November 2003 volume 19 number 11 Division of Public Health http://health.state.ga.us Kathleen E. Toomey, M.D., M.P.H. Director State Health Officer Epidemiology Branch http://health.state.ga.us/epi Paul A. Blake, M.D., M.P.H. Director State Epidemiologist Mel Ralston Public Health Advisor Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer Georgia Department of Human Resources Division of Public Health Epidemiology Branch Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Please send comments to: Gaepinfo@dhr.state.ga.us The Georgia Epidemiology Report is a publication of the Epidemiology Branch, Division of Public Health, Georgia Department of Human Resources Diabetes in Georgia: Defining the Problem and Identifying Areas for Improvement Introduction Diabetes is one of the most common, serious, and costly chronic diseases in Georgia and the United States. Type 2 diabetes now affects more than 7% of adults in the United States,1 compared with less than 5% in 1990. 2 National data indicate that hospitalization costs for diabetes have more than doubled from 1997 ($44 billion) to 2002 ($92 billion). 3 Even after adjusting for age, sex, and race/ethnicity, persons with diabetes incur medical expenses five times that of persons without diabetes. 3 This report describes trends in diabetes, differences in prevalence and mortality rates by demographic characteristics, the burden of diabetes-related hospitalizations, self-management practices, and opportunities for improvement in clinical practice in Georgia. Methods Data from the Georgia Behavioral Risk Factor Surveillance System (BRFSS) in 2000 and 2001 were aggregated and analyzed to assess diabetes self-management patterns and risk behaviors among adult Georgians. The BRFSS is a survey conducted throughout the year by the Division of Public Health, Georgia Department of Human Resources. Each year, over 4,000 randomly selected adults 18 years of age and older are interviewed by telephone. To compare people with and without diabetes, behavioral prevalence estimates were age-adjusted using the US standard population (year 2000 projected population). We analyzed data from death certificates filed on residents of Georgia with an underlying cause of death coded as diabetes (ICD-10 codes E10-E14) in 2000. To calculate mortality rates, we used the 2000 United States Bureau of Census population for Georgia as the denominator; we used the direct method of calculating age-adjusted rates based on the US standard population. Using the hospital discharge database compiled by the Georgia Hospital Association for nonfederal acute-care hospitals in Georgia, we selected hospitalization records with principal discharge diagnosis of diabetes (ICD-9 code 250) in year 2000. Diabetes-related complications were determined by using the following ICD-9 codes: CVD, 390-448; lower extremity amputation, 84.1 (procedure code); end-stage renal disease, 585, 586, V56, V42.0, V45.1; diabetic ketoacidosis, 250.1. The Georgia Medical Care Foundation provided data on Medicare beneficiaries. Analyses for specific quality indicators were based on a definition of diabetes as two outpatient visits at least 30 days apart or one inpatient visit with a diagnosis of diabetes during a one-year period. Results Trends in Diabetes Prevalence Among adults 18 years and older in Georgia, 6.8% (approximately 411,000 adults) know that they have diabetes. Because the early symptoms of diabetes may be mild, the actual prevalence of the disease is estimated to be 50% higher than the prevalence of those with diagnosed diabetes. 4 Therefore, the total number of adults with diabetes, including an estimated 205,000 individuals who are unaware they have diabetes, is about 616,000, or 10.5% of the adult population in Georgia. The percentage of adults who know they have diabetes is higher in the southern half and northwestern corner of Georgia. The prevalence of diabetes has increased substantially over the last decade. In Georgia from 1994 through 2001, the prevalence of diabetes has increased at an average annual rate of 8% per year (Figure 1). The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file starting in 2004. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. Diabetes is more common among older people. Approximately 1% of Georgians from 18 through 29 years of age have the disease, but more than 16% of those greater than 60 years of age are affected (Figure 2). The prevalence of diabetes is higher in women (7.4%) than men (6.2%), and higher among blacks (9.4%) than whites (6.0%). The prevalence of diabetes among black women is almost twice as high as in any other race-sex group (Figure 3). Hospitalizations from 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, totaling an estimated 68,000 hospital days. In Georgia in 2000, hospital charges for persons hospitalized with a primary discharge diagnosis of diabetes or diabetic ketoacidosis were approximately $138 million. Diabetes was also a contributing factor to thousands of other hospitalizations. In 2000, 29.5% of Georgia residents hospitalized with CVD, 27.4% of those hospitalized with end-stage renal disease, and 49.5% of those with a lower extremity amputation had diabetes. Diabetes Mortality Diabetes is the 6th most common cause of death in Georgia. In 2000, there were almost 1,500 people for whom diabetes was the primary cause of death. Diabetes, however, contributes to many more deaths. For every death for which diabetes is the primary cause, approximately two other people die with diabetes as a contributing cause. In Georgia and in the rest of the United States, death rates from diabetes have been increasing (Figure 4). From 1980 to 2000, the age-adjusted death rate from diabetes in Georgia increased from 18.5 to 22.6 per 100,000, an average annual increase of 1% per year. The increase cannot be attributed to an aging population, because the age-adjusted rate takes into account the changes in the age distribution of the population. Death rates for diabetes as the primary cause of death increase dramatically with age among all race and ethnic groups. In Georgia the death rate in 2000 was 1.7 per 100,000 adults aged 25 to 34 years and 284.6 per 100,000 adults aged 85 years and older. Death rates 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. Risk Behaviors for Diabetes Research indicates that approximately 14% or more deaths in the United States were attributed to activity patterns and diet.5 The Diabetes Prevention Program Study found a reduction in the incidence of onset of diabetes by 58% in the test group that made lifestyle modifications. 6 Lifestyle intervention showed positive effects in individuals regardless of age, sex, race, or ethnicity.6 -2 - In Georgia, people with diabetes are more likely than people without diabetes to be overweight or obese, to have been told they have high blood pressure, or to have been told they have high blood cholesterol (Table 1). A high percentage (81%) of adults with diabetes eat less than the recommended five fruit and vegetable servings per day, 32% get no leisure time physical activity, and 28% smoke cigarettes (Table 1). Data from Medicare confirm that many elderly patients with diabetes are not receiving recommended preventive care. Approximately 25% of Medicare enrollees with diabetes in Georgia do not receive annual A1C testing. The percentage of Medicare enrollees receiving dilated eye exams (46%) falls well below the Healthy People 2010 objective (Table 2). Only 13% of persons with diabetes aged 65 and over receive annual microalbuminuria tests, despite the high risk for developing kidney disease (Table 2). Conclusions Recent information about diabetes in Georgia indicates that 1) the prevalence of diabetes is increasing rapidly in Georgia, 2) older people and blacks are more likely to have diabetes, and 3) the death rate from diabetes has been rising in Georgia for nearly two decades. Although the reasons for the increasing prevalence and death rate are not precisely known, the increased percentage of Georgians who are overweight or physically inactive -- two of the primary risk factors for diabetes -- are likely involved. Clinical Practice Recommendations The Clinical Practice Recommendations developed by the American Diabetes Association set standards of medical care for persons with diabetes. 