high cholesterol National survey data suggests that an estimated 47 million Americans, or one in five, have Metabolic Syndrome41 This syndrome seems to be more common in older people and Mexican Americans People with Metabolic Syndrome
are twice as likely to develop CVD and four times more likely to develop diabetes compared to individuals who do not have Metabolic Syndrome Metabolic Syndrome was first defined in the third report of the National Cholesterol Education Program NCEP on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults ATPIII in May 2001 It is believed that the root cause of Metabolic Syndrome for many individuals is poor diet and insufficient exercise 40,41,42

20

Risk Factors for Metabolic Syndrome: A waist measurement of at least 35 inches women or at least 40 inches men Fasting blood sugar of at least 110 mg/dl Triglyceride levels of at least 150 mg/dl HDL cholesterol of less than 40 mg/dl men or less than 50mg/dl women Blood pressure of at least 130 systolic or at least 85 diastolic Symptoms of Metabolic Syndrome: Feeling sluggish after eating Gaining weight slowly and having trouble losing it Suffering from brain fog feeling dazed and unclear in thoughts Craving sweets or other carbohydrates shortly after a meal Treatment for Metabolic Syndrome: Exercise Weight loss Healthy eating diet low in fat, refined sugar, cholesterol, and saturated fat, and high in
fiber

People with Metabolic Syndrome are twice as likely to develop cardiovascular disease CVD and four times more likely to develop diabetes compared to individuals who do not have Metabolic Syndrome

Reversing Metabolic Syndrome Reversing Metabolic Syndrome can reduce a patients risk for diabetes, heart disease and stroke Talk to your physician if you have risk factors or symptoms of Metabolic Syndrome

21

Clinical Practice Recommendations for People with Diabetes
People with diabetes need to see their doctor regularly Although the type and frequency of screenings, visits, and tests should be individualized for every patient, a minimum frequency has been recommended The American Diabetes Associations Clinical Practice Recommendations43 and Healthy People 2010 Objectives44 were adapted to develop the following list of recommended practices for people with diabetes At least one visit with a health professional each year Promote daily self-monitoring of blood glucose and evaluate techniques Measure A1C at least twice yearly if the patient is meeting treatment goals, quarterly if therapy has changed Provide diabetes education as needed Provide individualized medical nutrition
therapy as needed Recommend regular physical activity program Measure blood pressure at each visit Screen for lipid abnormalities annually Provide aspirin therapy for all adults if tolerable Advise all patients not to smoke Perform annual foot exams Refer for annual dilated eye exams Perform annual cardiovascular risk assessment Provide annual influenza vaccine Provide pneumonia vaccine Screen annually for microalbuminuria Refer for annual dental exams Surveys of people with diabetes in Georgia indicate that substantial numbers of patients with diabetes in Georgia are receiving less than the recommended minimal level of care The prevalence of Georgia adults with diabetes receiving the recommended level of care ranges from 89 of Georgian adults with diabetes visiting a health professional during the past year to 43 receiving aspirin therapy Table 5 Regular treatment of diabetes can reduce the risk of blindness, kidney disease, and nerve damage by 50 For the services for which a national goal has been set, Georgia meets the national goal for only three: receipt of diabetes education, two or more A1C
22

Substantial numbers of patients in Georgia with diabetes are
receiving less than the recommended minimal level of care

tests per year, and receipt of aspirin therapy This suggests that there are many areas where improvement of provider and patient education is needed Education begins with getting people with diabetes into the health practice system

Table 5 Percentage of Persons with Diabetes Who Receive Routine Recommended Care, 2000-2001
Recommended Minimal Frequency for Routine Care
Visit to health professional Self glucose monitoring daily A1C test, 2 per year Received diabetes education Received nutrition education

