2003 Georgia diabetes report

The Georgia Diabetes Advisory Council (DAC) is pleased to support the 2003 Georgia Diabetes Report.The 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 state.The mission of the DAC is to reduce the prevalence of diabetes in Georgia and improve the well-being of those affected by diabetes.The 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 Georgia.Working together, we can create healthier communities.
Sincerely,
Rita Louard, M.D. Chair

Acknowledgments

Georgia Department of Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jim Martin, Commissioner Division of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kathleen E.Toomey, M.D., M.P.H., Director Office of Health Information and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Gordon R. Freymann, M.P.H., Director Chronic Disease Prevention and Health Promotion Branch . . . . . . . . . . . . . . . . . . . Carol B. Steiner, R.N., M.N., Acting Director Epidemiology Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paul Blake, M.D., M.P.H., Director Chronic Disease, Injury, and Environmental Epidemiology Section . . . . . . . . . . . . . . . . Kenneth E. Powell, M.D., M.P.H., 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, N.W. Atlanta, GA 30303-3142 404-463-2748 Internet: http://health.state.ga.us

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://www.diabetes.org

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
Diabetes Prevalence, Deaths, and Hospitalizations, Georgia (Table 1) Diabetes-Related Complications, Georgia, 2000 (Table 2)
Deaths from Diabetes in Georgia . . . . . . . . . . . . . . . . . . . . . . . . . . 11
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 don't 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 States.1 There are over 17 million people in the U.S. with diabetes and an

estimated 6 million with undiagnosed diabetes. The increasing prevalence of type 2 diabetes is presumably due, all or in large part, to the increasing prevalence of obesity. From 1991 to 2000, the prevalence of obesity in the United States increased 61%; from 1990 to 2000, the prevalence of diabetes increased 49%.1
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

COMPLICATIONS OF DIABETES
Heart disease Stroke High blood pressure Blindness (retinopathy) Kidney disease Amputations Nerve damage (neuropathy) Dental disease Impotence

Georgia (Figure 1). People with diabetes are more likely than people without diabetes to develop several other

Complications of pregnancy Susceptibility to infection

conditions, which are commonly referred to as "complica-

tions" of diabetes (See text box). Even more often, diabetes is a contributing cause to

deaths from other causes.2 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 year.3 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

4,534

13,628

Unintentional Injury

3,141

Chronic Respiratory Disease

3,043

Diabetes

1,483

Influenza/Pneumonia Alzheimers

1,426 1,280

Kidney Disease

1,279

Sepricemia

1,139

Other

14,702

18,002

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 provides information about routine healthy behaviors that prevent the onset of type 2 diabetes, as well as behaviors and medical services that prevent complications of diabetes.

Minority groups have a prevalence of diabetes that ranges from two to six times

higher than the white

About Diabetes

population.

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 body's main source of energy cannot get into the body's 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

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 diabetes.4 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 body's 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 diabetes.This 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 overweight.5 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 nationwide.6,7,8 Up to 80% of deaths in people with diabetes are due to CVD.6 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 7.1%; among people without diabetes, it is 3.6%. For coronary heart disease, the age-adjusted prevalence is 8.3% among people with diabetes versus 3.3% among people without diabetes; for stroke, 8.0% versus 1.8%. 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 population.7 Over two-thirds of all morbidity, mortality, and health care costs among people with diabetes is attributed to CVD.9
Diabetes is the leading cause of end-stage renal disease (ESRD), i.e., kidney failure requiring dialysis or transplantation.10,11,12 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 diabetes.14 Persons with diabetes are the fastestgrowing population receiving kidney dialysis or transplantation. In patients with established kidney problems (e.g. elevated microalbuminuria or nephropathy), hypertension and uncontrolled blood glucose were found to be the most important factors contributing to disease progression.10
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 diabetes.13 After undergoing limb amputation, as many as 50% of these patients will have another amputation within two to five years.15
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 U.S.15 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 retinopathy.16
Because the diagnosis of diabetes is often delayed, up to 21% of people with type 2 diabetes have retinopathy by the time of diagnosis.15,16
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 (i.e. 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 45%17 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 nigricians.18 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 diabetes.19
8

