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Diabetes in Virginia:
A Comprehensive Data Report
2009 Edition
Virginia Department of Health
Diabetes Prevention and Control
Project
Diabetes in Virginia, 2009
REPORT PREPARED BY
Stephanie M. Gruss, PhD, MSW
Epidemiologist, Division of Chronic Disease Prevention and Control
(DCDPC)
Henry Carretta, MPH
Statistical Consultant
ADDITIONAL CONTRIBUTIONS BY
Gail C. Jennings, PhD
Epidemiologist, DCDPC
REVIEWER ACKNOWLEDGEMENTS
Office of Family Health Services
David Suttle, MD, Director
DCDPC
Ramona Dawn Schaeffer, MSEd, CHES, Director
DCDPC
Myra Shook, MPH, Chronic Disease Program Supervisor
Diabetes Prevention and Control Project
Ann M. Forburger, MS, Project Director
Send comments or questions about the report to:
Virginia Department of Health (VDH)
Division of Chronic Disease Prevention and Control
Diabetes Prevention and Control Project
109 Governor Street, Tenth Floor
Richmond, Virginia 23219
(804) 864-7877
This report is also available on the VDH Division of Chronic Disease
Prevention and Control website: http://www.vahealth.org/cdpc/
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Diabetes in Virginia, 2009
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................................................................................................ii
TABLE OF CONTENTS ..................................................................................................iii
LIST OF TABLES ............................................................................................................ v
LIST OF FIGURES..........................................................................................................vi
INTRODUCTION............................................................................................................vii
Diabetes in Virginia is … .........................................................................................vii
PURPOSE AND USE OF THE DIABETES IN VIRGINIA DATA REPORT ................... viii
EXECUTIVE SUMMARY.................................................................................................ix
TECHNICAL NOTES....................................................................................................... x
Statistical Methods....................................................................................................... x
Data Availability ...........................................................................................................xi
DIABETES IS COMMON, SERIOUS, COSTLY, CONTROLLABLE, & PREVENTABLE 1
Impact of Diabetes on the Nation ................................................................................ 1
DIABETES IS COMMON ................................................................................................ 2
“Who in Virginia has diabetes?”................................................................................... 2
Prevalence ............................................................................................................... 2
Prevalence by Population Subgroup ........................................................................ 4
Undiagnosed Diabetes, Gestational Diabetes, Diabetes in Children, and
Prediabetes.............................................................................................................. 6
Prevalence and Incidence of Gestational Diabetes Mellitus (GDM) ......................... 9
Prevalence of Gestational Diabetes Mellitus (GDM): ............................................... 9
Incidence (new cases) of GDM: ............................................................................... 9
Estimated Prevalence of Diabetes in Children ....................................................... 11
Appalachian Region and Diabetes ......................................................................... 12
Prevalence of Diabetes by Health District .............................................................. 13
DIABETES IS SERIOUS ............................................................................................... 15
Mortality ..................................................................................................................... 15
Diabetes as the Primary Cause of Death ............................................................... 15
Mortality by Population Subgroup .......................................................................... 16
Diabetes as the Secondary Cause of Death .......................................................... 21
Prevalence of Disabilities in Adults with Diabetes .................................................. 23
DIABETES IS COSTLY................................................................................................. 24
Hospitalizations.......................................................................................................... 24
Hospitalizations by Population Sub-Group............................................................. 24
Hospital Discharges by Virginia Health District ...................................................... 26
Lower Extremity Amputation Hospitalizations Related to Diabetes ........................... 29
NT-LEA Hospitalizations by Population Sub-Group ............................................... 30
End Stage Renal Disease among Persons with Diabetes ......................................... 32
Unhealthy Days among Adults with Diabetes ............................................................ 34
DIABETES IS CONTROLLABLE .................................................................................. 35
Diabetes Management............................................................................................... 35
Eye Exam............................................................................................................... 35
Foot Exam.............................................................................................................. 35
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Diabetes in Virginia, 2009
Hemoglobin A1c..................................................................................................... 35
Influenza Vaccination ............................................................................................. 35
Pneumococcal Vaccination .................................................................................... 35
Self Monitoring of Blood Glucose ........................................................................... 36
Diabetes Patient Education ....................................................................................... 38
DIABETES IS PREVENTABLE ..................................................................................... 39
Risk Factors............................................................................................................... 39
Overweight or Obesity............................................................................................ 41
High Blood Pressure .............................................................................................. 43
High Cholesterol..................................................................................................... 44
Physical Activity ..................................................................................................... 45
Smoking ................................................................................................................. 46
Lifestyle Interventions ............................................................................................ 47
ADDITIONAL RESOURCES ......................................................................................... 48
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Diabetes in Virginia, 2009
LIST OF TABLES
Table 1. Prevalence of Diabetes in Virginia by Age Group, 2007.................................... 4
Table 2. Prevalence of Diabetes in Virginia by Income Level, 2007................................ 5
Table 3. Prevalence of Diabetes in Virginia by Education Level, 2007 ........................... 5
Table 4. Estimated Prevalence of All Types of Diabetes and Prediabetes in Virginia,
2006 ..................................................................................................................... 8
Table 5. Incidence of Gestational Diabetes in Virginia by Year, 2000-2004.................... 9
Table 6. Prevalence of Diabetes by Virginia Health District, 2006 ................................ 13
Table 7. Mortality Rates for Diabetes as the Primary Cause of Death by Race and
Gender for Virginia, 1999-2006 .......................................................................... 17
Table 8. Diabetes Mortality Rates by Race, Gender, & Age Group in Virginia, 2006 .... 18
Table 9. Diabetes Mortality per 100,000 by Virginia Health District,
2006……………………………………………………………………………………..20
Table 10. Summary Statistics for Hospital Discharges with a Primary Diagnosis of
Diabetes in Virginia, 2006................................................................................... 24
Table 11. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by
Gender in Virginia, 2006..................................................................................... 24
Table 12. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by Race
and Ethnicity in Virginia, 2006 ............................................................................ 25
Table 13. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by Age
Group in Virginia, 2006....................................................................................... 25
Table 14. Age-Adjusted Hospital Discharge Rates with a Primary Diagnosis of Diabetes
in Virginia Health Districts, 2006......................................................................... 27
Table 15. Summary Statistics for Diabetes-related NT-LEA Hospital Discharges in
Virginia, 2005...................................................................................................... 29
Table 16. Percent of Hospital Discharges for Diabetes-related NT-LEA by Gender,
Race/Ethnicity, and Age Group in Virginia, 2005................................................ 31
Table 17. Progress on Diabetes Management Practices —Percent of Adult Diabetics
Meeting Healthy People 2010 (HP2010) Goals in Virginia, 1995-2006 .............. 37
Table 18. Participation in a Diabetes Education Program by Gender in Virginia, 2006..38
Table 19. Participation in a Diabetes Education Program by Race in Virginia, 2006 .... 38
Table 20. Risk Factors Related to Diabetes .................................................................. 40
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Diabetes in Virginia, 2009
LIST OF FIGURES
Figure 1. Prevalence of Diagnosed Diabetes among Adults in Virginia and U.S., 1995-
2007. .................................................................................................................... 3
Figure 2. Prevalence of Diabetes in Virginia by Race, Ethnicity, and Gender, 2007 ...... 4
Figure 3. Estimated Number of Virginians with All Types of Diabetes and Prediabetes in
Virginia, 2006........................................................................................................ 7
Figure 4. Cumulative Incidence of GDM in Women of Child-bearing Age in Virginia,
2000-2004 .......................................................................................................... 10
Figure 5. Prevalence of Diabetes in Appalachian vs. Non-Appalachian Counties, 2006
...................................................................................................................................... 12
Figure 6. Prevalence Map of Diabetes by Virginia Health District, 2006………………...14
Figure 7. Mortality Rates for Diabetes as the Primary Cause and Any Cause of Death in
Virginia, 1999-2006 ............................................................................................ 15
Figure 8. Mortality Rates for Diabetes as the Primary Cause of Death by Race and
Gender for Virginia, 1999-2006 .......................................................................... 16
Figure 9. Mortality Rates for Diabetes as the Primary Cause of Death by Race, Gender,
and Age Group in Virginia, 2006......................................................................... 18
Figure 10. Diabetes Mortality Map by Virginia Health District, 2006……………………..21
Figure 11. Percent of Deaths Due to Cardiovascular Disease among Persons with
Diabetes in Virginia and U.S., 2006.................................................................... 22
Figure 12. Adults Reporting Having a Disability by Diabetes Status in Virginia, 2006... 23
Figure 13. Diabetes Hospital Discharge Map by Virginia Health District, 2006…………28
Figure 14. Hospital Discharge Rates for Non-Traumatic Lower Extremity Amputation per
10,000 Population by Gender and Race in Virginia, 2005 .................................. 30
Figure 15. Prevalence of ESRD by Gender and Race in Virginia, 2003........................ 32
Figure 16. Current Cases of ESRD by Primary Condition Diagnosis in Virginia, 2005.. 33
Figure 17. Percent of Unhealthy Days in One Month by Diabetes Status in Virginia,
2006 ................................................................................................................... 34
Figure 18. Body Mass Index (BMI) by Diabetes Status in Virginia, 2006 ...................... 42
Figure 19. High Blood Pressure by Diabetes Status in Virginia, 2006........................... 43
Figure 20. High Cholesterol by Diabetes Status in Virginia, 2006 ................................. 44
Figure 21. Sedentary Lifestyle by Diabetes Status in Virginia, 2006 ............................. 45
Figure 22. Current Smoking by Diabetes Status in Virginia, 2006................................. 46
Figure 23. Reduction in Incidence of Diabetes Due to Lifestyle Interventions, Diabetes
Prevention Program Study, 2001........................................................................ 47
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Diabetes in Virginia, 2009
INTRODUCTION
Diabetes in Virginia is …
Common – From 1995 to 2007, the Virginia population increased by 16%, but the
prevalence of diabetes in Virginia has increased by 95%. In 2007, an estimated 466,883
adult Virginians had diagnosed diabetes and another estimated 233,441 had
undiagnosed diabetes.
