Co-Lead Agencies:		Centers for Disease Control and Prevention National Institutes of Health

[Note: The Healthy People 2010 Information Access Project provides dynamic, pre-formulated PubMed searches for selected objectives in this focus area so that current information and evidence-based strategies related to these objectives are easier to find. The National Library of Medicine has also provided PubMed links to available references that appear at the end of this focus area document.]

Contents

GoalPage 5-3

Overview. Page 5-3

Issues. Page 5-3

Trends. Page 5-4

Disparities. Page 5-8

Opportunities. Page 5-9

Interim Progress Toward Year 2000 Objectives. Page 5-9

Healthy People 2010—Summary of Objectives. Page 5-11

Healthy People 2010 Objectives. Page 5-12

Related Objectives From Other Focus Areas. Page 5-32

Terminology. Page 5-33

References. Page 5-34

Goal

Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes.

Overview

Diabetes poses a significant public health challenge for the United States. Some 800,000 new cases are diagnosed each year, or 2,200 per day.[1], [2] The changing demographic patterns in the United States are expected to increase the number of people who are at risk for diabetes and who eventually develop the disease. Diabetes is a chronic disease that usually manifests itself as one of two major types: type 1, mainly occurring in children and adolescents 18 years and younger, in which the body does not produce insulin and thus insulin administration is required to sustain life; or type 2, occurring usually in adults over 30 years of age, in which the body’s tissues become unable to use its own limited amount of insulin effectively. While all persons with diabetes require self-management training, treatment for type 2 diabetes usually consists of a combination of physical activity, proper nutrition, oral tablets, and insulin. Previously, type 1 diabetes has been referred to as juvenile or insulin-dependent diabetes and type 2 diabetes as adult-onset or noninsulin dependent diabetes.

Issues

The occurrence of diabetes, especially type 2 diabetes, as well as associated diabetes complications, is increasing in the United States. 1, 2 , [3] The number of persons with diabetes has increased steadily over the past decade; presently, 10.5 million persons have been diagnosed with diabetes, while 5.5 million persons are estimated to have the disease but are undiagnosed. This increase in the number of cases of diabetes has occurred particularly within certain racial and ethnic groups.[4] Over the past decade, diabetes has remained the seventh leading cause of death in the United States, primarily from diabetes-associated cardiovascular disease. While premenopausal nondiabetic women usually are at less risk of cardiovascular disease than men, the presence of diabetes in women is associated with a three- to four-fold increase in coronary heart disease compared to nondiabetic females.[5] In the United States, diabetes is the leading cause of nontraumatic amputations (approximately 57,000 per year or 150 per day); blindness among working-aged adults (approximately 20,000 per year or 60 per day); and end-stage renal disease (ESRD) (approximately 28,000 per year or 70 per day).[6] (See Focus Area 4. Chronic Kidney Disease and Focus Area 28. Vision and Hearing.)

These and other health problems associated with diabetes contribute to an impaired quality of life and substantial disability among people with diabetes.[7] Diabetes is a costly disease; estimates of the total attributable costs of diabetes are around $100 billion ($43 billion direct; $45 billion indirect).[8], [9] Hospitalizations for diabetes-associated cardiovascular disease account for the largest component of the direct costs. However, diabetes management is occurring increasingly in the outpatient setting, and more people with diabetes are using nursing home facilities. 8, 9

Diabetes is a major clinical and public health challenge within certain racial and ethnic groups where both new cases of diabetes and the risk of associated complications are great.4, [10]

These realities are especially disturbing given the validated efficacy and economic benefits of secondary prevention (controlling glucose, lipid, and blood pressure levels) and tertiary prevention (screening for early diabetes complications [eye, foot, and kidney abnormalities], followed by appropriate treatment and prevention strategies).[11], [12], [13], [14], [15], [16], [17] For many reasons, however, these scientifically and economically justified prevention programs are not used routinely in daily clinical management of persons with diabetes.[18], [19], [20] Diabetes is thus a “wasteful” disease. Strategies that would lessen the burden of this disease are not used regularly, resulting in unnecessary illness, disability, death, and expense.

Trends

The toll of diabetes on the health status of people in the United States is expected to worsen before it improves, especially in vulnerable, high-risk populations—African Americans, Hispanics, American Indians or Alaska Natives, Asians or other Pacific Islanders, elderly persons, and economically disadvantaged persons. Several factors account for this chronic disease epidemic, including behavioral elements (improper nutrition, for example, increased fat consumption; decreased physical activity; obesity); demographic changes (aging, increased growth of at-risk populations); improved ascertainment and surveillance systems that more completely capture the actual burden of diabetes; and the relative weakness of interventions to change individual, community, or organizational behaviors.1, 3, 7, [21] Several other interrelated factors influence the present and future burden of diabetes, including genetics, cultural and community traditions, and socioeconomic status (SES). In addition, unanticipated scientific breakthroughs, the characteristics of the health care system, and the level of patient knowledge and empowerment all have a great impact on the disease burden associated with diabetes.