Healthy People 2010 Objectives51
60 50 60 -

BRFSS Medicare Assessment Assessment
89 51 82 62 -

Physical activity recommended 64 The American Diabetes Association guideBlood pressure measured, each visit lines for blood glucose monitoring recomLipid test, 1 per year 57 mend that patients with type 2 diabetes on Receiving aspirin therapy 30 43 Advised not to smoke insulin and/or oral medications self moniFoot exam, 1 per year 75 64 tor blood glucose at least once daily to Dilated eye exam, 1 per year 75 67 46 CVD risk assessment, 1 per year 25 better manage their diabetes45 Research Influenza vaccine, 1 per year 48 42 shows
that daily self monitoring of blood Pneumonia vaccine, ever 48 Microalbuminuria test, 1 per year 13 glucose SMBG encourages better blood Dental exam, 1 per year 75 sugar control and patients who complete - Data not available BRFSS data were aggregated for 2000-2001 whenever possible Recommendations listed with asterisk have only one daily self monitoring have lower hemogloyear of data available Based on Medicare cohort definition of diabetes as 2 outpatient visits at least 30 days apart or 1 inpatient visit with a bin A1C levels Additionally, people with diagnosis of diabetes during a one-year period Medicare assessed that 75 of patients with diabetes received at least one A1C test in the past year diabetes who self monitor blood glucose are more likely to have yearly eye examinations and use diet and exercise as a part of their treatment45 In Georgia, 49 of people with diabetes do not check their blood sugar daily Table 5

Daily self-monitoring supplies such as glucose testing strips and glucometers are covered by Medicare Part B and other private insurance plans The benefits of daily blood glucose monitoring outweigh the cost and provide useful data that is not only beneficial
to patients, but also to health professionals involved in diabetes care This testing provides a quick reference for all persons of the health care team, and allows health professionals to better guide persons with diabetes toward goal setting To address questions about access and cost related to daily blood glucose monitoring, people with diabetes are encouraged to speak with members of their health care team Hemoglobin A1C, sometimes called glycosolated hemoglobin or glycated hemoglobin, may be the most important indicator of diabetes control Unlike blood glucose, which measures the concentration of glucose in the blood at a specific moment, A1C estimates the average concentration of glucose in the blood for about the last three months In Georgia, approximately 82 of all persons with diabetes had their A1C checked as recommended in the past year Table 5 Seventy-five percent of Medicare patients with diabetes are reported to have had at least one A1C test in the past year

23

People with diabetes are encouraged to get a flu shot in October or November of each year46 For people with diabetes, the flu can be more than aches and pain it could mean a long illness, hospitalization,
and even death People with diabetes are three times more likely to die from complications of the flu and pneumonia than people without diabetes Each year between 10,000 and 30,000 people with diabetes will die of flu or pneumonia complications Nationally, the Centers for Disease Control and Prevention reports that 55 of people with diabetes get an annual flu shot47,48 Only 48 of Georgians with diabetes reported getting a flu shot in the past year Table 5 Pneumonia shots are also recommended for people with diabetes because they are three times more likely to die from pneumonia or the flu than those without diabetes The CDC reports that pneumonia shots protect people not only against pneumonia, but also from bacteremia and meningitis Pneumonia shots can be taken anytime during the year For most people one shot is good for a lifetime, but people with diabetes and other chronic diseases, should ask their doctor if they might need another shot within five to ten years Only 48 of Georgians with diabetes reported ever having a pneumonia shot Table 5 Flu and pneumonia shots are covered by Medicare Part B, and are available at a minimal cost at community health centers, local health
departments, private doctors offices, pharmacies, and at some hospitals

Table 6 Annual Testing Rates of Medicare Beneficiaries Aged 65 with Diabetes by Race, Georgia, 2001

Total Whites Blacks Other
No of Patients with Diabetes with 1 HbA1c Tests 94,643 75 69,783 76 24,154 73 706 76

The Lower Extremity Amputation Prevention LEAP project has been conducted and evaluated in several with Eye Exam 46 48 40 41 areas of the country Studies found that by training with Lipid Profile 57 60 48 60 primary health care providers ie physicians, podia with Quantitative Urine Protein 13 13 13 15 trists, nurses, dieticians, and health educators to Source: Georgia Medical Care Foundation change clinical foot care practices to include initial screening, documentation of peripheral vascular disease or injury, and appropriate referral, persons with diabetes are likely to experience a reduction of foot problems that can lead to amputations 49,50 Additionally, implementing patient education programs to self-check feet for sores or irritations, or simple techniques such as encouraging people with diabetes to remove shoes and socks when visiting a health care provider will improve early detection of
lower extremity complications Only 67 of adults with diabetes received an annual foot exam Table 5 Diabetes is a major cause of visual impairment and blindness Yet in Georgia, the standard recommendations for care of persons with diabetes are not being met for annual eye exams Only 64 of adults with diabetes received an annual eye exam Table 5