Serious – Diabetes was the 6th leading cause of death in Virginia in 2006. It was the
primary cause of 1,627 deaths in 2006. Virginia’s mortality rate due to diabetes has
decreased slightly from 1999 (24.0 per 100,000) to 2006 (21.8 per 100,000).
Costly – In 2006, 11,881 Virginians were hospitalized with a primary diagnosis of
diabetes. The average charge per hospitalization was $19,145.65 and the total cost for
these hospitalizations exceeded $227 million.
Controllable – Relative to recent years, the percentage of Virginians with diabetes who
followed recommended diabetes management practices in 2006, increased for
Hemoglobin A1c (A1c) checks, eye exams, daily blood glucose checks, and pneumonia
vaccines. In 2006, management practice rates decreased slightly for foot exams and
remained the same for flu shots. The A1c and daily blood glucose checks met the
Healthy People 2010 goal for these indicators in 2006.
Preventable – In 2006, prevalence rates of obesity, high cholesterol, and high blood
pressure among Virginians with diabetes was approximately two to three times higher
than those among people without diabetes.
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Diabetes in Virginia, 2009
PURPOSE AND USE OF THE DIABETES IN VIRGINIA DATA
REPORT
Diabetes is a complex disease. In an attempt to quantify and qualify its dimensions and
effects, this report offers:
• Baseline data for the ongoing surveillance of diabetes in Virginia. Diabetes
surveillance efforts began in the Commonwealth in 1994 with the beginning of
the Virginia Diabetes Prevention and Control Project (DPCP). In 1998, a data
report was written and used internally for the purposes of program planning and
assessment at the state and local levels of the DPCP. The first published report
was completed in 2002 and this report builds on those previous efforts.
• Identification of gaps in surveillance and limitations of existing data sources.
Historically, infectious disease surveillance has relied on the reporting of
individual cases by physicians, hospitals, and laboratories, but this is much more
difficult with chronic diseases. Other than cancer, there is no single chronic
disease area that relies on a comprehensive, diagnosis-based reporting system.
Thus, tracking new cases of diabetes in Virginia is not presently possible. The
Virginia diabetes surveillance system is modeled after the National Center for
Chronic Disease Prevention and Health Promotion’s national chronic disease
surveillance system.
• Critical information for diabetes prevention and control decision-makers. Analysis
of diabetes data by age, race, gender, and other factors (where data are
available) makes possible the identification of subpopulations that are at highest
risk for developing diabetes and suffer disproportionately from diabetes.
• Documentation that diabetes in Virginia is common (Prevalence section), serious
(Mortality section), costly (Hospitalization section), controllable (Diabetes
Management section), and preventable (Risk Factors section).
• Attention to the unrealized magnitude of diabetes in Virginia. The hidden
diabetes statistics include the estimates of Virginians with undiagnosed diabetes
and prediabetes (impaired fasting glucose or impaired glucose tolerance). It also
includes Virginians with diabetes who are hospitalized with cardiovascular
disease (CVD) and who die of CVD, and whose hospitalizations and deaths are
therefore recorded as CVD statistics rather than diabetes statistics.
• Justification for securing additional resources to reverse some of the alarming
trends of diabetes in Virginia. From 1996 to 2007, prevalence of diabetes has
increased by 95%.
• Validation for every Virginian living with diabetes and its effects. This report bears
witness to the burden of diabetes not only on the Commonwealth of Virginia, but
also on each Virginian who lives with diabetes.
viii
Diabetes in Virginia, 2009
EXECUTIVE SUMMARY
“Who in Virginia has diabetes?”
In 2007, more than 466,800 Virginians had diabetes. The prevalence of adult diabetes
in Virginia and the United States are similar (~8%). Virginia and the U.S. have seen the
prevalence of diabetes increase by about 16% since 2000. There is particular concern
about the increase in type 2 diabetes prevalence among younger age groups in the U.S.
and Virginia. Subpopulations in Virginia that are disproportionately affected by diabetes
include blacks relative to whites; the uninsured; residents of Appalachian counties; and
those with lower education and income levels.
“What are the complications of diabetes, and who gets hospitalized for them?”
In 2006, there were more than 11,880 hospital discharges for diabetes as the primary
diagnosis, costing the Commonwealth of Virginia over $227 million and 165 years of
loss of work productivity. Additionally, while the average length of diabetes-related
hospital stays has decreased over time, the average charges for hospital stays have
increased. Complications include diabetic retinopathy of the eyes, peripheral vascular
disease resulting in cardiovascular events (i.e. heart disease and stroke), diabetes
ketoacidosis, renal disease or renal failure, and non-traumatic lower extremity
amputations in cases where one’s diabetes is uncontrolled.
“What are Virginians with diabetes doing to manage their disease and minimize
complications?”
The long-term trends for the percentage of Virginians with diabetes that get their eyes,
feet, and A1c (glycosolated hemoglobin; average blood sugar levels over a three-month
timeframe) checked, and to receive flu and pneumonia vaccines in order to reduce the
complications of their disease, demonstrate considerable improvement. However, the
rate of improvement has slowed in recent years and only A1c and daily blood glucose
checks meet the current Healthy People 2010 goals. Continued improvement in these
recommended diabetes management practices are necessary for continued reduction in
hospitalization and morbidity associated with diabetes.
“How many die from diabetes, and how many die with diabetes?”
Diabetes deaths are more often coded as a secondary rather than a primary cause. In
Virginia in 2006, about 75% of diabetes deaths coded as a secondary cause were
attributable to major cardiovascular disease. Most persons diagnosed with diabetes die
with diabetes but not from diabetes. Mortality rates in 2006 were 21.8 per 100,000 for
diabetes as the primary cause of death but 66.0 per 100,000 for any cause.
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Diabetes in Virginia, 2009
TECHNICAL NOTES
Statistical Methods
• Some population subgroups are so small that data may be suppressed for two
reasons:
o To protect confidentiality. The Division of Chronic Disease Prevention and
Control, as a part of the Virginia Department of Health, has the
responsibility to protect the confidentiality and privacy of citizens of the
Commonwealth while adequately presenting information and data
concerning health conditions that affect the public. All data take into
consideration possible restrictions from local, state, and federal laws such
as the Privacy Rule of the Health Insurance Portability and Accountability
Act (HIPAA). Unfortunately, this does create the limitation of less available
data for some minority populations (e.g., American Indian, Chinese,
Filipino, Korean, Vietnamese), small geographic areas (e.g., county, city),
or rare diagnoses (e.g., liver cancer).
o To ensure accuracy of population estimates. When comparing two
populations, rates based on sufficiently large numbers provide stable
estimates for comparison. Rates based on low counts are statistically
unreliable and raise issues concerning accuracy and usefulness of data.
• To provide as much reliable data as possible, while protecting confidentiality,
some data have been combined by collapsing multiple years of data, merging
race categories, or expanding geographic areas (e.g., health districts versus
counties).
• Hospitalization rates in this report are based on a primary diagnosis of diabetes
and, therefore, underestimate diabetes hospitalization rates. This is because
diabetes most often appears as a secondary diagnosis with cardiovascular
disease listed as the primary diagnosis.
• All rates presented in this report use Virginia population estimates published by
the United States Census Bureau as their denominator for each year indicated.
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Diabetes in Virginia, 2009
Data Availability
• Certain diabetes indicators have more recent years of available data than others.
All indicators discussed in this report use the most recently published and/or
available data. Thus, there will be different years represented across some
indicators.
• The following data are unavailable in Virginia and, therefore, are not included in
this report:
o Eye disease – No central registry exists for the surveillance of blindness or
other eye diseases related to diabetes.
o Youth – The prevalence of diabetes in the state is determined by a
telephone survey in which respondents are at least 18 years old; thus,
there is no system in place to measure prevalence in Virginia’s youth less
than 18 years of age. Therefore, national estimates are used in this report
for this population.
o Out-patient care – The reporting of hospitalizations for diabetes is
mandatory, but the reporting of out-patient visits for diabetes care is not.
o Cholesterol testing among persons with diabetes – There are currently no
data sources in Virginia for measuring cholesterol testing and control in
persons with diabetes with a large enough sample size to draw state-level
conclusions on this measure.
o Hemoglobin A1c level – There are currently no data sources in Virginia
measuring Hemoglobin A1c levels in persons with diabetes with a large
enough sample size to draw state-level conclusions on this measure.
o LDL cholesterol level among persons with diabetes – There are currently
no data sources in Virginia measuring LDL cholesterol levels in persons
with diabetes with a large enough sample size to draw state-level
conclusions on this measure.
o Retinopathy prevalence among persons with diabetes – There are
currently no data sources in Virginia measuring the prevalence of
retinopathy in persons with diabetes with a large enough sample size to
draw state-level conclusions on this measure.