Personal behaviors. “Westernization,” which includes a diet high in fat and processed foods as well as total calories, has been associated with a greater number of overweight persons in the United States when compared to a decade ago, especially within certain racial and ethnic groups, for example, African American females.[22], [23] Obesity, improper nutrition (including increased ingestion of fats and processed foods), and lack of physical activity are occurring in persons under age 15 years. These behaviors and conditions may explain the increasing diagnosis of type 2 diabetes in teenagers.[24], [25] Increased television watching associated with diminished physical activity also may contribute to the emergence of type 2 diabetes in youth.24, 25, [26], [27]

Demographics. Diabetes is most common in persons over age 60 years.[28] Increased insulin resistance and gradual deterioration in the function of insulin-producing cells may account for this phenomenon. As the population in the United States ages, especially as the number of persons aged 60 years and older grows, an increase in the number of people with diabetes is expected. While studies indicate that aging itself may not be a major factor in the substantial increase in the number of persons with diabetes,21 present and future prevention strategies for diabetes will be associated with a greater lifespan for persons with diabetes.[29]

Other changes in the U.S. population can be expected to affect the number of persons with diabetes. By 2050, almost half of the population will be other than white (53 percent white, 24 percent Hispanic, 14 percent African American, and 8 percent Asian).[30] Because these racial and ethnic groups are at greater risk for diabetes and associated complications, and because of rising levels of obesity and physical inactivity in the general population, the number of persons with diabetes is expected to continue to increase into the first few decades of the 21st century.[31]

Ascertainment. Known as the “hidden” disease, diabetes is undiagnosed in an estimated 5 million persons.[32], [33] In addition, complications and health services associated with diabetes frequently are not recorded on death certificates,[34], [35] hospital discharge forms,[36] emergency department paperwork, and other documents. Much of this “missing” burden of diabetes now is being captured due to improved surveillance and data systems,[37] including boxes on data forms to indicate the presence of diabetes and screening programs for undiagnosed diabetes in high-risk persons.32 Thus, the real—but previously undocumented—burden of diabetes is becoming better recognized.

Limitations in programs to change behaviors. Scientific evidence indicates that secondary and tertiary prevention programs are effective in reducing the burden of diabetes. Yet changing the behaviors of persons with diabetes, health care providers, or other individuals or organizations involved in diabetes health care (for example, health maintenance organizations and employers) is difficult. Although many factors account for these challenges,[38] more effective interventions will need to be developed and implemented to improve the practice of diabetes care. Several other factors influence the present and future burden of diabetes, including genetics, culture, SES, scientific discoveries, and the characteristics of both chronic diseases and the health care system.

Both type 1 and type 2 diabetes have a significant genetic component.[39], [40] For type 1 diabetes, genetic markers that indicate a greater risk for this condition have been identified; they are sensitive but not specific. Type 2 diabetes, especially in vulnerable racial and ethnic groups, may be associated with a “thrifty gene.”40, [41] Family and twin studies demonstrate considerable influence of genetics for type 2 diabetes, but a specific genetic marker for the common variety of type 2 diabetes has not been identified. The degree to which such genetic indicators can be both validated and clinically available will determine the effectiveness of primary prevention trials.[42], [43]

Personal behaviors are influenced by beliefs and attitudes, and these are greatly affected by community and cultural traditions.[44], [45] In many racial and ethnic communities, fatalism, use of alternative medicine, desirability of rural living conditions, lack of economic resources, and other factors will influence significantly both availability of health care and the capabilities of persons with diabetes in handling their own care. Thirteen percent of the total U.S. population speak a language at home other than English. Cultural and linguistic factors affect interactions with health care providers and the system. The degree to which diabetes prevention strategies recognize and incorporate these traditions will largely determine program effectiveness.[46], [47]

The public health and medical communities increasingly are recognizing the influence of SES in the occurrence of new cases and progression of chronic diseases.[48], [49], [50] Chronic diseases, such as diabetes, reflect the social fabric of our society: the degree to which employment, financial security, feelings of safety, education, and the availability of health care are addressed and improved within the United States will influence the likelihood of developing type 2 diabetes as well as effectively managing both types of diabetes.[51] For example, unemployment without access to health insurance will substantially limit attention to and expenditures for preventive health practices.