24

Medicare data on Georgians with diabetes who are 65 years and older confirm that many elderly patients are not receiving recommended preventive care These data suggest that whites are more likely than blacks to receive annual dilated eye exams and lipid profiles, whereas the frequency of receiving A1C and quantitative urine protein tests are similar Table 6 The percentage of dilated eye exams among the Medicare population falls well below the recommendation Only 13 of persons with diabetes aged 65 and over receive annual microalbuminuria tests, however many more of these patients are likely to be at high risk of developing kidney disease Medicare patients with diabetes in the southern and southwestern part of the state appear to be tested for A1C less often than patients in other parts of the state Figure 12

Figure 12 Annual A1C Testing
Rates for Medicare Beneficiaries Age 65 with Diabetes, Georgia, 2001

A1C Test Rate Quartile Ranking
347 640 723 772 639 722 771 859

Source: Georgia Medical Care Foundation

25

Conclusions
This report summarizes recent information about diabetes in Georgia based primarily upon telephone interviews of Georgia residents, hospital discharge data, and death statistics The findings indicate: 1 the prevalence of diabetes is increasing rapidly in Georgia, 2 older people and blacks are more likely to have diabetes, and 3 that the death rate from diabetes has been rising in Georgia for nearly two decades Although the exact reasons for the increasing prevalence and death rate are not known, it is most likely the result of the increasing percentage of Georgians who are overweight or physically inactive two of the primary risk factors for type 2 diabetes These findings suggest that if more people were physically active on a regular basis and maintained normal body weight, the prevalence of diabetes would decline Although many people know that they should be more active and eat a healthier diet, behavioral changes are difficult to make, even for motivated people Therefore, it will be
important to find ways to help people be more physically active and eat healthier diets Parents and community leaders can act as role models The environment of schools, worksites, and the community can be modified to facilitate healthy behaviors: schools can offer healthier foods in the cafeteria, worksites can offer fitness classes, and communities can make improvements to parks and trails The data in this report also suggest that some Georgians who have diabetes are not receiving recommended routine care Only 82 of Georgians with diabetes have had the recommended number of hemoglobin A1C tests in the past year, an important indicator of the control of their diabetes Routine care can help people with diabetes keep the disease under better control and can detect and treat complications promptly Individuals with diabetes need to know what care they should be getting Medical care providers can help educate the patients and remind them when their check-ups are due Diabetes is a serious and costly disease, affecting hundreds of thousands of Georgians However, it can be managed Working together, we can improve the lives of people with diabetes and reduce the burden of diabetes in
Georgia

