In an effort to better understand this disease, Council staff conducted independent research and reviewed submitted information. This section discusses (1) the prevalence of diabetes; (2) the types, risk factors, prevention, diagnosis, and treatments of diabetes; (3) complications associated with diabetes; and (4) costs for diabetic supplies and education.
Diabetes is a chronic disease which is estimated to affect 1 in every 11 Pennsylvania citizens, or 9% of the population. This figure represents one of the highest rates in the nation, accounting for 7 percent of the estimated 15.7 million cases nationally, or 1.1 million cases. According to the Centers for Disease Control and Prevention:
According to a recent article in the Philadelphia Inquirer, the impact of diabetes has been particularly devastating in some rural areas. "Nine areas of Pennsylvania, covering 18 counties, had death rates that were double or triple the national rate for the period 1989-1992, federal data show." Three of those areas, Tioga, Luzerne and Mercer Counties, "ranked among the 20 areas with the highest death rates nationally." In analyzing the Council's own data, staff confirmed that the number of diabetes-related hospitalizations differ across Pennsylvania counties. On the low side, one county had fewer than 3 residents per 1,000 hospitalized with diabetes. On the high side, one county had more than 14 residents per 1,000 hospitalized with diabetes.
The prevalence of diabetes increases with age. In 1994, diabetes affected:
Diabetes appears to affect men and women with equal frequency. According to the Centers for Disease Control and Prevention, 8.2% of both men and women have diabetes. According to the Council's data, diabetes-related hospitalization rates are similar for men and women.
The incidence of diabetes is affected by race/ethnicity. On average, non-Hispanic African-Americans are 1.7 times as likely to have diabetes as non-Hispanic whites of similar age. Furthermore, on average, Hispanic/Latino Americans are almost twice as likely to have diabetes as non-Hispanic whites of similar age.
Healthy People 2000 outlines objectives for disease prevention and control. One objective is to reduce the diabetes prevalence rate [of diabetes and chronic disabling conditions] among all adults to no more than 25 per 1,000. Although the rate is projected to decrease in the Commonwealth, the Pennsylvania Department of Health noted that, "the projected decreases will probably not be nearly enough to help Pennsylvania meet this national year 2000 objective." The following table outlines the Healthy People 2000 goals, the Mid-Decade Review (1995) figures published by the Pennsylvania Department of Health, and the Department of Health projections as to where Pennsylvania will be in the year 2000.
| * Weight is a contributing factor to diabetes | |||
| Subject | Goal for "Healthy People 2000" | Pennsylvania's actual figures in 1995 | Pennsylvania's projection for 2000 |
|---|---|---|---|
| Prevalence of Diabetes | 25 per 1,000 | 56 per 1,000 | 46-48 per 1,000 |
| Prevalence of Diabetes among African Americans | 32 per 1,000 | 72 per 1,000 | Unable to determine |
| Diabetes Death Rate | 34 per 100,000 | 45.5 per 100,000 | 45 per 100,000 |
| Diabetes Death Rate among African Americans | 58 per 100,000 | 71.3 per 100,000 | unable to determine |
| Percentage of population who are overweight* | 20% of population aged 20 and older | 31% of population aged 20 and older | 35% of population aged 20 and older |
Diabetes mellitus is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin secretion, insulin usage, or both. There are two main types of diabetes.
There is a third type of diabetes known as gestational diabetes. This develops in 2% to 5% of all pregnancies but disappears when a pregnancy is over. Of women who experience gestational diabetes, nearly 40% will develop Type 2 diabetes later in life. Gestational diabetes occurs more frequently in African Americans, Hispanic/Latino Americans, and American Indians.
The risk factors for Type 1 diabetes are not well defined. According to the American Diabetes Association, people do inherit a tendency to get diabetes, but not all people with this tendency will get the disease. Other factors such as illness must also come into play for diabetes to begin. The Centers for Disease Control and Prevention state that autoimmune, genetic, and environmental factors are involved in the development of Type 1 diabetes.
Risk factors for Type 2 diabetes include age (primarily those people over age 45), obesity, physical inactivity, and family history of diabetes. Women with a prior history of gestational diabetes are also at increased risk for Type 2 diabetes. As previously stated, race/ethnicity is also a significant risk factor. African-Americans and Hispanics are twice as likely to develop diabetes as whites.
Although researchers are making progress in identifying the exact genetics and "triggers" that predispose some individuals to develop Type 1 diabetes, preventive efforts have not been discovered.
According to the Centers for Disease Control and Prevention, there have been a number of studies which show that regular physical activity can significantly reduce the risk of developing Type 2 diabetes. This may be due in part to the link between Type 2 diabetes and obesity. The American Diabetes Association estimates that a combination of weight loss, diet, and exercise can prevent up to half of all cases of Type 2 diabetes.
According to the American Diabetes Association, weight loss, diet, and exercise may also prevent up to one third of the cases of gestational diabetes.
The routine diagnostic test for diabetes is a fasting plasma glucose test, a test of the level of glucose in the blood. A fasting plasma glucose value of greater than or equal to 126 milligrams/deciliter (mg/dL) indicates a diagnosis of diabetes. Symptoms of Type 1 diabetes include: frequent urination (including bed-wetting in children), excessive thirst, unexplained weight loss, extreme hunger, fatigue, mood swings, and nausea.
Since Type 2 diabetes develops slowly, people may confuse the symptoms with signs of aging. The result is a large population of people with undiagnosed diabetes. Symptoms for Type 2 diabetes include: all symptoms for Type 1 diabetes, sudden changes in vision including blurring, numbness in the extremities, dry and itchy skin, and sores which are slow to heal, including infections of the skin and gums.