Because acute infectious diseases were the dominant health threats during the first half of the 20th century, a dichotomous view of health developed: for example, people were either alive or dead, vaccinated or not vaccinated. Death and length of life were the most important markers of disease burden and program effectiveness during those years. Chronic diseases, such as diabetes, pose different challenges because qualitative terms such as “doing better” are valid indicators of health improvement, as are measures of quality of life and disability. Further, a variety of nonphysician health professionals (for example, nurses or pharmacists) and nonhealth care professionals (for example, faith or community leaders, employers) can be involved in critical decisions affecting chronic diseases. Diabetes, like other chronic conditions, is long term and is affected by the environment where people live, work, and play. For diseases like diabetes, the accurate measurement of quality of life as an indicator of program effectiveness and the incorporation of nonhealth professionals at work or worship on the health team will influence the successes of preventive treatment programs. 37, 45, 46

The rapidity and utility of scientific discoveries also will influence the control of the diabetes burden. In all aspects of scientific investigation, important observations about diabetes will continue to occur. These scientific results will greatly influence diabetes prevention and management,[52], [53], [54] but any scientific study that is not translated and used in daily practice ultimately is “wasted.”10, [55]

The availability of a responsive and effective health care system will determine access to quality care, especially in secondary and tertiary prevention.[56], [57] With the emergence of managed care, a person with diabetes theoretically could receive effective, economical, and planned preventive care that would minimize the diabetes burden.[58] Several additional changes need to occur within the managed care setting, however, to maximize fully this theoretical opportunity for persons with diabetes, including managed care (1) not denying access to potentially expensive patients, (2) allowing adequate time for health professionals to interact with patients, and (3) ensuring patient protection rights.

In addition, the apparent movement toward primary care will affect diabetes management and outcomes. At present, about 90 percent of all persons with diabetes receive continuous care from the primary care community. This is highly unlikely to change. Thus, the degree that improved relationships can be established be-tween diabetes specialists and primary care health providers will determine the quality of diabetes care.[59]

People with diabetes spend a small percentage of their time in contact with health professionals. In addition to family, friends, and work colleagues, individual patient knowledge, beliefs, and attitudes affect diabetes management and outcomes. The ability to understand and influence individual, community, and organizational behaviors will influence significantly the success of preventive programs in diabetes.[60], [61], [62]

Disparities

Gaps exist among racial and ethnic groups in the rate of diabetes and its associated complications in the United States. Certain racial and ethnic communities, including African Americans, Hispanics, American Indians, and certain Pacific Islander and Asian American populations as well as economically disadvantaged or older people, suffer disproportionately compared to white populations. For example, the relative number of persons with diabetes in African American, Hispanic, and American Indian communities is one to five times greater than in white communities.4 Deaths from diabetes are 2 times higher in the African American population than they are in the white population, and diabetes-associated renal failure is 2.5 times higher in the African American population than it is in the Hispanic population.1, 6, 7

Particularly within certain racial and ethnic groups, there are four potential individual reasons for the greater burden of diabetes:

Greater number of cases of diabetes. If diabetes is more common, then more amputations, death, and other complications from diabetes would be expected.

Greater seriousness of diabetes. If hyperglycemia or other serious comorbid conditions, such as high blood pressure or elevated blood lipids, are present in certain racial and ethnic groups, a greater diabetes-related disease burden will occur. Many other factors could be involved, including genetics and excess weight. Greater seriousness of diabetes can be determined by comparing, for example, death or amputation rates for specific racial and ethnic diabetic groups with those rates in the general diabetic population.

Inadequate access to proper diabetes prevention and control programs. If proven diabetes services, such as self-management training programs or eye-retina examinations, are not a part of routine diabetes care, then effective programs to reduce the burden of diabetes will not be accessed and used. These essential diabetes services often are provided by specialists. Unfortunately, many diabetes at-risk groups reside in medically underserved areas or are without adequate insurance and thus do not receive these types of preventive services.

Improper quality of care. If diabetes management services are available, but the quality of that service is inadequate, prevention programs would not be effective in reducing the burden of diabetes.

Identifying the reasons for disparities in diabetes health outcomes is important in tailoring programs to those specific areas where deficiencies exist. Collection of racial and ethnic health services data for all health activities is critical to designate the reason for the greater disease burden.

Opportunities

Opportunities to meet the challenges of diabetes lie in four transition points in the natural history of this disease and the preventive interventions that target them: primary prevention, screening and early diagnosis, access, and quality of care (secondary and tertiary prevention).[63]

The transition points and associated public health interventions are as follows:

n	Transition Point 1: From No Diabetes to Diabetes Present (although not recognized). Intervention, Primary Prevention.

n	Transition Point 2: From Diabetes Not Recognized to Diabetes Recognized (but preventive diabetes care not provided). Intervention, Screening/Early Diagnosis.

n	Transition Point 3: From No Care to Diabetes Care Applied. Intervention, Access.

n	Transition Point 4: From Improper Care to Proper Care. Intervention, Quality of Care. (Secondary and Tertiary Prevention—for example, glucose control and decreasing diabetes complications.)

