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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/

                                    ii
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


                                                                iii
                                                                                                  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




                                                              iv
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




                                                                v
                                                                                                         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




                                                                   vi
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.




                                           vii
                                                                       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.




                                           ix
                                                                  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.




                                         x
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.




                                                 xi
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


                                               1
                                                                     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.




                                           6
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




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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