DIABETES IN GEORGIA 2009 PREVALENCE RISK FACTORS PREVENTIONS 1 Reducing the Burden of Diabetes in Georgia | Progress toward a Healthier Community Division of Public Health | Georgia Department of Community Health Acknowledgements Georgia Department of Community Health Clyde L. Reese, III, Esq, Commissioner Division of Public Health M. Rony Francois, MD, MSPH, PhD, Director Epidemiology Branch Anilkumar Mangla, MS, MPH, PhD, Acting Director Chronic Disease, Healthy Behaviors and Injury Epidemiology Section Rana Bayakly, MPH, Acting Director Health Promotion and Disease Prevention Programs Kimberly C. Redding, MD, MPH, Director Office of Chronic Disease Prevention and Wellness Shonta Chambers, MSW, Director Diabetes Program Manager Clem Jeffers, MBA, MPA Graphic Design: Jimmy Clanton, Jr. This publication is supported by Cooperative Agreement Number 4274928421 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the author and do not necessarily represent the official views of the CDC. Suggested citation: Cho, P; Mdodo, R; Cheng, V; Pragle, A; Wu, M; Horan, J. Diabetes in Georgia 2009. Georgia Department of Community Health, Division of Public Health, April 2010. For further information about this report, please contact: Rennatus Mdodo, DrPH, MS Georgia Department of Community Health Division of Public Health Epidemiology Branch Chronic Disease Epidemiology Team 2 Peachtree Street, NW, 14th Floor Atlanta, GA 30303-3142 404-463-4630 2 Diabetes is a common, costly and serious chronic disease in Georgia. Diabetes is Common. Prevalence estimates (2008) Diagnosed cases of adult diabetes (9.9% of adult Georgian population) Estimated number of undiagnosed cases 707,000 (for every two diagnosed cases there is one undiagnosed case)4 +354,000 Total estimated number of adult Georgians living with diabetes (equivalent to one in seven Georgians) 1,061,000 Incidence estimates (2006-2008) Newly diagnosed cases of adult diabetes (9.6 per 1,000 adult Georgians, a 118% increase from 4.4 per 1,000 adults in 1999) 51,450 per year Diabetes is Costly. Health care utilization and associated costs (2006) Hospital charges = More than $288 million Urgent care costs (emergency room visits) = More than 3.2 million Average hospital charges per patient = $18,470 Average length of hospital stay per patient = 5 days Estimated total economic cost = More than $5.1 billion1 Diabetes is Serious. Mortality and morbidity profiles (2006) Seventh leading cause of death, responsible for 1,626 deaths or about 31 deaths each week Contributed to 15,593 hospitalizations and 19,459 emergency room visits For every hospital admission with a primary diagnosis of diabetes, there were about 10 other cases where diabetes was listed as an associated illness 3 Table of Contents Page 1. Introduction..................................................................................................................................... 5 2. Overview......................................................................................................................................... 6 3. Morbidity......................................................................................................................................... 7 Incidence Prevalence Hospitalizations Diabetes-related Complications 4. Mortality.......................................................................................................................................... 12 5. Risk Factors..................................................................................................................................... 14 6. Status of Recommended Routine Care for People with Diabetes................................................... 15 7. Diabetes Management by Medications........................................................................................... 16 8. Program Activities........................................................................................................................... 17 9. Selective Services............................................................................................................................ 