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Diabetes in Virginia, 2009
DIABETES IS COMMON, SERIOUS, COSTLY,
CONTROLLABLE, & PREVENTABLE
Impact of Diabetes on the Nation
National Summary Statistics:
• The total prevalence of diabetes in the United States in 2007 among all age
groups was 23.6 million persons or 7.8% of the population. Among that group,
5.7 million persons are estimated to have undiagnosed diabetes.
• Among persons 20 years of age or older:
o 10.7% of all people have diabetes.
o Diabetes prevalence is even higher in older age groups. Over twelve
million persons (23.1%) of persons age 60 years or older have diabetes.
o Diabetes is slightly more common in men. Among men, 11.2% have
diabetes as compared with 10.2% of women.
o Non-Hispanic blacks are 1.5 times as likely to have diabetes as non-
Hispanic whites.
o Mexican Americans are 1.2 times as likely as non-Hispanic whites.
• 1.6 million new cases of diabetes were diagnosed in people aged 20 years or
older in 2005.
• Diabetes was the 7th leading cause of death in 2006. This ranking is based on
the 72,507 deaths listed as the underlying cause of death on U.S. death
certificates; however, there were 233,619 deaths that listed diabetes as
contributing to death in 2005, the latest year for which contributing death data are
available.
• Adults with diabetes have heart disease death rates about two to four times
higher than adults without diabetes.
• About 75% of adults with diabetes have blood pressure greater than or equal to
130/80 millimeter of mercury or use prescription medication to control
hypertension.
• Diabetes is the leading cause of new cases of blindness among adults aged 20-
74 years.
• Diabetes is the leading cause of kidney failure.
• 60% to 70% of people with diabetes have mild to severe forms of nervous
system damage resulting in impaired sensation or pain in the feet or hands,
slowed digestion, carpal tunnel syndrome, and other nerve problems.
• About 71,000 non-traumatic lower extremity amputations were performed on
people with diabetes in 2004.
Source: Centers for Disease Control and Prevention’s National Diabetes Fact Sheet,
United States, 2007
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Diabetes in Virginia, 2009
DIABETES IS COMMON
“Who in Virginia has diabetes?”
Prevalence
Definition: The prevalence rate is the number of people with an existing condition or
disease, and the number of new cases, at one point in time.
• Currently, in Virginia, the prevalence of diabetes is only measured in adults 18
and over using the Behavioral Risk Factor Surveillance System (BRFSS).
• The Centers for Disease Control and Prevention (CDC) estimate that in the U.S.
the total prevalence of diabetes for all ages was 7.8% in 2007. It was 8.0% in
Virginia in 2007.
• The prevalence of diagnosed diabetes among adults (> 18 years of age) in
Virginia has increased 95 % from 3.9% in 1995 to 8.0% in 2007. Virginia’s rising
prevalence has remained close to the national prevalence during the past 11
years and for 2007 they are virtually identical, 8.0% and 7.8%, respectively.
• The prevalence of diabetes in Virginia increases with age, decreases with rising
levels of education, and is highest in blacks.
• Prevalence rates by gender tend to change from year to year, revealing no
consistent trend.
• Prevalence rates in Virginia tend to be higher in Appalachian counties as
compared to other counties.
2
Diabetes in Virginia, 2009
Figure 1. Prevalence of Diagnosed Diabetes among Adults in Virginia and U.S.,
1995-2007
9
8
7
6
P
e
5
r
c
e 4
n
t 3
2
1
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Virginia U.S.
• As seen in Figure 1. - The prevalence of diabetes has increased by 95% since
1995.
• Virginia prevalence rate trends have tended to follow U.S. trends. In the last
couple of years, the rates have been almost identical.
Source: BRFSS, CDC 1995-2007; CDC National Diabetes Fact Sheet, 2007
Data Note: Percents are weighted towards annual population estimates.
3
Diabetes in Virginia, 2009
Prevalence by Population Subgroup
• Age is a major risk factor for diabetes. The prevalence of diabetes typically
accelerates with age. This underlines the importance of addressing other
modifiable risk factors for type 2 diabetes, early and throughout the lifespan.
Table 1. Prevalence of Diabetes in Virginia by Age Group, 2007
Age Group Percentage with Diabetes
18-24 1.4
25-34 1.2
35-44 3.9
45-54 7.6
55-64 14.8
65+ 20.4
• Race and ethnicity are also important risk factors for diabetes. The prevalence of
diabetes is highest among black Virginians. Note the Hispanic sample is small
and almost certainly underestimates the higher prevalence of diabetes usually
found in this group nationally. In terms of gender, prevalence has become higher
among females than males. However, rates by gender tend to change from year
to year, revealing no consistent trend.
Figure 2. Prevalence of Diabetes in Virginia by Race, Ethnicity, and Gender, 2007
16 14.4
14
12
10
Percent
8.3
7.4 7.6
8 7
6.3
6
4
2
0
Prevalence
Black White Hispanic Other All Males All Females
Source: BRFSS, CDC 2007; CDC National Diabetes Fact Sheet, 2007
Data Note: Percents are weighted towards annual population estimates.
4
Diabetes in Virginia, 2009
• In 2007, people with diabetes with lower household incomes, were more likely to
have diabetes. As income increased, the prevalence of diabetes decreased.
Table 2. Prevalence of Diabetes in Virginia by Income Level, 2007
Income Percent
Less than $15,000 14.3
$15,000 - 24,999 14.0
$25,000 – 34,999 11.7
$35,000 – 49,999 10.8
$50,000+ 5.1
• In 2007, education had a similar effect as income. As education increased, the
prevalence of diabetes decreased.
Table 3. Prevalence of Diabetes in Virginia by Education Level, 2007
Education Level Percent
Less than High School 15.1
High School or GED 10.4
Some Post-High School 8.0
College Graduate 5.1
Prevalence of Diabetes by Virginia City and County, 2004 and 2005
The CDC now provides county-level estimates of diabetes prevalence. Estimates for
2004 and 2005 can be found at the following web site-
http://apps.nccd.cdc.gov/DDT_STRS2/CountyPrevalenceData.aspx?StateId=51.
Source: BRFSS, CDC 2007; CDC National Diabetes Fact Sheet, 2007
Data Note: Percents are weighted towards annual population estimates.
5
Diabetes in Virginia, 2009
Undiagnosed Diabetes, Gestational Diabetes, Diabetes in Children, and
Prediabetes
When we consider all forms of diabetes and undiagnosed diabetes in Virginia, there are
more persons other than the 466,883 diagnosed adults (8.0% in 2007) affected by this
chronic disease.
• In 2007, an additional 233,441 adult Virginians are estimated to have
undiagnosed diabetes.
• In 2007, about 113,786 women had gestational diabetes (diabetes during
pregnancy), increasing their risk of developing type 2 diabetes by 20 to 50% in
the next five to 10 years following pregnancy.
• Based on national estimates, the prevalence of diabetes among youth under age
20 in 2007 was 0.20%. Type 2 diabetes, although still rare, is being diagnosed
more frequently in children and adolescents, particularly in American Indians,
African Americans, and Hispanic/Latino Americans.
• By far the largest group at risk for diabetes are people who have somewhat
elevated blood glucose levels (impaired fasting glucose or impaired glucose
tolerance). This condition is now termed prediabetes in order to signal its
seriousness.
• The CDC estimates that 40.1% of adults between the ages of 40-74 years have
prediabetes. There is an estimated 1,226,628 adult Virginians with prediabetes in
the same age range.
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Diabetes in Virginia, 2009
Figure 3. Estimated Number of Virginians with All Types of Diabetes and
Prediabetes in Virginia, 2007
Diagnosed Adults
(Age 18+)4,
Prediabetes (Age 466,883
40-74)1,
1,226,628
Undiagnosed
Adults (Age 18+)4,
233,441
Gestational (Age
15-44)2, 113,786
Children (Under
Age 20)3, 4,037
Sources:
1. National Center for Health Statistics, Centers for Disease Control and Prevention,
Third National Health and Nutrition Examination Survey (NHANES III) 1988–1994
2. National Diabetes Education Program (NDEP), Type 2 Diabetes Risk after
Gestational Diabetes Fact Sheet, April 2006; 7% of child-bearing women ages 15-44
3. CDC, National Diabetes Fact Sheet, 2007
4. U.S. Behavioral Risk Factor Surveillance System, CDC 2007
7
Diabetes in Virginia, 2009
Table 4. Estimated Prevalence of All Types of Diabetes and Prediabetes in
Virginia, 2007
Estimated Number of
Population Calculation Virginians with
Diabetes/Prediabetes
Diagnosed State adult prevalence = 8.0%.1 466,883
Ratio of diagnosed cases to undiagnosed
Undiagnosed 233,441
cases is 2:1.2
NDEP estimates state prevalence= 7.0%
Gestational in women of childbearing age, 15-44 113,786
years.3
CDC estimates that .20% of all people in
Children the U.S. who are under the age of 20 4,037
have diabetes.4
CDC estimates that 40.1% of adults
Prediabetes5 between the ages of 40-74 years have 1,226,628
prediabetes.6
Total 2,044,775
1
CDC national rate with Virginia 2006* population data for those 18 years and older= 5,836,037. 8.0% of
5,836,037= 466,883; *(most recent year of ‘state population estimates’ data available to VDH employees).