In Georgia, the current statewide prevalence of type 2 diabetes in children is unknown.The development of diabetes during childhood increases the likelihood of developing complications as a young adult, as well as the likelihood of premature mortality.
State Statistics
The Number of People in Georgia with Diabetes
Among adults (18 years and older) in Georgia, 6.8% (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 10.2% 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).
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 any other race/sex group (Figure 4).

Percentage

Percentage with Diabetes

Percentage with Diabetes

Figure 2. Prevalence of Diabetes by Year, Georgia and US, Adults (18+ years), 1994-2001

8

7

GA

6

US

5

4

3

2

1

0 1994 1995 1996 1997 1998 1999 2000 2001
Year
Source: BRFSS

Figure 3. Prevalence of Diabetes by Age Group,

20

Georgia, 2000-2001

18

17.3 16.3

16

14

12.7

12

10

8
5.9
6

4

2.6

2

1.2

0

18-29 30-39 40-49 50-59 60-69 70+

Age group in years

Source: BRFSS

Figure 4. Prevalence of Diabetes by Race and Sex,

Georgia, Adults (18+ years), 2000-2001

12

11.1

10

8

7.2

6.1 6.0
6

4

5.0 4.4

2

0 White White Black Black Other Other Males Females Males Females Males Females

Groups

Source: BRFSS

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 ($91.8 billion).3 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
410,790

Percent
6.8

Deaths* 1996-2000

Number
6,935

Rate
22.6

Hospitalizations* 2000

Number Rate

Total Charges

13,356 200.0 $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, 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 (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

Primary Diagnosis

Number of Hospitalizations

Number of Hospitalizations with Secondary Diagnosis of
Diabetes

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

133,075 765
4,060 3,702

39,242 (29.5%) 215 (27.4%)
2,009 (49.5%) 3,702 (100%)

Source: Office of Health Information and Policy 10

Age-adjusted death rate per 100,000

Deaths per 100,000

30 25 20 15 10 5 0 1980

Figure 5. Age-Adjusted Diabetes Death Rates, Georgia and US, 1980-2000
1982 1984 1986 1988 1990 1992 1994 1996 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.

US GA
1998 2000
Source:Vital Statistics

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

300

284.6

250

200
157.0
150

100

80.8

50

37.3

0.0 0.5 1.7 4.1 13.0
0 0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age Group in Years

Source:Vital Statistics

Age-Adjusted Deaths per 100,000

Figure 7. Age-Adjusted Diabetes Death Rates

45

by Race and Sex,Georgia, 2000

40

38.9

35

33.5

30

25

23.4

20

16.7

15

10

5

0

White

White

Black

Black

Males

Females

Males

Females

Groups

Source:Vital Statistics

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

18.5 to 22.6 per 100,000 per year, 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.

The death rate from diabetes for black females in 2000 was more than twice that of white females.

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 1.7 per 100,000 adults aged 25-34 to 284.6 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).

11

Number of Deaths

Figure 8. Number of Diabetes Deaths by Age Group in Georgia, 2000

500

450

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).

400

33% of Deaths < 65 Years of Age

350

317

County Statistics

300

250

251

238 Table 3 shows the estimated number (column 1) and

percentage (column 2) of adults in each county who

200

150

125

know they have diabetes. The actual number of

100

79

people who have diabetes is likely to be higher,

50

1 4 24

0

because about one-third of people with diabetes 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+

Age Group in Years

Source:Vital Statistics adults who know they have diabetes is higher in the

southern half and northwestern corner

Figure 9. Estimated Prevalence of Diabetes by County, Georgia, 2000-2001

of Georgia (Figure 9). Column 4 shows the age-adjusted death rate for diabetes from 1996 until 2000 for each county.