17 10. References....................................................................................................................................... 18 11. Appendices...................................................................................................................................... 19 Glossary Abbreviations 4 Introduction Diabetes mellitus, or simply diabetes, is the medical term for the presence of high blood glucose levels in the body. Diabetes is one of the most common chronic diseases in Georgia as well as in the United States. It is a slowly progressive, lifelong, systemic disease and can damage many parts of the body over time. However, people with diabetes usually have few or no obvious symptoms, especially in the early stage. Thus, diabetes can go undiagnosed for many years. Once it is diagnosed, serious complications may have already developed inside the body, and vital organs of the body such as the heart, the brain, the kidneys, and the eyes may have been damaged. Diabetes is always a serious disease, and in fact, it is a notorious silent killer. It is also a costly chronic disease. Its economic impact on the nation's health care system as well as on its productivity is enormous. Yet, diabetes is controllable. People with diabetes can take charge of their disease and lead a happy, active and productive life by adopting healthy lifestyles, avoiding risky behaviors, reducing risk factors and managing the disease properly. 5 Overview Diabetes is a group of diseases marked by high blood glucose levels due to defects in insulin production, insulin action, or both. Diabetes is also associated with impaired glucose production in the liver.1 Diabetes can cause serious complications and even premature death, but people with diabetes can take steps to control the disease and lower the risk for developing complications.1 Diabetes is always manageable. One can take charge of the disease and control diabetes for life. Major Types of Diabetes Type 1 diabetes develops when the body's immune system destroys pancreatic beta cells the only cells in the body that make the hormone insulin. To survive, people with type 1 diabetes must have insulin delivered by injection or pump from outside the body. This form of diabetes usually strikes children and young adults, although disease onset can occur at any age. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes.1 Type 2 diabetes usually begins as insulin resistance, a disorder in which the body cells cannot use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce sufficient insulin to meet the increasing demand. Eventually, the pancreas fails and stops producing insulin. At this stage, type 2 patients, like their type 1 counterparts, need insulin from an outside source.1 women and is one of the most common medical complications of pregnancy.2 It can affect both the mother and the baby. Preeclampsia, spontaneous abortions, congenital malformations, stillbirths, and need for cesarean sections are some of the serious complications of diabetes during pregnancy. Women who have had gestational diabetes have a 35% to 60% chance of developing type 2 diabetes in the next 10 to 20 years.1, 2 Since a subsequent pregnancy can increase the risk of having recurrent episodes of high blood glucose levels, women with history of gestational diabetes should be screened and monitored carefully, starting from the preconception stage.1, 2 Pre-diabetes is a condition in which a person's blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes. It can entail impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both (Table 1). Having pre-diabetes is a serious risk factor for developing type 2 diabetes. Currently, about 57 million Americans have pre-diabetes, having IFG, IGT, or both.2 Other types of diabetes result from specific genetic conditions, surgery, drugs, malnutrition, infections, and other illnesses, accounting for 1% to 5% of all diagnosed cases.1 Type 2 diabetes is the most common form, accounting for 90% to 95% of all diagnosed cases of diabetes. It is also strongly associated with obesity and physical inactivity and is typically related to increasing age. Thus, type 2 diabetes