26

References
1 Mokdad AH, Bowman BA, Ford ES,Vinicor F, Marks JS, Koplan JP The continuing epidemics of obesity and diabetes in the United States JAMA 2001;28610:1195-200 2 Centers for Disease Control and Prevention, Division of Diabetes Translation 2002 National Diabetes Fact Sheet 3 American Diabetes Association Economic Costs of Diabetes in the US in 2002 Diabetes Care 2003; 26: 917-932 4 Diabetes Prevention Program Research Group Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin New England Journal Of Medicine 2002; 3466: 393-403 5 Sowers JR, Murray Epstein et al Diabetes, hypertension, and cardiovascular disease Hypertension 2001; 37:1053 6 Fagot-Campagna A, Gary TL, Benjamin SM Cardiovascular risk in diabetes: a story of missed opportunities? Diabetes Care 2001;2411:2015-6 7 Karissa Y Kim, PharmD, Eli Lilly and Company Managing Cardiovascular Risk in Type 2 Diabetes Mellitus securepharmacytimescom/lessons/html/CV_risk_in_diab2htm 8 Duckworth WC, McCarren M, and Abraira C Glucose Control and Cardiovascular Complications:The VA Diabetes Trial Diabetes Care 2001;245: 942-945 9 Ritz, E Nephropathy in Type 2 diabetes Journal of
Internal Medicine 1999;245 2:111-126 10 Ritz E,Tarng DC Renal disease in Type 2 diabetes Nephrol Dial Transplant 2001;16 Suppl 5:11-8 11 Crook ED Diabetic renal disease in African Americans Am J Med Sci 2002;3232:78-84 12 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report 1991; 40 43: 737-739 13 American Diabetes Association Facts Figures: Diabetes and Eye Conditions wwwdiabetesorg/main/info/facts/eye/defaultjsp 14 2000 Annual Report, ESRD Network 6 Southeastern Kidney Council, Inc 15 Meltzer DD, Pels S, Payne WG, Mannari RJ, Ochs D, Forbes-Kearns J, Robson MC Decreasing amputation rates in patients with diabetes mellitus: An outcome study J Am Podiatr Med Assoc 2002;928:425-8 16 American Diabetes Association Diabetic Retinopathy Diabetes Care 2002;25S1: 90S-93S 17 Diabetes Disparities Among Racial and Ethnic Minorities November 2001 AHRQ Publication No 02-P007 Agency for Healthcare Research and Quality, Rockville, MD http://wwwahrqgov/research/diabdisphtm 18 Fagot-Campagna A Emergence of Type 2 diabetes in children: the epidemiological evidence J Ped Endoc Metab 2000;13: 1394-1402 19 Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss
LS,Valdez R, Beckles GL, Saaddine J, Gregg EW,Williamson DF, Narayan KMV Type 2 Diabetes among North American children and adolescents: an epidemiologic review and a public health perspective J Pediatr 2000; 1365: 664-72 20 Araujo, LMB, Porto, MV, Netto, EM et al Association of acanthosis nigricans with race and metabolic disturbances in obese women Braz J Med Biol Res 2002; 351: 59-64

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21 Mukhtar Q, Cleverley G,Voorhees RE, McGrath JW Prevalence of acanthosis nigricans and its association with hyperinsulinemia in New Mexico adolescents J Adolescent Health 2001;285:372-6 22 Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GS, King AC, Kriska A, Leon AS, Marcus BH, Morris J, Paffenbarger RS, Patrick K, Pollock ML, Rippe JM, Sallis J,Wilmore JH Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine JAMA 1995;273:402-407 23 US Department of Health and Human Services Physical Activity and health: a report of the Surgeon General Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, 1996 24 US Department of Health and Human Services Physical activity fundamental to preventing disease 2002 http://aspehhsgov/health/reports/physicalactivity 25 Centers for Disease Control and PreventionTake Charge of Your Diabetes 3rd edition Atlanta: US Department of Health and Human Services, 2002 26 Centers for Disease Control and Prevention Physical Activity and Good Nutrition: Essentials Elements to Prevent Chronic Diseases and Obesity At A Glance 2002; 1-7 27 Center for Disease Control and Prevention 5-A-Day Fruits and Vegetables 2002 http://wwwcdcgov/nccdphp/dnpa/5aday/indexhtm 28 Hahn RA,Teutsch SM, Rothenberg RB, Marks JS Excess deaths from nine major chronic diseases in the United States, 1986 JAMA 1998;264 20: 2554-2559 29 National Research Council Diet and health: Implications for reducing chronic disease risk Washington, DC, National Press, 1989 30 National Institutes of Health Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults Bethesda, Maryland Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, 1998 31
Centers for Disease Control and Prevention Defining Overweight and Obesity September 2002 1-4 32 US Department of Health and Human Services, Healthy People 2010: Understanding and Improving Health 2nd ed Washington, DC: November 2000 33 Karter AJ, Ackerson LM, Darbinian JA, DAgostino RB Jr, Ferrara A, Liu J, Selby JV Self-monitoring of blood glucose levels and glycemic control:The Northern California Kaiser Permanente Diabetes Registry American Journal Of Medicine 2001; 111:1-9 34 National Center for Health Statistics National Health and Nutrition Examination Survey, 1999-2000 35 Meigs JB Epidemiology of the Metabolic Syndrome, 2002 American Journal of Managed Care 2002; 8 11 Suppl: S283-S292 36The Centers for Disease Control and PreventionThe prevention and treatment of complications of diabetes: A guide for primary care practitioners 2000 http://wwwcdcgov/diabetes/pubs/complications/benefithtm 37 National Center for Health Statistics News Release: Obesity Still on the Rise, New Data Show, October 2002 http://wwwcdcgov/nchsreleases/02news/obesityonrisehtm 38 Hanson L, Zanchetti A, et al Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension
Principal results of the Hypertension Optimal Treatment HOT randomized trial Lancet 1998; 3519118: 1755-1762