The 21 counties with rates in bold print

have rates that are statistically higher

Diabetes Prevalence
>11% >9-11% 7-9% <7%

than the state rate of 22.6 per 100,000 persons.
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 6.8% 12

Source: BRFSS

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

410,790

6.8

APPLING

1,140

9.0

ATKINSON

640

12.0

BACON

760

10.2

BAKER

220

7.5

BALDWIN

2,530

7.2

BANKS

820

7.7

BARROW

1,870

5.6

BARTOW

3,580

6.5

BEN-HILL

1,670

13.2

BERRIEN

1,810

15.4

BIBB

8,310

7.4

BLECKLEY

620

7.2

BRANTLEY

680

6.5

BROOKS

1,460

12.2

BRYAN

1,080

6.7

BULLOCH

3,920

9.0

BURKE

1,430

9.3

BUTTS

780

5.3

CALHOUN

480

9.7

CAMDEN

1,610

5.4

CANDLER

700

9.9

CARROLL

3,840

5.9

CATOOSA

2,980

7.5

CHARLTON

600

8.1

CHATHAM

11,310

6.5

CHATTAHOOCHEE

930

8.7

CHATTOOGA

1,770

9.0

CHEROKEE

4,910

4.8

CLARKE

5,840

7.0

CLAY

190

7.7

CLAYTON

8,920

5.4

CLINCH

580

11.7

COBB

18,230

4.1

COFFEE

3,780

14.1

COLQUITT

3,500

11.5

COLUMBIA

3,850

6.1

COOK

1,390

12.3

COWETA

3,020

4.7

CRAWFORD

700

7.7

CRISP

1,350

8.7

DADE

930

8.1

DAWSON

760

6.3

DEKALB

29,600

5.9

DECATUR

1,800

8.9

DODGE

1,400

9.8

DOOLEY

640

7.4

DOUGHERTY

6,380

9.2

DOUGLAS

3,150

4.7

EARLY

710

8.1

ECHOLS

400

14.9

EFFINGHAM

1,970

7.5

ELBERT

940

6.2

6,935

22.6

25

32.2

7

-

9

-

2

-

27

14.7

18

31.6

26

16.1

45

14.6

23

26.2

18

22.3

207

26.9

8

-

12

23.1

15

16.6

21

28.6

42

22.0

18

19.1

25

30.5

12

45.3

23

26.8

13

25.8

70

20.5

66

29.2

7

-

205

18.8

4

-

21

15.4

71

18.0

81

25.2

9

-

136

21.8

7

-

291

17.6

61

43.5

33

16.6

48

17.8

17

22.4

55

16.9

11

26.3

44

40.4

12

16.9

11

17.2

522

24.1

46

35.5

27

28.2

16

29.7

77

18.2

61

21.3

28

37.5

2

-

24

22.9

31

26.4

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

200.0 109.6 349.5 421.0
185.7 167.2 185.8 151.1 242.6 312.4 243.4 306.7 183.1 242.1 172.8 151.9 246.6 221.6 390.0 117.9 331.3 226.4 41.9 222.0 179.5
168.3 78.4 267.1
168.5 215.2 99.6 371.9 167.1 85.0 414.5 181.7 121.6 384.6 80.5 177.2 137.8 314.9 310.2 260.1 240.2 151.8 103.3
176.3 349.1

$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

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.