is common among people aged 45 and older, with the highest peak among senior citizens. Today, about 24 million Americans have type 2 diabetes.1, 2 Gestational diabetes is a form of glucose intolerance that occurs or is noticed for the first time in some women during pregnancy. Gestational diabetes occurs in 4% to 7% of pregnant 6 Table 1. Diagnostic Criteria for Pre-diabetes and Diabetes Metabolic State Normal Pre-diabetes3 Measure (plasma glucose levels in mg/dl) FPG1 2hPG2 <100 <140 100-125* 140-199** Diabetes 126 200 1Fasting plasma glucose 22-hour plasma glucose after 75 grams oral glucose (Oral Glucose Tolerance Test, OGTT). 3Either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both *IFG **IGT Source: American Diabetes Association. Morbidity Diabetes is a COMMON disease in Georgia Incidence As in other parts of the nation, diabetes is a growing public health problem in Georgia, with incidence rapidly increasing in the past decade. In 2008, the overall diabetes incidence was 10.7 per 1,000 adults, a 143% increase from 4.4 per 1,000 in 1999. The incidence of diabetes in Georgia is 30% higher than the national average of 7.5 per 1,000 (Figure 1). In Georgia, the age-adjusted incidence per 1,000 population for men (10.8) was higher than that for women (10.0). In the combined years 2006-2008, the age-adjusted incidence for blacks (14.2) was significantly higher than that for whites (8.0). Black women had the highest age-adjusted incidence of 14.5 per 1,000 adults, followed by black men (13.9), white men (8.2) and white women (7.8) (Figure 2). Prevalence The prevalence of a disease depends on its incidence and the duration of illness.3 Thus, an increase in the incidence of a chronic disease like diabetes will generally lead to an increase in prevalence. The prevalence of diabetes is increasing in both Georgia and the United States at an alarming rate. In the last 15 years, the number of people in the United States with diagnosed diabetes has more than doubled, reaching 23.6 million in 2007.1, 3 A similar trend was also noted in Georgia as the proportion of adult Georgians with diagnosed diabetes went up from 4.3 % in 1994 to 9.9% in 2008. In 2008, about 707,000 Georgia adults aged 18 years and older reported that they had been diagnosed with diabetes at sometime in their lives. Since 2000, the prevalence of diabetes in Georgia has been consistently higher than in the United States (Figure 3). Of the more than 23.6 million Americans with diabetes, 5.7 million still do not know they have the disease.1, 2 Figure 1. 12 10 Incidence of Diabetes* Georgia vs. United States, 1999-2008 GA Cases per 1,000 population 8 US 6 4 2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 *Three-year moving averages. Sources: Georgia BRFSS (1999-2008) and National Health Interview Survey (1999-2005). FFiigguurree22.. AgAe-gaed-ajudsjutesdteDd iDaibaebteetsesInIncicdideenncceeRRaatteess bybRyaRceacaenadnSdeSxe,xG, Geoerogrigai,a2A0d0u6l-t2s,008 2006-2008 Male Female 20 15 13.9 14.5 New cases per 1,000 population 10 8.2 7.8 5 0 White Black Source: Georgia BRFSS FiFguigruer3e.3. PrPerveavleanlecnecoef oSfelSf-erlef-proerptoerdtDediaDbeiatebse*tes* GeGoregoiragaiandanUdnUitenditSedtaStetsa,tes, AdAudltus,lt1s9, 9149-9240-028008 Percent 10 GA 8 6 US 4 2 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 * Doctor-diagnosed diabetes Source: CDC BRFSS, 1994-2008. 7 For every two people with diabetes who have been diagnosed, another has not yet been diagnosed.4 Thus, in 2008, approximately 354,000 additional adult Georgians could have had undiagnosed diabetes, and the total number of adult Georgians living with diabetes could have been over 1,000,000. Thousands more are at increased risk of getting diabetes because of aging, obesity, unhealthy eating habits, smoking and physical inactivity. Diabetes disproportionately affect older adults, women, and certain racial and ethnic groups. One in five Unitied States adults over age 65 has diabetes. African American, Hispanic, American Indian, and Alaska Native adults are at least twice as likely as white adults to have diabetes.3 The prevalence of diabetes is highest among Georgians