Each transition point represents a diabetes prevention and control opportunity that is contained in the diabetes objectives of Healthy People 2010. Objectives are categorized as: (1) diabetes education, (2) burden of disease (new cases, existing cases, undiagnosed diabetes, death, pregnancy complications), (3) macrovascular, microvascular, and metabolic complications, (4) laboratory services (lipids, glycosylated hemoglobin, microalbumin measurements), (5) health provider services (eye, foot, and dental examinations), and (6) patient protection behaviors (aspirin, self-blood-glucose-monitoring). These objectives measure both the processes and outcomes of preventive diabetes programs.

To improve the quality of diabetes care, the Diabetes Quality Improvement Project (DQIP)—a joint public/private effort—has identified a set of measures to track critical performance measures of diabetes management. Through the Quality Interagency Coordination (QuIC) task force, Federal agencies with health care responsibilities are collaborating to use DQIP to better focus efforts to improve diabetes care.

Interim Progress Toward Year 2000 Objectives

In Healthy People 2000, five diabetes-related objectives were included in a group of objectives addressing chronic conditions linked by their potential impact on quality of life and disability. Of these five objectives, eye examinations is moving toward the 2000 target. Death from diabetes, nonretinal diabetes complications, new cases of diabetes, and the number of existing cases all are moving away from the 2000 targets. Diabetes education is increasing in frequency among persons with diabetes.

These changes in direction need to be considered carefully with regard to significance, causes, and implications. The greater number of new cases of ESRD among persons with diabetes may in part be due to “ascertainment”; that is, persons with diabetes were not in the past but now are allowed access to ESRD treatment programs. Similarly, while new cases of type 2 diabetes truly may be increasing in association with obesity and inactivity, a higher number of cases of diabetes also may reflect increased efforts to screen for previously undiagnosed diabetes as well as decreased deaths from such conditions as diabetic acidosis or amputations. Thus, an increased number of existing cases of type 2 diabetes may in part reflect successes in other types of diabetes prevention programs.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

 

Healthy People 2010—Summary of Objectives

Diabetes

Goal: Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes.

Number	Objective Short Title
5-1	Diabetes education
5-2	New cases of diabetes
5-3	Overall cases of diagnosed diabetes
5-4	Diagnosis of diabetes
5-5	Diabetes deaths
5-6	Diabetes-related deaths
5-7	Cardiovascular disease deaths in persons with diabetes
5-8	Gestational diabetes
5-9	Foot ulcers
5-10	Lower extremity amputations
5-11	Annual urinary microalbumin measurement
5-12	Annual glycosylated hemoglobin measurement
5-13	Annual dilated eye examinations
5-14	Annual foot examinations
5-15	Annual dental examinations
5-16	Aspirin therapy
5-17	Self-blood-glucose-monitoring

 

Healthy People 2010 Objectives

5-1.		Increase the proportion of persons with diabetes who receive formal diabetes education.

Target: 60 percent.

Baseline: 45 percent of persons with diabetes received formal diabetes education in 1998 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Diabetes patient education is viewed uniformly as effective and economical in the ultimate prevention of long-term complications from diabetes. An individual with diabetes spends less than 1 percent of his or her time in contact with the health care system and on a daily basis must make a variety of critical decisions about diabetes. An informed and motivated patient is essential in managing the disease and reducing the risk of complications (for example, foot ulcers, hypoglycemia, and hypertension).[64], [65]

5-2.		Prevent diabetes.

Target: 2.5 new cases per 1,000 population per year.

Baseline: 3.5 new cases of diabetes per 1,000 population (3-year average) occurred in 1994–96 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best (retain year 2000 target).

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

5-3.		Reduce the overall rate of diabetes that is clinically diagnosed.

Target: 25 overall cases per 1,000 population.

Baseline: 40 overall cases (including new and existing cases) of diabetes per 1,000 population occurred in 1997 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best (retain year 2000 target).

Data source: National Health Interview Survey (NHIS), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

5-4.		Increase the proportion of adults with diabetes whose condition has been diagnosed.

Target: 80 percent.

Baseline: 68 percent of adults aged 20 years and older with diabetes had been diagnosed in 1988–94 (age adjusted to the year 2000 standard population).

Target setting method: Better than the best.

Data source: National Health and Nutrition Examination Survey (NHANES), CDC, NCHS.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Diabetes is increasingly common in the United States and the world. Many factors could be contributing to this “chronic disease epidemic,” including an increase in new cases, a decrease in deaths, and improvements in detection.1, 2, 3, 21, 63 Given the seriousness and costs associated with diabetes and the complexities of the disease, factors that account for the increasing frequency of diabetes should be identified. [66], [67], [68], [69]