13

Prevalence

2000-2001

Number

Percent

Deaths*

1996-2000

Number

Rate

Hospitalizations*

2000

Number

Rate

Total Charges

EMANUEL

1,480

9.4

10

9.6

70

324.4

$517,000

EVANS

470

6.1

9

-

36

349.7

$213,000

FANNIN

1,070

6.8

39

31.0

37

155.0

$271,000

FAYETTE

3,190

4.9

51

17.9

77

97.9

$892,000

FLOYD

6,850

10.0

82

17.7

167

180.6

$1,913,000

FORSYTH

3,420

4.8

34

13.3

52

65.6

$630,000

FRANKLIN

1,170

7.6

21

18.7

84

391.2

$604,000

FULTON

25,940

4.2

733

25.2

1751

238.5

$19,737,000

GILMER

1,180

6.6

13

11.2

40

157.0

$309,000

GLASCOCK

150

7.6

13

76.5

6

-

$78,000

GLYNN

2,890

5.7

59

16.5

115

165.8

$1,275,000

GORDON

3,010

9.2

28

16.0

78

180.8

$1,116,000

GRADY

1,480

8.6

34

29.5

42

177.5

$297,000

GREENE

630

5.8

36

51.4

58

386.7

$601,000

GWINNETT

20,440

4.8

280

22.4

369

82.5

$4,445,000

HABERSHAM

2,160

7.9

30

17.0

55

151.3

$605,000

HALL

5,510

5.4

125

24.5

164

131.3

$2,835,000

HANCOCK

390

5.1

12

25.4

36

351.2

$257,000

HARALSON

1,600

8.4

34

26.7

53

198.2

$431,000

HARRIS

1,190

6.7

23

22.2

24

94.0

$158,000

HART

1,420

8.1

27

21.1

36

139.2

$298,000

HEARD

620

7.9

11

22.8

19

169.5

$252,000

HENRY

5,250

6.2

68

20.0

134

135.0

$1,524,000

HOUSTON

5,650

7.1

84

21.8

149

149.9

$1,285,000

IRWIN

1,040

14.7

19

36.4

34

320.3

$225,000

JACKSON

2,340

7.7

39

23.8

85

215.5

$936,000

JASPER

540

6.5

7

-

15

135.8

$375,000

JEFF-DAVIS

1,240

13.4

19

35.1

18

144.2

$93,000

JEFFERSON

1,030

8.3

31

34.6

48

272.6

$471,000

JENKINS

580

9.4

10

23.1

34

394.0

$195,000

JOHNSON

470

7.9

9

-

12

133.2

$153,000

JONES

1,250

7.3

24

24.9

22

94.4

$172,000

LAMAR

680

5.7

20

27.0

31

185.9

$166,000

LANIER

790

15.0

11

36.6

24

362.3

$229,000

LAURENS

2,410

7.3

26

11.8

95

209.1

$703,000

LEE

1,750

10.2

9

-

21

104.5

$140,000

LIBERTY

1,920

4.6

20

18.5

60

185.3

$599,000

LINCOLN

420

6.7

13

29.0

19

211.0

$124,000

LONG

260

3.7

4

-

9

-

$216,000

LOWNDES

9,560

14.1

66

19.8

191

245.9

$1,548,000

LUMPKIN

1,010

6.3

33

43.4

29

146.9

$327,000

MACON

700

6.9

36

55.9

48

229.8

$524,000

MADISON

1,410

7.4

22

20.3

19

155.7

$821,000

MARION

450

8.8

17

63.4

44

312.2

$108,000

MCDUFFIE

970

6.3

22

23.3

57

228.4

$315,000

MCINTOSH

460

5.9

8

-

10

152.4

$214,000

MERIWETHER

1,340

8.1

25

21.9

67

292.9

$659,000

MILLER

360

7.7

11

26.9

13

179.0

$53,000

MITCHELL

1,450

8.3

16

15.5

44

188.1

$527,000

MONROE

1,320

8.2

31

34.5

33

160.8

$186,000

MONTGOMERY

650

10.5

8

-

8

-

$152,000

MORGAN

400

3.5

9

-

33

214.4

$384,000

MURRAY

2,020

7.7

29

26.3

62

190.4

$589,000

MUSCOGEE

10,170

7.5

239

29.1

401

228.3

$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

2,930

6.5

OCONEE

940

5.1

OGLETHORPE

520

5.6

PAULDING

3,470

6.1

PEACH

1,260

7.2

PICKENS