2
CDC estimates that for every two people diagnosed with diabetes, there is at least one person with
undiagnosed diabetes; 50% of 466,883= 233,441.
3
Based on estimates from the National Diabetes Education Program (NDEP) April 2006 Fact Sheet.
Virginia 2006 population that was 15-44 years (child-bearing age) = 1,625,508. 7.0% of 1,625,508=
113,786.
4
Based on National Health and Nutrition Examination Survey data reported in CDC Diabetes Fact Sheet,
2007; Virginia 2006 population under the age of 20= 2,036,038; .20 percent of 2,018,407= 4,037. There is
a two-year overlap between prevalence estimates using VA BRFSS data of adults ages 18+ and CDC
data for children under age 20, due to the fact that Virginia does not have state-level NHANES estimates
of adult prevalence for ages 20 and over.
5
Prediabetes is defined as having impaired glucose tolerance or impaired fasting glucose or both.
6
Virginia 2006 population that was between 40-74 years= 3,058,923. 40.1% of 3,058,923= 1,226,628.
8
Diabetes in Virginia, 2009
Prevalence and Incidence of Gestational Diabetes Mellitus (GDM)
What is GDM?
According to the CDC, GDM is a form of glucose intolerance diagnosed in some women
during pregnancy. GDM occurs more frequently among Blacks/African Americans,
Hispanic/Latino Americans, and American Indians. It is also more common among
obese women and women with a family history of diabetes. During pregnancy,
gestational diabetes requires treatment to normalize maternal blood glucose levels to
avoid complications in the infant. After pregnancy, five to 10% of women with
gestational diabetes are found to have type 2 diabetes. Women who have had
gestational diabetes have a 20 to 50% chance of developing diabetes in the next five to
10 years. Their offspring are at an increased risk for obesity as well as impaired glucose
tolerance and type 2 diabetes. GDM may also be associated with intrauterine fetal
death, increased frequency of maternal hypertensive disorders and the need for
cesarean delivery.
Prevalence of Gestational Diabetes Mellitus (GDM):
In 2007, BRFSS estimated the Virginia prevalence of gestational diabetes to be only 1.5
% of adult Virginians. Currently, this is not a reliable source of prevalence data for
diabetes during pregnancy. The CDC has added a module to the BRFSS system in
2008 that will permit a more reliable estimate of GDM prevalence. The National
Diabetes Education Program estimated that the national prevalence of GDM in 2005
was approximately 7.0% in women of childbearing age, 15-44 years. This estimate was
reiterated by the CDC in 2007.
Sources: CDC National Fact Sheet, 2007; VA BRFSS, 2007
Data Note: Percents are weighted towards annual population estimates.
Incidence (new cases) of GDM:
• Age-specific incidence rates for women of childbearing ages 15-44 years,
indicate that there was a significant increase (p<.05) in the incidence of GDM
from 2000 (3.8/1,000) to 2004 (4.7/1,000).
Table 5. Incidence of Gestational Diabetes in Virginia by Year, 2000-2004*
2000 2001 2002 2003 2004
Incidence
3.8 4.3 4.4 4.4 4.7
Rate
9
Diabetes in Virginia, 2009
Figure 4. Cumulative Incidence of GDM in Women of Child-bearing Age in
Virginia, 2000-2004*
14 12.2
Per 1,000 Women 15-44 Years
12 9.5
10 7.3
6.5
8
6
4
2
0
White Black Hispanic Asian
• The age- and race/ethnicity-adjusted yearly cumulative incidence per 1,000
woman ages 15-44 years was highest in the Hispanic population (12.2/1,000),
followed by Asians (9.5/1,000), then blacks (7.3/1,000).
• C-sections increased in mothers with GDM by 84% from 2000 to 2004
• The mean length of stay for a woman with GDM was three days across the five-
year period, but the mean charge per visit increased from $5,851 in 2000 to
$7,682 in 2004.
Healthy People 2010 Objective:
(5-8) Decrease the proportion of pregnant women with gestational diabetes; no target
set.
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2000-2004
Data notes: *Cumulative incidence rates were aggregated for years 2000-2004 in order
to have a significant sample size; all data include cases of live births containing birth
procedure code ICD-9 V-27 and GDM code 648.8-648.84; records for each year were
de-duplicated. This study has not yet been repeated as it represents five years of
aggregated data in order to have a sufficient sample size in which to draw conclusions
by race.
10
Diabetes in Virginia, 2009
Estimated Prevalence of Diabetes in Children
Currently, there are no state-level data sources for which to estimate the prevalence of
type 1 or type 2 diabetes in children. The CDC, estimate the following:
• Type 1 diabetes accounts for 5 to 10% of all diagnosed cases of diabetes.
• Type 2 diabetes can occur in children and is happening more frequently,
although, it is still very rare.
• According to clinical studies and regional reports, type 2 diabetes in children has
been found to occur more frequently in the American Indian, black, and Hispanic
populations.
• About 186,300 children and adolescents have type 1 or type 2 diabetes.
• The estimated prevalence of diabetes in children is 0.2%.
• For more information on diabetes in children, please see the following websites:
CDC National Diabetes Fact Sheet, 2007:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf
SEARCH for Diabetes in Youth Project:
http://www.searchfordiabetes.org/public/provider/index.cfm
Source: CDC Diabetes Indicators and Data Source Internet Tool, 2008.
Appalachian Region and Diabetes
According to the Appalachian Regional Commission (ARC), the Appalachia region is a
200,000-square-mile region that follows the Appalachian Mountains from southern New
York to northern Mississippi. It includes all of West Virginia and parts of 12 other states:
Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio,
Pennsylvania, South Carolina, Tennessee, and Virginia.
Appalachian counties within Virginia include: Alleghany, Bath, Bland, Botetourt,
Buchanan, Carroll, Craig, Dickenson, Floyd, Giles, Grayson, Highland, Lee,
Montgomery, Pulaski, Rockbridge, Russell, Scott, Smyth, Tazewell, Washington,
Wise/Norton, and Wythe. The following independent cities in Virginia are also within the
Appalachian Region: Bristol, Buena Vista, Covington, Galax, Lexington, Norton, and
Radford.
Appalachia is unique in terms of its geography, culture, and focus on coal and other
natural resources as the mainstay of its economy. Persons living in Appalachia have
difficulty in accessing healthcare, due to geography, lack of such resources, and low
socioeconomic status. According to research conducted by ARC, persons living in
11
Diabetes in Virginia, 2009
Appalachia also experience higher disease prevalence, morbidity, and mortality rates
than persons living in non-Appalachian regions.
• Virginians living in the Appalachian region have a higher prevalence of diabetes
those living in non-Appalachian areas. In 2006, Appalachians had a diabetes
prevalence of 11.0%, as compared to non-Appalachians with a rate of 7.2%.
Figure 5. Prevalence of Diabetes in Appalachian vs. Non-Appalachian Counties,
2006
Non-Appalachian
Counties: 7.2%
Appalachian Counties: 11.0 %
• This is a striking example of a geographic disparity. In the Appalachian counties
of Virginia, diabetes is 65% more prevalent than in non-Appalachian counties.
Significant* contributing factors to the higher diabetes prevalence rate in the
Appalachian region in 2006 are:
• Less than half (48.5%) of Appalachians reported having some college education
or more as compared to 64.8% of non-Appalachians.
• 31.9% of Appalachians reported earning a household income of less than
$25,000 as compared to only 15.4%% of non-Appalachians.
• 30.4% of Appalachians were obese as compared to 24.6% of non-Appalachians.
• 35.5% of Appalachians had high blood pressure as compared to 30.1% of non-
Appalachians.
• 44.3% of Appalachians had high cholesterol as compared to 39.7% of non-
Appalachians.
Sources: Appalachian Regional Commission- www.arc.gov/; VA BRFSS, 2006
Data Note: Percents are weighted towards annual population estimates; *Person Chi-
square tests were run on all Appalachia-related data points with resulting p-values of
<.001.
12
Diabetes in Virginia, 2009
Prevalence of Diabetes by Health District
Diabetes prevalence also varies by health district regions.
• The five health districts with the highest prevalence of diabetes in 2006 were:
o Southside (16.5%)
o Cumberland Plateau (16.0%)
o Pittsylvania-Danville (14.2%)
o Piedmont (12.1%)
o Lenowisco (12.0%)
Table 6. Prevalence of Diabetes by Virginia Health District, 2006
Virginia Health District Prevalence Rate
Alexandria 4.7%
Alleghany 7.8%
Arlington 4.1%
Central Shenandoah 6.1%
Central Virginia 6.7%
Chesapeake 3.4%
Chesterfield 6.2%
Crater 11.9%
Cumberland Plateau 16.0%
Eastern Shore 7.2%
Fairfax 7.8%
Hampton 6.7%
Chickahominy (formerly Hanover) 8.8%
Henrico 4.1%
Lenowisco 12.0%
Lord Fairfax 9.9%
Loudon 2.5%
Mount Rogers 8.8%
New River 10.9%
Norfolk 10.9%
Peninsula 5.4%
Piedmont 12.1%
Pittsylvania/Danville 14.2%
Portsmouth 8.7%
Prince William 7.6%
Rappahannock 4.3%
Rappahannock/Rapidan 7.2%
Richmond 8.2%
Roanoke 8.8%
Southside 16.5%
13
Diabetes in Virginia, 2009
Thomas Jefferson 6.5%
Three Rivers 10.1%
Virginia Beach 5.5%
West Piedmont 7.2%
Western Tidewater 3.8%
State Average: 8.0%
Source: BRFSS, VA 2006
Data Note: Percents are weighted towards annual population estimates.