aged 65 years and older (Figure 4). Black males and females in Georgia are significantly more likely to suffer from diabetes than white males and females (Figure 5). Diabetes is not equally distributed in Georgia. The 2000-2008 combined BRFSS data reveal that several southern and northwestern public health districts have higher prevalences than other districts (Figure 6). FiFgiugruere4.4. PrPevraelveanlceenocfe SoeflSf-erlefp-roerpteodrtDediaDbeitaebsetes bybAygAe gGerGourpo,uGp,eoGregoiar,g2ia00A7d-2u0lt0s8 2007-2008 25 23.1 20 18.2 Percent 15 11.1 10 5.6 5 4.0 1.7 0 18-24 25-34 35-44 45-54 55-64 65+ Age group (in years) Source: Georgia BRFSS. Figure 5. Prevalence of Diabetes by Race and Figure 5. GPreeovSragelixean,ncGeAeodofurlgDtsiia,a2bA0e0dt7eus-l2tb0sy,082R0a0c7e-a2n0d08Sex Male Female 15 10 8.5 8.6 13.1 12.1 11.6 10.9 11.6 9.2 Percent 5 0 White Black Non-Hispanic Non-Hispanic Hispanic Other Race Non-Hispanic Source: Georgia BRFSS. FFiigguurree 66.. DiabDeitaebsePtersevParleevnacleenincePiunbPliucbHliecaHltheaDltihstricts GeoDrgisitar,i2c0ts0,0G-2e0o0r8gia Adults, 2000-2008 StaPtreeAvvaelernacgee (-%7.0)% 4.9 6.0 6.1 7.5 7.6 8.5 8.6 9.4 Source: Georgia BRFSS, 2000-08. State Average 7.0% 8 Hospitalizations, Healthcare and Healthcare Costs Diabetes is a COSTLY disease in Georgia. People with diabetes have poor health and if their illness is untreated or uncontrolled they are likely to need acute care and hospitalization. In 2006, diabetes was the principal diagnosis for 15,593 hospitalizations in Georgia, resulting in more than $288 million in hospital charges and approximately 78,346 days (or about 215 years) of hospital stay. Among Georgians who needed in-patient care in 2006, 31% of those hospitalized with cardiovascular disease and 30% of those admitted with end-stage renal disease had diabetes. For those in-patients who required lower limb amputation procedures, two-thirds of them had diabetes. Although the number of lower limb amputations decreased by more than 100 cases from 2000 to 2006, the proportion of cases with diabetes went up from 49% in 2000 to 66% in 2006. In 2006, nearly 6,000 people with diabetes were treated as in-patients for diabetic ketoacidosis resulting from poor blood glucose control. This was a 62% increase from 3,702 diabetic ketoacidosis cases in 2000 (Table 2). A study by the American Diabetes Association (ADA) reported that the annual cost of diabetes in Georgia due to excess medical costs and lost productivity increased from over $4 billion in 2002 to over $5 billion in 2006.5 In 2006, nearly 20,000 emergency room visits in Georgia were also attributable to diabetes. Many of these visits could have been avoided by proper blood glucose control. Unfortunately, they required urgent care resulting in more than $3.2 million in medical care charges. The health care cost for a person with diabetes is approximately $13,200 per year compared with $2,600 per year for a person of comparable age without diabetes.6 The ADA reports that one out of every five health care dollars was spent to care for someone with diabetes.7 Georgia counties in the east, southwest and south central regions tend to have higher hospital discharge rates for diabetes than the statewide average for 1999 - 2006 (Figure 7). These areas also have higher prevalence of diabetes and have heavier economic burden from diabetes as a result. Table 2. Hospitalizations with Diabetes-related Table 3. HoCspoimtalpizlaitciaontisownisth, GDieaobregteisa-rAeldatuedltsComplications Ge2o0r0gi0a,a2n00d02a0n0d62006 Primary Diagnosis or Procedure Total 2000 DDiiaabbeetteess aasssseeccoonnddaarryy ddiiagnnoosseiss Total 2006 DDiiaabbeetteess aasssseeccoonnddaarryy ddiiaagnnoosseiss Cardiovascular disease 133,075 39,242 144,902 (29%) 44,999 (31%) End-stage renal disease (ESRD) 785 215 675 203 (27%) (30%) Diabetic ketoacidosis 3,702 3,702 (100%) 5,997 5,977 (100%) Lower extremity amputation* 4,060 2,009 (49%) 3,942 2,593 (66%) * Non-traumatic amputations Source: Georgia hospital discharge data, 2000 & 2006. Figure 7. HosHpoitsapliDtailsDchisacrhgaerRgeatResatfeosrfDoriaDbieatbeestes GeoGrgeoiargCiaouCnotuienst,ie1s9,9199-9290-026006 