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39 Adler A, Stratton I, et al Association of systolic blood pressure with macrovascular and microvascular complications of Type 2 diabetes British Medical Journal 2000; 3217258: 412-419 40Third Report of the National Cholesterol Education Program Expert Panel on detection, evaluation, and treatment of high cholesterol in adults Adult Treatment Panel III 2001 41 Reusch J Current concepts in insulin resistance,Type 2 diabetes, and the Metabolic Syndrome American Journal of Cardiology 2002; 90 5 Suppl 1: 19 42 Hans TS,Williams K, et al Analysis of obesity and hyper-insulinemia in the development of Metabolic Syndrome: San Antonio Study Obesity Research 2002; 109: 923-931 43 American Diabetes Association 2002 Clinical Practice Recommendations Diabetes Care 2002, 25:S1-S2 44 Centers for Disease Control and Prevention National Center for Health Statistics Healthy People 2010: Data Summary Table http://wwwcdcgov/nchs/about/otheract/hpdata2010/FA5/FA5-Summary tableXLS 45 American Diabetes Association Position Paper Standards of medical care for patients with diabetes mellitus
Diabetes Care 2002;25:S33-S49 46 Lui S, Manson JE, et al Fruit and vegetable intake and risk for cardiovascular disease 2000;724: 922-928 47 Centers for Disease Control and Prevention Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices 2002 http://wwwcdcgov/mmwr/preview/mmwrhtml/rr5103a1htm 48 Centers for Disease Control and Prevention Diabetes: Disabling, Deadly, and on the Rise At A Glance 2002; 1-4 49 Patout, Jr, CA Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population Diabetes Care 2000; 239: 1339-1342 50 Bruckner M, Mangan M, Godin S, Pogach L Project LEAP of New Jersey: lower extremity amputation prevention in persons with Type 2 diabetes Am J Manag Care 1999;55:609-16

29

Appendix
Methods
Age-adjusted mortality rates for the US and Georgia from 1980 through 1999 were obtained via WONDER at http://wondercdcgov from the compressed mortality file compiled by the National Center for Health Statistics NCHS International Classification of Diseases 9th and 10th Revision Codes ICD-9 codes of 250 and ICD-10 code of E10E14 were used The US
2000 projected population was used as the standard population Leading causes of death for 2000 were determined using the following ICD-10 codes for the disease categories: 1 diabetes: E10-E14; 2 heart disease: I00-I09, I11, I13, I20-I51; 3 cancer C00-C97; 4 stroke: I60-I69; 5 unintentional injuries:V01-X59,Y85-86; 6 chronic lung disease J40-J47; 7 pneumonia/influenza: J10-J18; 8 suicide: X60-X84,Y870; 9 AIDS: B20-B24; 10 homicide: X85-Y09,Y871; and 11 other: all disease codes not already categorized Age-adjusted mortality rates for Georgia in 2000 were based on death certificate data provided by the Vital Statistics Branch and Office of Health Information and Policy of the Georgia Department of Human Resources, Division of Public Health Age-adjusted death rates for diabetes were calculated using the direct method with population estimates for the US Bureau of the Census release date: July 1, 2001 and the US 2000 projected population as the standard Age-adjusted death rates for the US in 2000 were obtained from the NCHS National Vital Statistics Report, volume 49, number 12 The Georgia Behavioral Risk Factor Surveillance System BRFSS data were analyzed to assess diabetes
self-management patterns among adult Georgians The BRFSS is a survey conducted throughout the year by the Georgia Department of Human Resources, Division of Public Health Each year, approximately 300 randomly selected adults 18 years of age and older in each of the 19 public health districts are interviewed by telephone using standardized methods and questionnaires The BRFSS covers a wide range of health behaviors including seat belt use, high blood pressure, physical activity, and dietary consumption, providing estimates of the prevalence of these risk factors for injury and disease BRFSS data have been collected in Georgia since 1984 When comparing people with and without diabetes, behavioral prevalence estimates were age-adjusted using the direct method using the US 2000 population as the standard County-specific estimates were obtained by including, if necessary, responses from participants in adjacent counties If a county had fewer than 200 respondents, in 2000 and