Figure 6. Prevalence Map of Diabetes by Virginia Health District,
2006
14
Diabetes in Virginia, 2009
DIABETES IS SERIOUS
Mortality
Diabetes as the Primary Cause of Death
• Diabetes was the 6th leading cause of death in Virginia in 2006.
• Diabetes can cause heart disease, stroke, blindness, kidney failure, pregnancy
complications, amputations of the leg, foot and toe, as well as, deaths related to
flu and pneumonia.
• Overall, Virginia’s mortality rate due to diabetes has decreased slightly from 1999
(24.0 per 100,000) to 2006 (21.8 per 100,000).
Figure 7. Mortality Rates for Diabetes as the Primary Cause and Any Cause of
Death in Virginia, 1999-2006
80
73.6 74.3 73.4
70 71.0 71.2 71.0 72.0
66
60
50
40
30
24.0 24.4 24.4 22.9 22.7 22.5
20 22.0 21.8
10
0
1999 2000 2001 2002 2003 2004 2005 2006
Primary Cause Any Cause
Healthy People 2010 Objective: (5-5) Reduce the diabetes death rate due to a primary
cause of diabetes to 45 deaths per 100,000 and (5-6) reduce diabetes-related deaths
among persons with diabetes to 8.8 per 1,000.
Sources for Figures 7, 8, and Table 9: VDH, Division of Health Statistics, 1999-2006
Data Note: Rates are age-adjusted per 100,000 population using 2000 U.S. Census
data. Rates are not available for other racial and ethnic groups due to insufficient
sample size; thus, Hispanics, Asians, American Indian/Alaskan Natives, and all others
are coded as “Other.”
15
Diabetes in Virginia, 2009
Mortality by Population Subgroup
• Blacks (both males and females) consistently have about 2.5 times the mortality
rates due to diabetes than whites: 45.0 per 100,000 vs. 17.8 per 100,000,
respectively in 2006.
• Diabetes mortality (death) rates have been slightly higher for males than females
since 1999. Female mortality rates have been declining at a faster rate than male
rates since 2002.
• Since 1999, black males and females have had higher diabetes mortality rates
than their white counterparts.
Figure 8. Mortality Rates for Diabetes as the Primary Cause of Death by Race and
Gender for Virginia, 1999-2006
60
50
40
Rates per 100,000
30
20
10
0
1999 2000 2001 2002 2003 2004 2005 2006
White Male White Female Black Male
Black Female Other Male Other Female
16
Diabetes in Virginia, 2009
Table 7. Mortality Rates for Diabetes as the Primary Cause of Death by Race and
Gender for Virginia, 1999-2006
White White Black Black Other Other
Year Total/State
Male Female Male Female Male Female
1999 22.8 19.0 46.9 40.6 2.3 25.8 24.0
2000 22.8 18.4 50.1 47.9 12.9 6.8 24.4
2001 23.0 18.1 49.0 44.2 17.3 17.5 24.4
2002 22.0 15.7 50.9 44.8 12.6 12.2 22.9
2003 22.6 16.2 43.3 43.0 18.6 17.6 22.7
2004 20.6 15.9 49.3 39.3 18.1 14.9 22.0
2005 19.0 20.8 27.5 34.6 8.2 8.7 21.6
2006 22.0 14.7 51.3 40.8 13.9 14.1 21.8
• Mortality rates tend to increase with increasing age across all races and
ethnicities (see Figure 8. page 16).
• Blacks have significantly higher mortality rates in all age categories than whites
and ‘other’ races/ethnicities.
• Black males and black females were more likely to die from diabetes in middle
age groups (55-74) than their white counterparts in 2006.
17
Diabetes in Virginia, 2009
Figure 9. Mortality Rates for Diabetes as the Primary Cause of Death by Race,
Gender, and Age Group in Virginia, 2006
700
600
Rates per 100,000
35-44
500
45-54
400 55-64
300 65-74
200 75-84
85+
100
0
te
e
e
e
e
e
e
al
al
al
al
al
al
ta
M
m
M
m
m
M
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Fe
Fe
Fe
er
k
te
ta
ac
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ac
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W
th
hi
Bl
O
W
Table 8. Diabetes Mortality Rates by Race, Gender, & Age Group in Virginia, 2006,
Diabetes as Primary Cause
Age White White Black Black Other Other Total
Group Male Female Male Female Male Female State
35-44 5.8 3.3 14.5 7.3 0.0 0.0 5.2
45-54 13.8 11.1 33.5 30.3 3.9 3.3 15.5
55-64 34.9 20.3 69.0 51.9 12.2 4.9 31.6
65-74 65.9 42.1 201.7 145.9 0.1 49.1 70.5
75-84 153.6 106.6 297.9 318.7 124.0 174.0 152.9
85+ 295.8 203.3 686.3 450.7 413.2 142.5 272.0
18
Diabetes in Virginia, 2009
Healthy People 2010 Objective:
(5-5) Reduce the diabetes death rate to 45 deaths per 100,000 and (5-6) reduce
diabetes-related deaths among persons with diabetes to 8.8 per 1,000.
Sources: VDH, Division of Health Statistics, 2006
Data Note: Rates are age-adjusted per 100,000 population using 2000 U.S. Census
data. Rates are not available for other racial and ethnic groups due to insufficient
sample size; thus, Hispanics, Asians, American Indian/Alaskan Natives, and all others
are coded as “Other.”
Diabetes Mortality Rates by Virginia Health District, 2006
• Diabetes mortality rates for contributing cause of death were significantly
higher in the Portsmouth (51.0/100,000) and Western Tidewater
(43.4/100,000) health districts than any other district in the state.
• Health districts with the highest diabetes mortality rates were:
o Portsmouth
o Western Tidewater
o Cumberland Plateau
o Pittsylvania/Danville
o Richmond
19
Diabetes in Virginia, 2009
Table 9. Diabetes Mortality per 100,000 by Virginia Health District, 2006
Virginia Health District Prevalence Rate
Alexandria 10.3
Alleghany 17.3
Arlington 13.5
Central Shenandoah 26.1
Central Virginia 21.8
Chesapeake 25.8
Chesterfield 21.9
Crater 16.9
Cumberland Plateau 35.2
Eastern Shore 32.4
Fairfax 24.3
Hampton 13.3
Chickahominy (formerly Hanover) 22.7
Henrico 20.6
Lenowisco 33.8
Lord Fairfax 20.6
Loudon 17.6
Mount Rogers 28.8
New River 23.5
Norfolk 26.4
Peninsula 18.6
Piedmont 25.8
Pittsylvania/Danville 35.0
Portsmouth 51.0
Prince William 20.5
Rappahannock 21.5
Rappahannock/Rapidan 23.8
Richmond 34.2
Roanoke 26.3
Southside 18.0
Thomas Jefferson 17.4
Three Rivers 18.4
Virginia Beach 15.8
West Piedmont 26.5
Western Tidewater 43.4
State Average: 21.8
Sources: VDH, Division of Health Statistics, 2005
Data Note: Rates are age-adjusted per 100,000 population using 2000 U.S. Census
data.
20
Diabetes in Virginia, 2009
Figure 10. Diabetes Mortality Map by Virginia Health District, 2006
Diabetes as the Secondary Cause of Death
• Diabetes deaths are more often coded as a secondary cause than a primary
cause.
• Cardiovascular disease is the leading cause of diabetes-related deaths.
• Diabetes affects the peripheral vascular system and can lead to a heart attack or
stroke.
• According to the American Diabetes Association, two out of three people with
diabetes die from a form of heart disease or a stroke.
• In Virginia about 75% of diabetes deaths coded as a secondary cause were
coded as “Major Cardiovascular Disease” as the primary cause in 2006.
• Approximately every 22 out of every 100,000 people die from diabetes as
primary cause and approximately 66 out of every 100,000 persons die from
diabetes as a secondary cause.
21
Diabetes in Virginia, 2009
Figure 11. Percent of Deaths Due to Cardiovascular Disease among Persons with
Diabetes in Virginia and U.S., 2006
100
80 75
65
60
Percent
40
20
0
Virginia U.S.
Healthy People 2010 Objective:
(5-5) Reduce the diabetes death rate to 45 deaths per 100,000 and (5-6) reduce
diabetes-related deaths among persons with diabetes to 8.8 per 1,000.
Sources: VDH, Division of Health Statistics, 2006
Data Note: Rates are age-adjusted per 100,000 population using 2000 U.S. Census
data.
22
Diabetes in Virginia, 2009
Prevalence of Disabilities in Adults with Diabetes
Adults with diabetes report having a physical or mental disability at a higher rate than
adults without diabetes. Relative risk analysis of Virginia BRFSS data reveals that
adults with diabetes are almost three times more likely to report having a disability than
those without diabetes. In Virginia, the overall prevalence rate for all persons with
disabilities is 17.7%.
Figure 12. Adults Reporting Having a Disability by Diabetes Status in Virginia,
2006
40
35
34.2
30
25
Percent
20 18.0
15
10
5
0
With Diabetes Without Diabetes
Source: BRFSS, VA 2006
Data Note: Percents are weighted towards annual population estimates.