Discharges per 100,000 population 326 464 (Very high) 251 325 (High) 176 250 (Average) 101 175 (Low) 55 100 (Very low) Source: GDPH, OASIS, 1999-2006. State Average Discharge Rate 169 discharges per 100,000 population 9 Diabetes-related Complications Diabetes is a DEBILITATING disease in Georgia. Diabetes can contribute to blindness, kidney failure, amputations, heart disease, stroke, hypertension, nerve damage, impotence, skin disorders, periodontal disease, pregnancy complications, disability, and premature death. Many complications can be prevented with early detection and comprehensive management. Major Complications Chronically elevated blood glucose levels can damage both large and small blood vessels supplying oxygen and nutrients to vital organs of the body. Damage to large vessels in organs such as the heart and the brain can cause heart attack and stroke. Insufficient blood flow to the legs can lead to ulcers, slow wound healing, gangrene, and eventually amputations. Damage to small vessels in other organs such as the eyes and the kidneys can give rise to diabetic retinopathy and diabetic nephropathy, leading to blindness and kidney failure. Cardiovascular Events People with diabetes are two to four times more likely to have a heart attack or stroke than those without the disease2, and two out of three people with diabetes die from heart attack or stroke.8 In 2008, people with diabetes in Georgia were three to four times more likely to have had either angina, heart attack, or stroke than those without the disease (Figure 8). When these events occur, healthcare for people with diabetes is more expensive than healthcare for those without diabetes. This is due to increased complexity of care and hospitalizations among people with diabetes.5 FFigiguurree88.. PrePvarleevnacleenofceCoafrCdiaorvdaisocvualasrcuElvaernEtsvents by by DDiiaabbeetteessSStatatutus,sG, GeoerogrigaiaAAdudlutsl*ts, ,2200088 Non-diabetic Diabetic 15 12.3 10.6 10 7.8 Percent 5 2.9 0 Angina * Age 18 and older. Source: Georgia BRFSS. 3.1 Heart Attack 1.9 Stroke 10 Vision Impairments Diabetic retinopathy is a common complication of diabetes, affecting about 140,000 Georgians aged FFiigguurree 99.. DiabDeitaicbReteictinRoeptianthopyaatmhyonagmGoneogrGgieaoArgdiualts* withADdiualbtes*tews*i*thbDy iSaebxeatensdbRyaScex, 2a0n0d8 Race, 2008 40 years and older in 2008. Black women had the highest prevalence of diabetic retinopathy (Figure 9). Diabetes also puts a person at increased risk for other eye diseases. In 2007, Georgians with diabetes had Percent Male Female 30 21.6 22.4 20 19.2 27.3 24.9 12.7 10 higher prevalence of cataract, glaucoma and age- related macular degeneration (AMD) than those without diabetes 0 All White Black (Figure 10). * Age 40 and older. ** Self-reported, doctor-diagnosed Kidney Failure (Diabetic Nephropathy) Source: Georgia BRFSS. Diabetes is a leading cause of kidney failure in the United States. The term "kidney disease" or "renal Figure 10. Prevalence of Major Eye Diseases disease" refers to a partial or complete loss of kidney function, which may lead to heart disease, bone disease, anemia, nerve damage, or premature death. Figure 10b. y DPiarebveatleesnScetaotfuMs, aGjoerorEgyieaDAisdeualstess*b, y2007 Diabetes Status among Georgia Adults 40 YeaNrsona-dniadbeOticlderD, 2ia0b0et7ic If detected early, the progression of kidney disease 40 34.8 and its complications can be delayed. Unfortunately, 30 Percent mild loss of kidney function has no symptoms. In contrast, severe kidney function loss can have a broad range of symptoms: weakness, shortness of breath, swelling of the hands, feet or face, difficulty in concentration, loss of appetite and nausea. 20 17.3 10 0 Cataract 9.5 2.6 Glaucoma 4.2 6.9 Macular Degeneration Certain types of kidney disease, if untreated, can cause progressive loss of kidney function and eventually kidney failure. People with kidney failure cannot survive without receiving dialysis or a transplant; this irreversible, terminal condition is called end-stage renal disease (ESRD). Diabetes and high blood pressure are the two most common causes of ESRD. Physicians in Georgia reported that there were 3,302 newly diagnosed ESRD patients in 2002. Of them, 76% had either diabetes (43%) and/or high blood pressure (33%).9 The United States Renal Data System (USRDS) report shows that the number of Georgians living with ESRD is growing (Figure 11).10 This increase coincides with increasing prevalence of chronic conditions in Georgia such as obesity, hypertension and diabetes. 