30

2001 combined, respondents in all bordering counties were included as if they were residents of the county of interest If there were still fewer than 200 respondents after adding one concentric ring of
counties, a second or third concentric ring was added Eight counties did not need a ring to reach the required sample size One hundred and two counties needed one ring, while 47 counties required two rings, and 2 counties needed three rings The county specific prevalence estimates are weighted according to state demographic information The Office of Health Information and Policy provided data on hospitalizations, compiled by the Georgia Hospital Association for non-federal acute-care hospitals Analyses were restricted to Georgia residents The ICD-9 code for diabetes, 250, was used for principal diagnosis Diabetes-related complications were determined by using the following ICD-9 codes: CVD, 390-448; lower extremity amputation, 841; end-stage renal disease, 585, 586; diabetic ketoacidosis, 2501 Age-adjusted mortality rates for counties and districts were calculated using data from death certificates provided by Vital Statistics Branch and Office of Health Information and Policy The number of diabetes-related deaths for 2000 was determined using the ICD-10 codes E10-E14 The number of deaths for 1996-1998 was determined using ICD-9 codes 250 that correspond to the new ICD-10 codes The
number of deaths for 1996-1998 was multiplied by the comparability ratio provided by NCHS National Vital Statistics Reports, volume 49, number 2 for diabetes 10082 before calculating age-adjusted mortality rates This comparability ratio compensates for the change in coding systems Age-adjusted mortality rates were calculated using county population estimates from the US Bureau of Census release date: July 1, 2001 and the 2000 US standard population The z-test was used to compare county rates to the state rate with significance at p005 The source of the formula for the z-test and the standard error for an age-adjusted rate was the National Center for Health Statistics, National Vital Statistics Report, volume 50, number 15, July 24, 2000, page 118 Georgia Medical Care Foundation provided data on Medicare beneficiaries Analyses for specific quality indicators were based on a cohort definition of diabetes as 2 outpatient visits at least 30 days apart or 1 inpatient visit with a diagnosis of diabetes during a oneyear period

31

Glossary
Age-adjusted death rate: A rate calculated in a manner that allows for the comparison of populations with different age structures A1C: A test that
sums up how much glucose has been sticking to part of the hemoglobin during the past three to four months Hemoglobin is a substance in the red blood cell that supplies oxygen to cells of the body Blood glucose: The main energy source that the body makes from the foods we eat, glucose is carried through the blood stream to provide energy to all of the bodys living cells A cell cannot use glucose without the help of insulin BMI: Body mass index weight in kilograms/height in meters2 Cholesterol: A fatty substance in blood that is made in the body or ingested in foods and gets deposited in blood vessel walls causing artherosclerosis when blood levels are high Contributing cause of death: Conditions that contribute to death but are not the primary, or underlying, cause of death Diabetes: A chronic disorder of metabolism affecting the way the body uses digested food for energy and growthWith type 1 diabetes, the body produces little or no insulinWith type 2 diabetes, the body does not utilize insulin effectively Flu: An infection caused by influenza flu virus The flu is a contagious viral illness that strikes quickly and severely Symptoms include high fever, chills, body aches, runny
nose, sore throat, and headache HDL high-density lipoprotein: A combined protein and fat-like substance low in cholesterol which carries cholesterol away from other parts of the body back to the liver for removal from the body HDL passes freely through the arteries; sometimes referred to good cholesterol High blood pressure: Defined as ever having been told by a doctor or nurse that your blood pressure was high; blood pressure 140/90