23
Diabetes in Virginia, 2009
DIABETES IS COSTLY
Hospitalizations
• Persons with diabetes are at greater risk of hospitalization due to complications
such as diabetic ketoacidosis, end-stage renal disease, lower extremity
amputation, and cardiovascular disease.
• In 2006, the total hospital discharge rate in Virginia for persons with a primary
diagnosis of diabetes was 15.3 per 10,000 persons.
Table 10. Summary Statistics for Hospital Discharges with a Primary Diagnosis of
Diabetes in Virginia, 2006
Total diabetes discharges 11,881
Total charges $ 227,469,424
Average charges per discharge $19,145.65
Average length of stay 5.1 days
Hospitalizations by Population Sub-Group
• Males account for a slightly higher percentage of hospitalizations due to a
primary cause of diabetes.
Table 11. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by
Gender in Virginia, 2006
Gender Percent
Female
48.7%
Male 51.3%
Health People 2010 Objective: (1-9) Reduce hospitalization rates for persons 18 to 64
years with diabetes to 7.2 per 10,000 admissions.
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2006 with a
primary diagnosis of ICD-9-CM 250.xx.
24
Diabetes in Virginia, 2009
Table 12. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by
Race and Ethnicity in Virginia, 2006
Race/Ethnicity Category Percent
White 54.0
Black 41.1
Hispanic 1.8
Other, Non-Hispanic 1.4
Unknown 1.7
• Most hospital discharges occur in the white population because they are the
largest population subgroup. However, prevalence of diabetes is higher in
blacks than whites (14.4% vs. 7.4%). Thus, a disproportionate share of
hospitalizations due to diabetes is among the black population.
Table 13. Percent of Hospital Discharges with a Primary Diagnosis of Diabetes by
Age Group in Virginia, 2006
Age Group Percent
Under 5 0.45
5-14 Years 3.7
15-24 Years 7.4
25-34 Years 8.8
35-44 Years 14.7
45-54 Years 18.8
55-64 Years 17.2
65-74 Years 13.9
75-84 Years 11.05
85+ Years 4.0
• Hospitalizations for diabetes are most common in the 45 to 64 age groups.
The smaller percentage of hospitalizations due to diabetes in the oldest
groups probably reflects smaller total population in those groups and shorter
life spans for persons with diabetes.
Health People 2010 Objective: (1-9) Reduce hospitalization rates for persons 18 to 64
years with diabetes to 7.2 per 10,000 admissions.
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2006 with a
primary diagnosis of ICD-9-CM 250.xx.
25
Diabetes in Virginia, 2009
Hospital Discharges by Virginia Health District, 2006
• Discharge rates varied considerably across health districts (7.0 to 34.8 per
10,000 population).
• Health districts with the highest diabetes hospital discharge rates were:
o Portsmouth
o Crater
o Roanoke
o Norfolk
o Southside
• The higher total hospital discharge rates for diabetes in these five health
districts may be related to the higher proportion of minority residents in those
areas. Minority populations are at greater risk of hospitalization due to
diabetes.
• The state total in 2006 was 15.3 hospital discharges per 10,000 population.
Health People 2010 Objective:
(1-9) Reduce hospitalization rates for persons 18 to 64 years with diabetes to 7.2 per
10,000 admissions.
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2006 with a
primary diagnosis of ICD-9-CM 250.xx.
Data note: Rates are age-adjusted per 10,000 population using Virginia estimated
population values published by the U.S. Census Bureau.
26
Diabetes in Virginia, 2009
Table 14. Age-Adjusted Hospital Discharge Rates with a Primary Diagnosis of
Diabetes in Virginia Health Districts, 2006
Virginia Health District Age-Adjusted Rate7
Alexandria 10.8
Alleghany 17.0
Arlington 7.7
Central Shenandoah 16.2
Central Virginia 20.6
Chesapeake 17.1
Chesterfield 11.8
Chickahominy (formerly Hanover) 11.8
Crater 34.8
Cumberland Plateau 18.8
Eastern Shore 14.0
Fairfax 7.0
Hampton 20.5
Henrico 12.0
Lenowisco 23.2
Lord Fairfax 11.3
Loudon 9.3
Mount Rogers 14.1
New River 21.6
Norfolk 27.3
Peninsula 15.7
Piedmont 21.4
Pittsylvania/Danville 21.4
Portsmouth 31.0
Prince William 11.3
Rappahannock 16.0
Rappahannock/Rapidan 16.5
Richmond 29.4
Roanoke 27.2
Southside 23.7
Thomas Jefferson 19.3
Three Rivers 14.0
Virginia Beach 11.7
West Piedmont 23.8
Western Tidewater 18.6
State Total 15.3
Source: VHI Hospital Discharge dataset, 2006; rate are age-adjusted per 10,000 population.
27
Diabetes in Virginia, 2009
Figure 13. Diabetes Hospital Discharge Map by Virginia Health District, 2006
28
Diabetes in Virginia, 2009
Non-Traumatic Lower Extremity Amputation (NT-LEA)
Hospitalizations Related to Diabetes
• According to the CDC, diabetes is the leading cause of non-traumatic lower
extremity amputations (NT-LEA).
• The age-adjusted rate for NT-LEA was 1.44 per 10,000 persons in Virginia for
2005.
Table 15. Summary Statistics for Diabetes-related NT-LEA Hospital Discharges in
Virginia 2005*
Total diabetes discharges 1,117
Total charges $43 million
Average charge per discharge $38,488.03
Average length of stay 10.84 days
NT-LEA rates vary by population subgroup:
• Black males have the highest age-adjusted, diabetes-related, NT-LEA
hospitalization rates (4.5/10,000).
• Black females have the second highest rate (2.5/10,000).
• Males have higher rates (2.1/10,000) than females (.91/10,000).
Healthy People 2010 Objective:
(5-10) Reduce the hospitalization rate to 2.9 lower extremity amputations per 1,000
persons with diabetes per year (age-adjusted).
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2005; *2006
analyses are pending due to methodological changes.
Data note: ICD-9-CM diagnosis codes associated with diabetes (250.xx) and NT-LEA
84.10 to 84.19
29
Diabetes in Virginia, 2009
NT-LEA Hospitalizations by Population Subgroup
• Overall, blacks have the highest rate of diabetes-related NT-LEAs (3.4/10,000)
than any other racial group. And, males have higher rates (2.1/10,000) than
females (.9/10,000).
Figure 14. Hospital Discharge Rates for Non-Traumatic Lower Extremity
Amputation per 10,000 Population with Diabetes by Gender and Race in Virginia,
2005*
4.0
3.5 3.4
3.0
2.5
2.1
2.0
1.5 1.4
1.0
1.0 0.9
0.5
0.0
Male Female Black White Total State
Healthy People 2010 Objective:
(5-10) Reduce the hospitalization rate to 2.9 lower extremity amputations per 1,000
persons with diabetes per year (age-adjusted).
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2005
Data note: ICD-9-CM diagnosis codes associated with diabetes (250.xx) and NT-LEA
84.10 to 84.19
30
Diabetes in Virginia, 2009
Table 16. Percent of Hospital Discharges for Diabetes-related NT-LEA by Gender,
Race/Ethnicity, and Age Group in Virginia, 2005*
Population Group Percent
Gender
Female 34.0
Male 66.0
Race/Ethnicity Percent
White 57.7
Black 39.3
Hispanic 1.3
Other, Non-Hispanic 0.4
Unknown Race/Ethnicity 1.3
Age Group Percent
Under 5 Years 0.0
5-14 Years 0.0
15-24 Years 0.0
25-34 Years 1.5
35-44 Years 8.2
45-54 Years 23.0
55-64 Years 26.7
65-74 Years 21.2
75-84 Years 15.0
85+ Years 4.4
Healthy People 2010 Objective:
(5-10) Reduce the hospitalization rate to 2.9 lower extremity amputations per 1,000
persons with diabetes per year (age-adjusted).
Source: Virginia Health Information, Inc. Hospital Discharge Dataset, 2005
Data note: ICD-9-CM diagnosis codes associated with diabetes (250.xx) and NT-LEA
84.10 to 84.19
31
Diabetes in Virginia, 2009
End Stage Renal Disease among Persons with Diabetes
End-stage renal disease is a major cause of hospitalization, disability, morbidity, and
mortality for persons with diabetes.
• In 2003, persons with diabetes had a significantly higher prevalence of end-stage
renal disease (ESRD) than those without diabetes- with diabetes 8.13/1,000 vs.
without diabetes 1.02/1,000.
• In 2003, black females had a significantly higher prevalence of ESRD at
19.82/1,000 than other females at 14.36/1,000 and white females at 3.71/1,000.
• In 2003, black males had a significantly higher prevalence of ESRD at
20.00/1,000 than other males at 10.39/1,000 and white males at 4.20/1,000.
Figure 15. Prevalence of ESRD by Gender and Race in Virginia, 2003*
25
20.0 19.8
20
Rate per 1,000
14.4
15
10.4
10
5 4.2 3.7 3.9
2.6
0.58 0.38 1.0 0.7
0
White Male White Black Male Black Other Male Other
Female Female Female
With Diabetes Without Diabetes
Source: CDC Diabetes Indicators and Data Source Internet Tool, 2007; Mid-Atlantic
Renal Coalition Data Set, 2003 & 2005
Date Note: *This is the most recent year that ESRD prevalence data are available;
rates are age-adjusted and are per 1,000 population.