1,410

8.0

PIERCE

960

8.4

PIKE

610

6.2

POLK

3,700

13.1

PULASKI

480

6.5

PUTNAM

850

5.8

QUITMAN

180

9.2

RABUN

810

6.9

RANDOLPH

560

9.8

RICHMOND

12,160

8.3

ROCKDALE

2,890

5.7

SCHLEY

230

8.7

SCREVEN

1,150

10.4

SEMINOLE

640

9.3

SPAULDING

2,510

5.9

STEPHENS

1,440

7.4

STEWART

410

10.3

SUMTER

2,310

9.6

TALBOT

370

7.5

TALIAFERRO

80

5.2

TATTNALL

1,210

7.1

TAYLOR

470

7.3

TELFAIR

1,250

13.7

TERRELL

790

10.0

THOMAS

3,310

10.6

TIFT

3,980

14.2

TOOMBS

1,670

8.9

TOWNS

540

6.9

TREUTLEN

540

10.7

TROUP

2,240

5.3

TURNER

1,040

15.4

TWIGGS

620

8.0

UNION

890

6.4

UPSON

1,630

7.9

WALKER

4,160

9.1

WALTON

2,380

5.5

WARE

2,440

9.1

WARREN

310

6.7

WASHINGTON

1,240

8.0

WAYNE

1,310

6.7

WEBSTER

160

9.0

WHEELER

540

11.3

WHITE

820

5.4

WHITFIELD

4,400

7.2

WILCOX

750

11.4

WILKES

540

6.6

WILKINSON

510

6.9

WORTH

1,660

10.6

47

20.2

17

19.6

15

28.1

44

23.7

32

32.9

18

17.3

26

37.1

6

-

29

15.5

6

-

15

16.6

1

-

19

20.1

14

30.2

208

25.8

65

24.5

14

81.9

14

18.0

10

19.3

34

12.7

26

18.2

22

68.2

39

25.0

11

30.7

5

-

14

14.7

18

42.0

34

52.6

11

19.0

48

21.6

59

35.3

18

14.8

10

12.1

11

34.2

40

13.7

18

37.0

9

-

11

9.0

48

31.0

102

31.3

58

24.8

44

21.4

11

27.4

20

19.4

17

14.7

2

-

19

66.7

16

15.3

103

30.9

12

28.6

21

31.5

7

-

19

20.7

99

170.0

35

155.5

9

-

69

115.2

68

311.1

32

136.3

26

163.2

26

201.3

97

251.8

27

271.7

35

190.3

5

-

38

243.0

25

317.9

393

210.5

80

122.9

4

-

62

406.7

19

183.6

129

224.3

58

219.9

21

369.9

97

310.6

15

225.2

7

-

32

154.7

11

121.3

56

453.9

35

327.2

84

191.4

91

251.2

73

287.1

19

158.3

10

141.0

199

344.5

24

258.3

17

159.2

31

134.4

81

278.9

78

122.5

82

144.9

102

277.7

18

280.5

39

186.0

63

242.6

8

-

14

222.8

31

146.4

132

168.3

26

290.3

23

183.7

31

309.2

43

194.3

$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

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.

15

Percentage of Adult Georgians

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%

Figure 10. Percentage of Adults Who Report No Regular Physical Activity and Being Overweight/Obese, Georgia, 1984-2001

90

80

70

No regular physical activity

60

50

40

30

Overweight or obese

20

10

0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Year

Source: BRFSS

reduction in the incidence of diabetes in the test group that made lifestyle modifications.4 Lifestyle intervention showed positive effects in individuals regardless of age, sex, race, or ethnicity.4 Since the mid-1980s, the percent of Georgia adults who are not regularly active has remained elevated, and the percent who are overweight or obese has been increasing (Figure 10). These trends are likely to influence the rising prevalence of diabetes and the 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.