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High cholesterol: Defined as ever been told by a doctor or nurse that your blood cholesterol level was high; a total cholesterol level over 200 mg/dl Hospital charges: Charges are based upon the hospitals fully established rates The amount a hospital is reimbursed may be less than what is charged LDL low-density lipoprotein: A combined protein and fat-like substance which contains most of the cholesterol in the blood and carries it to tissues and organs via arteries It is the main source of damaging buildup and blockage in the arteries; sometimes referred to as bad cholesterol Overweight: Having a body mass index from 25 to 29 kilograms per meters squared BMI equals weight in kilograms divided by height in meters squared Using weight in pounds
and height in inches, BMI equals 705 times weight divided by height squared Overweight in children is defined having a BMI-for-age above the 95th percentile Obese: Defined as a body mass index BMI over 30 kilograms per meter squared Prevalence: The percentage of a population that has a disease or risk factor at a given time Regular physical activity: Defined as at least 30 minutes of moderate activity such as walking five or more days per week or at least 20 minutes of vigorous activity such as aerobics three or more days per week Retinopathy: A general term for all disorders of the retina caused by diabetes Risk factor: A habit, characteristic, or finding on clinical examination that is associated with an increased probability of a disease

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Abbreviations:
A1C Hemoglobin A1C AIDS Acquired immunodeficiency syndrome BMI Body mass index BRFSS Behavioral Risk Factor Surveillance System CDC Centers for Disease Control and Prevention CVD Cardiovascular disease DKA Diabetic Ketoacidosis DPP Diabetes Prevention Program ESRD End-Stage Renal Disease HDL High density lipoprotein LDL Low density lipoprotein LEA Lower extremity amputation NIDDM Noninsulin-dependent diabetes
mellitus

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Take care of your diabetes
Guidelines for People with Diabetes
Reference: American Diabetes Association

When you take care of your diabetes, you may lower your risk for the long-term problems that sometimes come with diabetes Take charge and take care of yourself Just follow these simple tips If you need help, talk with your health care provider about your choices Take care of your eyes TIPS: 1 See your eye doctor right away if you have any changes in your eyesight 2 Get a dilated eye exam every year Take care of your heart TIPS: 1 Find out your blood pressure and LDL cholesterol numbers and keep a record of them 2 Keep a record of your blood sugar and A1C checks The A1C check will tell you your overall blood sugar for the past two or three months 3 Ask to get your blood pressure checked every time you visit the doctor 4 Keep a record of your blood pressure readings 5Take blood pressure medication as prescribed Do not skip your pills 6 Get your cholesterol checked at least once a year 7 Follow a low-fat and low-cholesterol diet Take care of your feet TIPS: 1 Check your feet every day for cuts, blisters, redness, and swelling 2 Have an annual foot exam to check for
loss of feeling, blood flow, and changes in the shape of your feet Check your glucose level at least daily TIPS: 1 Purchase a glucose meter for home use 2 Gain the skills needed to calibrate and use your glucose meter 3 Check your blood sugar at least once daily Know your number It helps everyone to provide better medical care for you

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Stay active TIPS: 1 Find an activity you like and engage in it daily 2 Park cars as far away as possible and walk to malls, shopping centers, etc 3 Make physical activity a way of life Dont smoke cigarettes TIPS: 1 If you smoke, stop 2 Use a nicotine patch to reduce dependency 3 Chew sugar-free gum as needed Eat less fat and more fruits and vegetables TIPS: 1 Keep your total fat intake less than 25 to 30 of calories 2 Read the nutritional information on labels and limit foods which are high in saturated fat 3 Reduce your intake of fats, oils, spreads, margarines, etc 4 Eat at least five servings of fruits and vegetables each day Have at least one serving of fruit or vegetables with each meal

Know Your Target Range
Check Your A1C Blood Pressure Cholesterol Total HDL LDL Triglycerides Blood Sugar Upon awakening and before meals Bedtime Target
Below 7 Below 130/80 Below 200 Men: Above 40 Below 100 Below 150 90 to 130 mg/dl 140 mg/dl

Women: Above 50

Take Care of Yourself

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Diabetes is controllable
Diabetes is not the end of the world Eating healthy foods, being physically active, monitoring blood glucose regularly, taking medications as prescribed, seeing your health care team, stopping smoking, and losing weight all help to control diabetes

What resources are available?
People with diabetes should look for diabetes education classes and information, health services and screenings, transportation assistance, nutrition education, and physical activity classes in their geographic area For more information, contact the American Diabetes Association at 1-888-DIABETES 1-888-342-2383

Source:walgreens.com