7 Surveys of patients with diabetes in Georgia indicate that substantial numbers of patients are receiving less than the recommended minimal level of care. The percentage of adults with diabetes in Georgia receiving the recommended level of care ranges from 89% visiting a health professional during the past year to 43% receiving aspirin therapy (Table 2). For services for which there is a Healthy People 2010 objective, Georgia meets the national goal for only three objectives two or more A1C (glycated hemoglobin or HbA1c ) tests per year, receipt of diabetes education, and receipt of aspirin therapy. This suggests that there are many areas for improvement in provider and patient education. Table 2. Percentage of Persons with Diabetes Who Receive Recommended Routine Care Recommendation Minimal Frequency for Routine Care 7 Healthy BRFSS Medicare People 2010 Assessment* Assessment Objectives 2000-2001 2001 Visit to health professional - 89% - Self glucose monitoring daily 60% 51% - A1C test, 2 per year 50% 82% - Received diabetes education 60% 62% - Received nutrition therapy - - - Physical activity recommended* - 64% - Blood pressure measured, each visit - - - Lipid test, 1 per year - - 57% Receiving aspirin therapy* 30% 43% - Advised not to smoke - - - Foot exam, 1 per year 75% 67% - Dilated eye exam, 1 per year 75% 64% 46% CVD risk assessment, 1 per year - - - Influenza vaccine, 1 per year - 48% 42% Pneumonia vaccine, ever* - 48% - Microalbuminuria test, 1 per year - - 13% Dental exam, 1 per year 75% - - - Data not available * BRFSS data were aggregated for 2000-2001. Recommendations listed with asterisk have only one year of data available. ** Based on Medicare cohort definition of diabetes as a diagnosis of diabetes during 2 outpatient visits at least 30 days apart or 1 inpatient visit. The data in this report suggest that a high percentage of adults with diabetes do not get the recommended levels of physical activity, eat enough fruits and vegetables, or quit smoking, which may be contributing to diabetes-related morbidity and mortality. The data in this report also suggest that some Georgians who have diabetes are not receiving the routine care that they should be receiving. Routine care, such as A1C testing, lipid tests, dilated eye exams, and foot exams, can help people with diabetes keep the disease under better control by detecting and treating complications promptly. 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;286:1195-200. 2. Mokdad AH, Ford ES, Bowman BA, Nelson DE, Engelgau MM, Vinicor F, Marks JS. Diabetes trends in the U.S.: 1990-1998. Diabetes Care 2000;23:1278-83. 3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2002. Diabetes Care 2003; 26: 917-932. 4. Centers for Disease Control and Prevention, Division of Diabetes Translation. 2002 National Diabetes Fact Sheet. 5. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12. 6. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or Metformin. N Eng J Med 2002; 346: 393-403 7. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2003;26:S33-S50 Written by Nkenge Jack, M.P.H., Manxia Wu, M.D., M.P.H., Kristen Mertz, M.D., M.P.H., and Kenneth Powell, M.D., M.P.H. -3 - The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 November 2003 Volume 19 Number 11 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for August 2003 Selected Notifiable Diseases Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis Total Reported for August 2003 2003 51 1525 6 4 65 792 1 23 6 2 0 3 0 1 0 228 43 3 5 13 1 0 23 Previous 3 Months Total Ending in August 2001 2002 2003 260 215 207 8763 8723 7251 51 39 25 17 20 12 277 283 197 5113 4939 3740 14 13 9 311 104 74 107 147 45 4 3 8 1 3 0 5 6 6 1 0 0 8 10 2 0 0 0 650 711 725 98 367 259 36 32 12 94 100 66 146 179 86 197 191 71 6 3 1 118 165 89 Previous 12 Months Total Ending in August 2001 2002 2003 637 600 624 32341 33815 33834 151 144 97 32 59 28 1051 909 820 19088 18767 17242 98 100 68 811 627 462 422 479 402 13 13 30 1 4 9 51 43 36 8 3 1 25 28 23 0 0 0 1608 1848 1885 335 1398 1821 108 102 93 300 301 356 580 716 655 836 787 641 22 19 6 583 619 464 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Latest 12 Months: 10/02-09/03 Five Years Ago: 10/98-09/99 Cumulative: 07/81-09/03 Total Cases Reported* <13yrs >=13yrs Total 0 1,624 1,624 16 1,675 1,691 211 26,934 27,145 Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 24.9 34.3 7.5 1.5 11.3 1.8 43.5 25.0 36.0 15.7 3.8 20.1 1.6 22.8 18.1 47.1 16.9 5.3 13.8 1.9 15.0 Race Distribution (%) White Black Other 21.6 73.9 4.5 19.8 77.8 2.4 33.3 64.1 2.6 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4 -