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 week.22,23 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 diet.24 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 disease.25,26

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 disease.25,26,27 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 desir-

able weight.28 Obesity is defined as an excessively high amount of body fat in relation to lean body

Table 4. Prevalence of Risk Factors Among Adults With and Without Diabetes, Georgia, 2000-2001

mass. In obesity, the concern is not only for the amount of fat, but its distribution throughout the body.28,29 Fat distributed in the mid-trunk area, which is classified as "central obesity," has been linked to diabetes and other chronic diseases.28,29,30,31 In both Georgia and the U.S., there has been a steady increase in the prevalence of overweight

Percent* of those Percent* of those WITH Diabetes WITHOUT Diabetes

Ever told blood pressure high

50%

26%

Ever told cholesterol high

43%

30%

Smoke

28%

23%

Don't eat 5+ fruits or vegetables daily

81%

77%

Get no non-occupational physical activity

32%

28%

Overweight or obese

82%

58%

(body mass index 25.0-29.9) and obese (body mass index > 30) individuals.

*Age-adjusted to 2000 US standard population

Source: BRFSS

17

Normal

Overweight

Obese

Among the U.S. 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 45.7% (34.8% overweight, 10.8% obese) in 1990 to 59.4% (44.4% 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 overweight.33 Another 10% of preschool aged children 2 to 5 were found to be overweight.34 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 13.4% of middle school students (9% girls, 17.5% boys) and 11.2% of high school students (7.6% girls, 14.9% 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 smoke.6,35,36 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 diabetes.36
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 140/90.37 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 control.6
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

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 15.3% in 1987 to 31.8% in 2001 (Figure 11). Forty-three

percent of Georgians with dia-

Figure 11. Percentage of Adults Who Report Being Told They Have High Cholesterol and High Blood Pressure, Georgia, 1984-2001
35
30 High cholesterol
25

betes report being told they have high cholesterol level compared with 30% of Georgians without diabetes (Table 4).

20

15

High blood pressure

10

5

People with diabetes are encouraged to maintain total cholesterol levels less than 200 mg/dl, triglyc-

0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Year

Source: BRFSS

erides levels less than 150 mg/dl, low-density lipoprotein (LDL) less than 100 mg/dl, and high-

density cholesterol (HDL)

over 40 mg for men and 50 mg for women.39 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 Syndrome.41 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

People with Metabolic Syndrome are twice as likely to develop cardiovascular disease

Suffering from "brain fog" (feeling dazed and unclear in thoughts)

(CVD) and four times

Craving sweets or other carbohydrates shortly after a meal
Treatment for Metabolic Syndrome: Exercise Weight loss

more likely to develop diabetes compared to individuals who do not have Metabolic Syndrome.

Healthy eating (diet low in fat, refined sugar, cholesterol, and saturated fat,

and high in fiber)

Reversing Metabolic Syndrome Reversing Metabolic Syndrome can reduce a patient's 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 Association's 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

Substantial numbers of patients in Georgia with diabetes are receiving less than the

Screen for lipid abnormalities annually Provide aspirin therapy for all adults (if tolerable)

recommended minimal level of care.

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

tests per year, and receipt of aspirin therapy. This suggests that there are many

Table 5. Percentage of Persons with Diabetes Who Receive Routine Recommended Care, 2000-2001

areas where improvement of provider and patient education is needed. Education begins with getting people with diabetes into the health practice system.
The American Diabetes Association guidelines for blood glucose monitoring recommend that patients with type 2 diabetes on insulin and/or oral medications self monitor blood glucose at least once daily to better manage their diabetes.45 Research shows that daily self monitoring of blood glucose (SMBG) encourages better blood sugar control and patients who complete daily self monitoring have lower hemoglobin A1C levels. Additionally, people with diabetes who self monitor blood glucose