8, 11, 12 * Age 40 and older. Source: Georgia BRFSS. Figurree 1111.. AgeA-agdej-uasdtjeudsPterdevParlenvcaeleanncde IanncdidIenncciedRenactees forREantdesStfaogreERnednaSltaDgiseeRaseen, al Disease, GeoGregoiar,g1i9a9, 91-929090-52005 Prevalence Incidence Cases per 100,000 population 150 125 100 75 50 25 0 1999 2000 2001 2002 2003 2004 2005 Source: The United States Renal Data System Annual Data Report, 2007. 11 Mortality Diabetes is a SERIOUS disease in Georgia. In 2006, diabetes was the seventh leading cause of death, killing 1,626 Georgians, equivalent to about 31 deaths per week (Figure 12). The overall age-adjusted diabetes death rate was 20.2 per 100,000 population. For every death for which diabetes is the primary cause, there are two more deaths for which diabetes is a contributing cause.6 Compared to the nation, Georgia has consistently had a lower age-adjusted death rate from diabetes since 1989 (Figure 13). Among different age groups, Georgians aged 85 and older had the highest death rate, 223.2 per 100,000 in 2006 (Figure 14). The age-adjusted diabetes death rate per 100,000 population was 1.3 times higher for men (23.3) than for women (17.8), and 2.3 times higher among Blacks (36.4) than Whites (16.1). Black men (42.4) and women (32.3) had higher age-adjusted diabetes death rates than their white counterparts (19.1 and 13.7, respectively) (Figure 15). In 2006, about 38% of diabetes deaths were in people under the age of 65; more than 600 people with diabetes died prematurely (Figure 16). Premature diabetes deaths (age less than 65 years) were highest among Black males (53.7%), followed by White males (41.1%), Black females (33.0%), and White females (26.6%) (Figure 17). FiFgiugruer1e31.3. AAgge-ea-dadjujsutsetdedDDiaibaebtesteDs eDaethatRhaRteastes GGeoeorgrigaiaanadndUU.Sn.,i1te9d81S-t2a0t0e6s, 1981-2006 Deaths per 100,000 population n 30 UUS.S. 25 20 GGAeorgia 15 10 5 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 Year 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 1999-2006 death records. Sources: GDPH, OASIS (1981-2006) and CDC Wonder (1981-2006). FiFguigruer1e41. 4. AAggee--ssppeecciiffiicc DDiiaabbeetteess DDeeaatthh RRaatteess GGeeoorrggiiaa,, 22000066 Deaths per 100,000 population n 300 250 223.2 200 150 128.1 100 75.7 50 0.6 2.1 36.6 4.2 12.8 0 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age group (in years) Source: GDPH, OASIS. Figure 12. Leading Causes of Death Figure 12. LeaindiGngeoCraguisae,s2o0f0D6eath in Georgia, 2006 Heart disease Cancer Stroke Unintentional injury CLRD Alzheimer's Diabetes Kidney disease Influenza/pneumonia Septicemia Hypertension Suicide 3,826 3,667 3,347 1,799 1,626 1,621 1,453 1,415 942 895 16,258 14,322 0 2,000 4,000 6,000 CLRD = Chronic lower respiratory diseases 8,000 10,000 12,000 Number of deaths 14,000 16,000 18,000 Total deaths due to all causes = 67,079 Source: GDPH, OASIS. 12 Figurree1155.. AgAeg-ea-dajdujsutsetdedDDiaiabbeetetessDDeeaatthhRRaatteess by byRRacaeceanadndSeSxe,xG, eGoerogriag,ia20, 026006 Male Female 60 Deaths per 100,000 population n 50 42.4 40 32.2 30 20 10 19.1 13.7 0 Black White Source: GDPH, OASIS. FFigiguurree1166. . DDiaiabbeteetsesDDeeaaththssbbyyAAggeeGGrroouupp,, GGeoeorgrgiaia,,22000066 Deaths 500 38% of deaths under 65 years of age 400 382 378 342 300 253 200 169 100 61 12 29 0 <24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age group (in years) Source: GDPH, OASIS. Georgia counties in the south, central and east regions tended to have the highest age-adjusted diabetes Fmoirgtaluityrraetes1fr8om. 19A99gthero-ugahd20j0u6 (sFtigeurde 18M). orta Diabetes, Georgia C Figure 18. Age-adjusted Mortality Rates for Diabetes, Georgia counties, 1999 - 2006 AAM FiFguigruer1e71. 7. PPrreemmaatuturereDDeaetahtsh(s