32
Diabetes in Virginia, 2009
In 2005, there were 3,681 diabetes-related cases of ESRD, accounting for 42% of all
existing cases in Virginia.
Figure 16. New Cases of ESRD by Primary Condition Diagnosis in Virginia, 2005*
4000
3681
3500
3000
2680
2500
No. of Persons
2000
1500
967 986
1000
500 238 289
0
ey
on
s
n
er
s
i
te
ow
rit
th
dn
i
ns
be
ph
O
kn
Ki
te
ia
ne
Un
er
D
tic
lo
yp
ys
eu
H
C
m
lo
G
Sources: CDC Diabetes Indicators and Data Source Internet Tool, 2007;
Mid-Atlantic Renal Coalition Data Set, 2003 & 2005
Data Note: *This is the most recent year that ESRD raw data are available; rates are
age-adjusted and are per 1,000 population.
33
Diabetes in Virginia, 2009
Unhealthy Days among Adults with Diabetes
• According to the Centers for Disease Control and Prevention (CDC), persons
with diabetes are at increased risk for complications that result in lower extremity
amputations, blindness, and other types of physical disability in addition to
increased stress, depression, and emotional problems that may be associated
with unhealthy days.
• The CDC defines ‘unhealthy days’ among adults with diabetes as the
combination of days that an adult reports experiencing poor physical or poor
mental health in the past month, totaling over 15 days.
• Adults with diabetes in Virginia are 2.4 times more likely to report 15 or more
unhealthy days in one month than adults without diabetes.
Figure 17. Percent of Unhealthy Days in One Month by Diabetes Status in Virginia,
2006
45 43
40
35
Percent
30
25
18.9
20
15
10
5
With Diabetes Without Diabetes
Sources: CDC Diabetes Indicators and Data Source Internet Tool for definition of
unhealthy days among persons with diabetes; VA BRFSS, 2006
Data Note: Percents are weighted towards annual population estimates.
34
Diabetes in Virginia, 2009
DIABETES IS CONTROLLABLE
Diabetes Management
Eye Exam
• Diabetes is the leading cause of blindness among working age adults. An annual
eye exam allows for early detection and prompt treatment of diabetic retinopathy.
• In Virginia, in 2006, 67.0% of adults with diabetes received an annual eye exam.
Foot Exam
• According to the CDC, diabetes is the leading cause of non-traumatic lower
extremity amputations. Persons with diabetes should have a comprehensive foot
exam annually that includes checking pulses and sensation, evaluating general
foot structure, and checking skin and nails for abnormalities.
• In Virginia, in 2006, 72.0% of adults with diabetes received an annual foot exam.
Hemoglobin A1c
• According to the CDC, glycemic control is essential for preventing diabetes-
related complications. Hemoglobin A1c exams provide information on blood
sugar levels over the prior two to three months. This indicator provides
information about the quality of diabetes care provided and/or the quality of
diabetes self-management.
• A hemoglobin A1c test (A1c) is a blood test performed by a doctor, nurse, or
other health professional in a clinical setting. The test estimates the average
amount of sugar in your blood over a three month period of time; this test is not
the same as a daily blood sugar test performed at home.
• In Virginia, in 2006, 79.0% of adults with diabetes had their A1c check at least
twice per year.
Influenza Vaccination
• Persons with diabetes are considered high-risk for having major complications if
they contract the influenza (flu) virus. Persons with diabetes who are 65 years-
old or older, are at risk for dying from the influenza virus. Thus, all persons with
diabetes are encouraged to receive annual influenza vaccines.
• In Virginia, in 2006, 49.0% of adults with diabetes received a flu vaccine.
Pnuemococcal Vaccination
• Persons with diabetes are at increased risk of hospitalization, morbidity, and
mortality associated with pneumonia.
35
Diabetes in Virginia, 2009
• Unlike the influenza vaccine, the pnuemococcal vaccine is not an annual
vaccine. The recommendation for pnuemococcal is that a person with diabetes
receives the vaccine at least once in their lifetime.
• Persons with diabetes over age 65 are at highest risk for dying from pneumonia
and may have to receive a booster if hospitalized and had been given the
vaccine much earlier.
• In Virginia, in 2006, 52.0% of adults with diabetes reported ever having received
a pnuemococcal vaccine.
Self Monitoring of Blood Glucose
• Self-monitoring of blood glucose (blood sugar) is important for assessing
treatment effectiveness and to inform nutrition therapy, physical activity, and
medications to achieve the best possible glucose control. Persons with diabetes
should check their blood glucose levels at least once daily.
• In Virginia, in 2006, 62.0% of adults with diabetes reported performing daily blood
glucose checks.
36
Diabetes in Virginia, 2009
Table 17. Progress on Diabetes Management Practices —Percent of Adults with
Diabetes Meeting Healthy People 2010 (HP2010) Goals in Virginia, 1999-2006
Management 1999 2000 2001 2002 2003 2004 2005 2006
Practice:
Daily blood
sugar checks
HP2010 Goal: 42.5% 46.4% 50.1% 54.4% 55.5% 58.6% 61.0% 62.0%
61%
Hemoglobin
A1c check
twice per
N/A 73.4% 71.5% 70.3% 71.7% 74.1% 78.0% 79.0%
year
HP2010 Goal:
65% (1/yr.)*
Annual foot
exam
HP2010 Goal: 59% 61.6% 62.5% 69.8% 72.2% 72.9% 73.0% 72.0%
91%
Annual eye
exam
HP2010 Goal: 64.4% 64.2% 62.2% 63.3% 63% 64.7% 65.5% 67.0%
76%
Annual 1997 1999 2001 2002 2003 2004 2005 2006
influenza
vaccine
41.2% 53.5% 52.2% 51.1% 49.5% 48.7% 49.0% 49.0%
HP2010 Goal:
60%
Once ever 1997 1999 2001 2002 2003 2004 2005 2006
pnuemo-
coccal
24.2% 30.1% 39.2% 39.7% 43.8% 45.7% 50.0% 52.0%
vaccine
HP2010 Goal:
60%
Sources: *Goal revised to twice per year; Healthy People 2010-
www.healthypeople.gov; Centers for Disease Control and Prevention-
http://apps.nccd.cdc.gov/DDTSTRS/statePage.aspx?state=Virginia; Data notes: Three-
year rolling averages were used to improve the precision of the annual estimates; rates
are age-adjusted.
37
Diabetes in Virginia, 2009
Diabetes Patient Education
• Participation in a diabetes education course can increase knowledge and
compliance in diabetes self-management, resulting in reduced complications.
• In 2006, 53.4% of adult Virginians with diabetes reported participating in a course
or class on how to manage their diabetes.
• Females were slightly more likely than males to report participating in a diabetes
education program.
Table 18. Participation in a Diabetes Education Program by Gender in Virginia,
2006
Gender Percent Participating
Male 52.6%
Female 54.2%
• Blacks were significantly more likely to report participating in a diabetes
education program.
Table 19. Participation in a Diabetes Education Program by Race in Virginia, 2006
Race Percent Participating with Diabetes
White 52.0%
Black 67.4%
Hispanic 55.3%
Other Sample size too small.
Healthy People 2010 Objective:
(5-1) Increase the proportion of persons with diabetes who receive formal diabetes
education to 60%.
Source: BRFSS, VA 2006
Data Note: Percents are weighted towards annual population estimates.
38
Diabetes in Virginia, 2009
DIABETES IS PREVENTABLE
Risk Factors
High blood pressure, obesity, and high blood cholesterol are three of the major
modifiable risk factors for type 2 diabetes. Adult Virginians with diabetes report having
these risk factors more often than adult Virginians without diabetes.
In Virginia, in 2006, persons with diabetes were:
• 3.0 times more likely to have high blood pressure than those without diabetes.
• 2.0 times more likely to be obese, and
• 2.0 times more likely to have high cholesterol.
Certain non-modifiable risk factors such as race (e.g., being black) and age (65+) also
place a person at higher risk for having type 2 diabetes. However, the relative
contribution of these is not as great as the contribution of modifiable/preventable risk
factors.
Source: BRFSS, VA 2006
Data Note: Percents are weighted towards annual population estimates.
39
Diabetes in Virginia, 2009
Table 20. Risk Factors Related to Diabetes
Risk Factor Risk for Developing Type 2 Complications of Diabetes
Diabetes Associated with Risk Factors
• Independent risk factor • Major risk factor for stroke,
coronary heart disease, and
peripheral vascular disease
• Risk factor for blindness,
Obesity ESRD, and amputation
• Possible risk factor for
ketoacidosis and congenital
malformation
• Independent risk factor • Major risk factor for stroke,
coronary heart disease, and
ESRD
High Blood
Pressure • Risk factor for peripheral
vascular disease, blindness,
and amputation
• Independent risk factor • Risk factor for stroke, coronary
heart disease, peripheral
High
vascular disease, and
Cholesterol
amputation
• High fat diet (independent of • Risk for peripheral vascular
obesity) is a possible risk disease
Eating factor.