Recommended Minimal Healthy People 2010 BRFSS

Medicare

Frequency for Routine Care

Objectives51

Assessment* Assessment**

Visit to health professional

-

Self glucose monitoring daily

60%

A1C test, 2 per year

50%

Received diabetes education

60%

Received nutrition education

-

Physical activity recommended*

-

Blood pressure measured, each visit

-

Lipid test, 1 per year

-

Receiving aspirin therapy*

30%

Advised not to smoke

-

Foot exam, 1 per year

75%

Dilated eye exam, 1 per year

75%

CVD risk assessment, 1 per year*

-

Influenza vaccine, 1 per year

-

Pneumonia vaccine, ever*

-

Microalbuminuria test, 1 per year

-

Dental exam, 1 per year

75%

89%

-

51%

-

82%

-

62%

-

-

-

64%

-

-

-

-

57%

43%

-

-

-

64%

-

67%

46%

25%

-

48%

42%

48%

-

-

13%

-

-

- Data not available
* BRFSS data were aggregated for 2000-2001 whenever possible. Recommendations listed with asterisk have only one year 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 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.

are more likely to have yearly eye examinations and use diet and exercise as a part of their

treatment.45 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 year.46 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 shot.47,48 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).

Table 6. Annual Testing Rates of Medicare Beneficiaries Aged 65+ with Diabetes by Race, Georgia, 2001
Total Whites Blacks Other

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.

No. of Patients with Diabetes

94,643 69,783 24,154

706

% with 1+ HbA1c Tests

75%

76%

73%

76%

The Lower Extremity Amputation Prevention (LEAP)

% with Eye Exam % with Lipid Profile % with Quantitative Urine Protein

46% 57% 13%

48%

40%

41%

60%

48%

60%

13%

13%

15%

Source: Georgia Medical Care Foundation

project has been conducted and evaluated in several areas of the country. Studies found that by training primary health care providers (i.e. physicians, podiatrists, nurses, dieticians, and health educators) to 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
34.7% 63.9% 64.0% 72.2% 72.3% 77.1% 77.2% 85.9%
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 cafe-
teria, 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

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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;28(5):372-6.
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25. Centers for Disease Control and Prevention.Take Charge of Your Diabetes. 3rd edition. Atlanta: U.S. Department of Health and Human Services, 2002.
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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.
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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. U.S. 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, D'Agostino 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. 36.The Centers for Disease Control and Prevention.The prevention and treatment of complications of diabetes: A guide for primary care practitioners 2000. http://www.cdc.gov/diabetes/pubs/complications/benefit.htm 37. National Center for Health Statistics. News Release: "Obesity Still on the Rise, New Data Show," October 2002. http://www.cdc.gov/nchs.releases/02news/obesityonrise.htm 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; 351(9118): 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; 321(7258): 412-419.
40.Third 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; 10(9): 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://www.cdc.gov/nchs/about/otheract/hpdata2010/FA5/FA5-Summary table.XLS 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;72(4): 922-928. 47. Centers for Disease Control and Prevention. Prevention and Control of Influenza. Recommendations of the
Advisory Committee on Immunization Practices. 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5103a1.htm 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; 23(9): 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;5(5):609-16.
29

Appendix
Methods
Age-adjusted mortality rates for the U.S. and Georgia from 1980 through 1999 were obtained via WONDER at http://wonder.cdc.gov 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 U.S. 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,Y87.0; 9) AIDS: B20-B24; 10) homicide: X85-Y09,Y87.1; 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 U.S. Bureau of the Census (release date: July 1, 2001) and the U.S. 2000 projected population as the standard. Age-adjusted death rates for the U.S. 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 U.S. 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, 84.1; end-stage renal disease, 585, 586; diabetic ketoacidosis, 250.1.
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 (1.0082) 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 U.S. Bureau of Census (release date: July 1, 2001) and the 2000 U.S. standard population. The z-test was used to compare county rates to the state rate with significance at p<0.05. 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 body's 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 growth.With type 1 diabetes, the body produces little or no insulin.With 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.
32

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 hospital's 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.
33

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
34

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. 5.Take 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.
35

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.
Don't 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

Women: Above 50

90 to 130 mg/dl 140 mg/dl

Take Care of Yourself!

36

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).