It should be noted that many people with diabetes are not diagnosed as diabetic until they have developed complications. For example, a diagnosis of diabetes may accompany a hospital admission for heart disease or kidney disease.
For people with diabetes, the key to a healthy life is to follow prescribed treatment plans. Treatment involves nutrition, exercise, and medication. According to the American Diabetes Association, training in self-management is integral to the treatment of diabetes. Although diabetics can learn to manage their disease, there is no cure for diabetes.
Lack of insulin production by the pancreas makes Type 1 diabetes particularly difficult to control. Treatment requires a strict regimen that typically includes a carefully calculated diet, planned physical activity, home blood glucose testing several times a day, and multiple daily insulin injections. At this time, it is not possible to "take a pill" to provide the body with insulin since stomach acids would destroy the insulin before it could begin to work. Research into new treatment methods, including insulin delivery, is ongoing.
Treatment of Type 2 diabetes typically includes diet control, exercise, home blood glucose testing, and in some cases, oral medication and/or insulin.
Complications resulting from diabetes are very serious, even life-threatening. The Council's inpatient data shows that 70% of the diabetes-related hospitalizations involve complications. It is widely recognized in the medical community that the best prevention against complications is tight monitoring of blood glucose levels, including strict compliance with a nutritional plan, exercise, and insulin injections, if necessary. Unfortunately, even though tight control of blood glucose levels has demonstrated a reduction in complications, there are still patients who suffer from complications even when following strict guidelines.
Diabetes is the leading cause of new cases of blindness in adults 20 to 74 years old. According to the American Diabetes Association, every year there are 937 new cases of diabetes-related blindness in Pennsylvania. The American Diabetes Association estimates that diabetes-related blindness can be prevented in 60% of cases through education and laser surgery. People with diabetes are 40 percent more likely than others to suffer from the eye disorder glaucoma. People with diabetes are 60 percent more likely to develop cataracts. Diabetics also tend to get cataracts at a younger age and have them progress faster.
The Council's inpatient data indicates that almost 12,000 hospitalizations a year involve diabetes with eye complications, for total hospital charges of over $217 million and more than 84,000 hospital days.
Kidney disease is a significant cause of premature mortality in people with diabetes. The American Diabetes Association estimates that 10% to 20% of diabetics have some form of kidney disease. Kidney failure is known as end-stage renal disease; treatment requires either dialysis or a transplant. Diabetes is the leading cause of end-stage renal disease, accounting for about 40% of new cases. There has been a noticeable rise in the percentage of end stage renal disease caused by diabetes. In 1982, diabetes contributed to 23% of end stage renal disease, whereas in 1991, that figure had climbed to 36%. In Pennsylvania, over 1,000 new cases of end-stage renal disease related to diabetes are diagnosed each year. According to the Council's own data, diabetes with end-stage renal disease accounts for over 25,000 hospitalizations per year. Total charges for these hospitalizations reach $556 million and encompass over 206,000 hospital days. The American Diabetes Association estimates that 50% of diabetes-related end stage renal disease is preventable by controlling blood pressure.
About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage, known as diabetic neuropathy. This nerve damage can affect all areas of the body but is most common in the legs, feet, and hands.
There can be serious complications of neuropathy. For example, with reduced feeling in one's feet, one may have an infection or open sore of which they are unaware. Left untreated, a simple sore can develop into a more serious condition. For this reason, it is recommended that diabetics have regular foot examinations from their physician. Diabetics are also educated to examine their feet on a daily basis in order to be aware of any sores or abnormalities.
Tight control of blood glucose has shown to decrease the risk of developing neuropathy by as much as 69% among individuals with no existing conditions.
Another complication of diabetes is peripheral vascular disease. This is the result of reduced blood flow to the feet and legs. If left untreated, vascular disease can lead to gangrene and amputation. Vascular disease is four times more common in diabetics than non-diabetics. It is estimated that 10% of diabetics have vascular disease. According to the American Diabetes Association, 60% of diabetes-related vascular disease can be prevented by controlling blood pressure and smoking cessation.
More than half of lower extremity amputations in the United States occur among people with diabetes. Using the Council's own data, staff determined that approximately 5,000 inpatient hospitalizations a year involve lower extremity amputations, resulting in more than $155 million in hospital charges and over 62,000 hospital days. The American Diabetes Association estimates that half of diabetes-related amputations can be prevented through improved glycemic control, education, improved control of blood pressure, and smoking cessation.
Heart disease is the leading cause of diabetes-related deaths. Fifty-five percent of deaths in people with diabetes are caused by cardiovascular disease. In examining the Council's own data on coronary artery bypass graft surgery, staff determined that almost 30% of the patients undergoing this procedure have diabetes. Further, the Council's data on heart attack patients, indicates that almost 40% have diabetes. The American Diabetes Association claims that controlling blood pressure and lipids (such as cholesterol) combined with smoking cessation may prevent 45% of diabetes-related cases of coronary heart disease.
The risk of stroke is 2 to 4 times higher in people with diabetes. In addition, people with diabetes are more likely to die from a stroke than are non-diabetics. By controlling blood pressure, the American Diabetes Association estimates 85% of diabetes-related stokes are preventable.
One reason people with diabetes are more prone to cardiovascular disease and stroke is the fact that hypertension (high blood pressure) is more common in diabetics. An estimated 60% to 65% of people with diabetes have high blood pressure.
Diabetes can cause acute life-threatening events, such as diabetic ketoacidosis. These medical conditions can result from a biochemical imbalance in uncontrolled diabetes. When recognized early and treated, these conditions are usually reversible. Education and self-management are essential to the prevention of acute complications.
People with diabetes are more susceptible to many other illnesses. For example, although pneumonia occurs just as frequently among non-diabetics as among those with diabetes, pneumonia is 70% more likely to result in death for those people with diabetes.
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