Habits • Directly related to other risk
factors; obesity, high blood
pressure, and high cholesterol
• Risk factor, independent of • Risk for peripheral vascular
Physical obesity disease
Inactivity
• Possible risk factor in certain • Major risk factor for coronary
minority groups heart disease, peripheral
Tobacco vascular disease, and
Use amputation
• Risk factor for stroke
• Possible risk factor for ESRD
40
Diabetes in Virginia, 2009
Overweight or Obesity
Adults who are obese are at higher risk for having complications from diabetes. Excess
body weight is linked to insulin resistance. Weight control can increase the efficiency of
the insulin receptors in the cells. The determination of being overweight or obese is
based on a calculated height to weight ratio known as Body Mass Index (BMI).
According to the American Heart Association (AHA), BMI is measured as weight in
kilograms divided by height in meters squared (kg/m2). In studies by the National
Center for Health Statistics,
• BMI values less than 18.5 are considered underweight.
• BMI values from 18.5 to 24.9 are healthy.
• Overweight is defined as a body mass index of 25.0 to 29.9. People with a BMI in
this range have an increased risk of heart and blood vessel disease, including
cardiovascular disease and diabetes.
• Obesity is defined as a BMI of 30.0 or greater, which is about 30 pounds or more
overweight. People with a BMI of 30 or more are at higher risk of cardiovascular
disease and diabetes.
• Extreme obesity is defined as a BMI of 40 or greater.
The AHA notes that, some well-trained people with dense muscle mass may have a
high BMI score but very little body fat. For them a waist circumference, skin fold or fat
fold measurement, or a more direct method of measuring body fat may be more useful.
A BMI calculator, where an individual can enter height and weight, can be found on the
Centers for Disease Control and Prevention’s website at:
http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/english_bmi_calculator/bmi_calculator
.htm.
In Virginia, in 2006, overweight and obesity trends in adults with diabetes are as follows:
• 39.3% of adults with diabetes are overweight as compared to 36.6% of adults
without diabetes.
• 45.5% of adults with diabetes are obese as compared to 23.3% of adults without
diabetes.
• Persons with diabetes are twice as likely to be obese than those without
diabetes.
Source: VA BRFSS, 2006
41
Diabetes in Virginia, 2009
Figure 18. Body Mass Index (BMI) by Diabetes Status in Virginia, 2006
50
45.5
45
40.1 39.3
40
36.6
35
30
Percent
25 23.3
20
15.2
15
10
5
0
Healthy Weight Overweight Obese
With Diabetes Without Diabetes
Healthy People 2010 Objectives:
(19-1) Increase the proportion of adults with diabetes who are at a healthy weight to
26%.
(19-2) Reduce the proportion of adults with diabetes who are obese to 41%.
Sources: American Heart Association,
www.americanheart.org/presenter.jhtml?identifier=3044776; CDC, Diabetes Indicators
and Data Source Internet Tool, 2007; VA BRFSS, 2005
Data Note: Percents are weighted towards annual population estimates.
42
Diabetes in Virginia, 2009
High Blood Pressure
High blood pressure is defined as a systolic pressure greater than 120-139 or a diastolic
pressure greater than 80-89.
• In 2005, 26.8% of all adult Virginians had high blood pressure.
• In 2005, 68.8% of adults with diabetes had high blood pressure as compared to
23.8% of adults without diabetes. Persons with diabetes are 2.9 times more likely
to have high blood pressure than those without diabetes.
Figure 19. High Blood Pressure by Diabetes Status in Virginia, 2005*
80
68.8
70
60
50
Percent
With Diabetes
40
Without Diabetes
30
23.8
20
10
0
Persons with High Blood Pressure
Healthy People 2010 Objective:
(12-9) Reduce the proportion of adults with high blood pressure to 16%. HP2010 data
are not analyzed specific to persons with diabetes.
American Diabetes Association Recommendation:
Recommended a blood pressure measurement be taken with every office visit.
Sources: U.S. Department of Health and Human Services, National Institutes of Health-
National Heart, Lung, and Blood Institute; VA BRFSS, 2005.
Data Note: *High blood pressure question not asked in Virginia BRFSS in 2006.
Percents are weighted towards annual population estimates.
43
Diabetes in Virginia, 2009
High Cholesterol
• Optimal cholesterol levels are:
o HDL (“Good”) greater than 60
o LDL (“Bad”) less than 100
o Triglycerides less than 150
o Total cholesterol less than 200
• LDL cholesterol over 100, or total cholesterol over 200, is considered high.
• In 2006, 40.1% of all adult Virginians had high cholesterol.
• In 2006, 63.1% of adults with diabetes had high cholesterol as compared to
37.9% of adults without diabetes. Persons with diabetes are 1.7 times more likely
to have high cholesterol than persons without diabetes.
Figure 20. High Cholesterol by Diabetes Status in Virginia, 2006
70
63.1
60
50
37.9
Percent
40
With Diabetes
30 Without Diabetes
20
10
0
Persons with High Cholesterol
Healthy People 2010 Objective:
(12-14) Reduce the proportion of adults with high total blood cholesterol levels to 17%.
HP2010 data are not analyzed specific to persons with diabetes.
American Diabetes Association Recommendation: Recommended total cholesterol,
Triglycerides, LDL, and HDL count every year for persons with diabetes.
Sources: U.S. Department of Health and Human Services; VA BRFSS, 2005.
Data Note: Percents are weighted towards annual population estimates.
44
Diabetes in Virginia, 2009
Physical Activity
Regular physical activity is associated with improved carbohydrate metabolism and
insulin sensitivity, and therefore can contribute to the prevention of complications of
diabetes. The risk factor for not participating in enough physical activity is called,
‘sedentary lifestyle’. Sedentary lifestyle is defined as not participating in any leisure-time
activity in 30 days (e.g., light housecleaning, bowling, golf, walking).
• In 2006, 21.7% of adults in Virginia reported being sedentary. Black females and
other non-Hispanic males had the highest rates of sedentary lifestyle.
• In 2006, 35.6% of adults with diabetes reported being sedentary as compared to
20.2% of adults without diabetes. Persons with diabetes are 1.7 times more likely
to be sedentary than those without diabetes.
Figure 21. Sedentary Lifestyle by Diabetes Status in Virginia, 2006
40
35.6
35
30
25
Percent
20.2
20
15
10
5
0
Sedentary Lifestyle
With Diabetes Without Diabetes
Healthy People 2010 Objectives:
(22-1) Reduce the proportion of adults who engage in no leisure-time physical activity to
20%.
Sources: CDC, http://www.cdc.gov/mmwr/; VA BRFSS, 2005
Data Note: Percents are weighted towards annual population estimates.
45
Diabetes in Virginia, 2009
Smoking
According to the CDC, persons with diabetes are at increased risk of complications from
cardiovascular disease, such as stroke, congestive heart failure, and angina. Smoking
cigarettes further increases this risk. Smoking increases the risk of renal (kidney)
damage and is associated with worsening retinopathy, especially in young smokers.
• In Virginia, in 2006, 19.3% of adults were current smokers.
• Persons with diabetes (17.6%) are less likely to smoke than those without
diabetes (19.6%).
• Smoking is the sole risk factor in which persons with diabetes are performing
better than those without diabetes. However, blacks with diabetes between the
ages of 55-64 years are more likely to smoke than their non-smoking
counterparts.
Figure 22. Current Smoking by Diabetes Status in Virginia, 2006
90 82.4 80.4
80
70
60
Percent
50
40
30
17.6 19.6
20
10
0
Current Smokers Not a Smoker
With Diabetes Without Diabetes
Healthy People 2010 Objective:
(27-1a.) Reduce cigarette smoking by adults to 12%.
Source: VA BRFSS, 2005
Data Note: Percents are weighted towards annual population estimates.
46
Diabetes in Virginia, 2009
Lifestyle Interventions
• Before people develop type 2 diabetes, they almost always have prediabetes.
• The Diabetes Prevention Program, a large national study of over 3,000 people,
showed that changes in lifestyle can substantially reduce the progression from
prediabetes to type 2 diabetes by 58%. Lifestyle changes include:
o Healthier eating (lowering fat and calories)
o Increased activity (about a half hour per day of moderate walking)
o Modest weight loss (5-7% of body weight)
Figure 23. Reduction in Incidence of Diabetes Due to Lifestyle Interventions,
Diabetes Prevention Program Study, 2001
12.0
11.0
10.0
58%
8.0
Percent reduction
6.0
4.8
4.0
2.0
0.0
Standard Care Intensive Lifestyle Intervention
Average Incidence Per Year
With modest lifestyle interventions, type 2 diabetes is
preventable. With participation in routine diabetes
management practices, all forms of diabetes are controllable.
One can have a high quality of life while living with diabetes.
Source: New England Journal of Medicine, Vol. 346, No. 6, February 7, 2002.
47
Diabetes in Virginia, 2009
ADDITIONAL RESOURCES
American Diabetes Association: http://www.diabetes.org/home.jsp.
Better Diabetes Care: http://www.betterdiabetescare.nih.gov/.
Centers for Disease Control and Prevention's Division of Diabetes
Translation: http://www.cdc.gov/diabetes/.
Diabetes at Work: http://www.diabetesatwork.org
Virginia Diabetes Council: http://www.virginiadiabetes.org/.
National Diabetes Education Program: http://www.ndep.nih.gov/.
Virginia Diabetes Indicators Database (VDID):
http://www.vahealth.org/cdpc/diabetes/VDID/index.htm.
Virginia Diabetes Prevention and Control Project:
http://www.vahealth.org/cdpc/diabetes/.
48
