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Health & Nutrition:
Chronic Disease - Diabetes

Current Situation

In Mississippi, diabetes is an important public health problem. It is a major cause of morbidity, disability, and mortality and a major source of health care costs. More than 225,000 residents, or approximately 7.9% of the total population, are currently estimated to have diabetes; one third of them are undiagnosed. Diabetes contributes to the deaths of an estimated 1,600 to 1900 residents each year. Diabetes is also responsible for a considerable amount of premature mortality, particularly in the African-Americans.

Complications of diabetes include diabetic eye disease, adverse outcomes in pregnancy, cardiovascular diseases, renal failure, and amputations. Diabetes is the leading cause of blindness among persons 20-74 years of age, and Mississippi has the highest incidence and prevalence of legal blindness in the nation. Persons with diabetes are 25 times more likely to have an amputation of an extremity, two to three times more likely to die from a heart attack, and 17 times more likely to develop terminal kidney disease. . An estimated 1,700 Mississippians (probably also an underestimate) suffer significant diabetes-related complications each year, including:

• approximately 950 lower extremity amputations
• approximately 450 new cases of end-stage renal disease
• more than 300 new cases of blindness

Diabetes is also an important risk factor for coronary heart disease, stroke, and various complications of pregnancy. More than 700,000 persons in Mississippi are at increased risk of undiagnosed diabetes because of being overweight and/or having a sedentary lifestyle. About 10% of these persons already have undiagnosed diabetes, and many more are at risk of developing diabetes in the future.

In Mississippi, legislation for reimbursement for diabetes education and treatment was passed in the 1998 legislative session.

Mortality data
Mortality numbers and rates due to diabetes (ICD-9 code N250) are based on death certificate data provided by the Bureau of Public Health Statistics, Mississippi State Department of Health (MSDH)ⁱⁱⁱ and also available through CDCs WONDER system at http://wonder.cdc.gov. A diabetes-related death is one where diabetes is listed as the primary or underlying cause of death. The highest, lowest diabetes mortality rates in 1998 per 100,000 population are Louisiana at 40.1 , and Colorado 15.1. The Mississippi diabetes mortality rate ranked 34th (at 20 .4) which is well below the mortality rate for many other states.

Years of Potential Life Lost (YPLL)* due to diabetes
In 1998, diabetes was responsible for 5,207 YPLL to age 75. Diabetes YPLL rates are markedly higher (70%) for nonwhites compared to whites. Nonwhite males have diabetes YPLL rates that are 40% higher than those of white males; nonwhite female YPLL rates are double white female YPLL rates. Thus, diabetes is responsible for a considerable amount of premature mortality in Mississippi, particularly in nonwhites. Years of potential life lost (YPLL) is a measure of the impact of premature mortality on a population. It is the sum of the differences between some predetermined end point and the ages of death for those who died before that end point. For example, using an end point of age 75, a person dying at age 65 has lost 10 years of potential life.

Prevalence estimates
Prevalence estimates are based on self-reported data from the Mississippi Behavioral Risk Factor Surveillance System (MS-BRFSS). The MS-BRFSS is a continuous, statewide, random-digit-dialed telephone survey of a representative sample of the Mississippi civilian non-institutionalized adult population (18 years of age and older)^iv. County prevalence data is weakened by the relatively small sample sizes of the county MS-BFRSS.

Persons at risk of developing type 2 diabetes in Mississippi
The major risk factors for developing type 2 diabetes (the predominant form of diabetes) are age (over 45 years), being overweight (BMI over 27.8 (men) / over 27.3 (women), equivalent to being 20% or more above ideal weight for height), and having a sedentary lifestyle (no physical activity or activities that are done for 20 minutes or less, three or fewer times per week). The most important risk factor is overweight. 80% of type 2 diabetics are overweight at the time of diagnosis, and type 2 diabetes is three times as common in persons who are at least 40% overweight. Mississippi continues to have the highest prevalence of self-reported overweight in the nation, and one of the highest rates of self-reported sedentary lifestyle in the nation. In 1998, approximately 36% of adult Mississippians were overweight, and in 1996, approximately 65% failed to maintain adequate levels of exercise. Since 1990, there has been an increase of almost 10 percentage points in the prevalence of self-reported overweight in the state, a relative increase of 37% .

Cardiovascular disease risk factors in persons with diabetes
The main cause of death in persons with diabetes is heart disease (especially ischemic heart disease);stroke incidence/mortality is also increased in persons with diabetes. Recently the National Heart, Lung, and Blood Institute , the National Institute of Diabetes and Digestive and Kidney Diseases, the American Heart Association, the American Diabetes Association (ADA) and the Juvenile Diabetes Foundation International released a joint statement emphasizing the role of diabetes as a major risk factor for cardiovascular disease (CVD).

Diabetes management performance indicators
Many of the complications of diabetes can be prevented or limited by appropriate and timely interventions, yet many people with diabetes may not be receiving medical care that meets published standards and guidelines. These guidelines and standards of care are also reflected in the Southern Extension Health Program Indicators( LINK) and the Healthy People 2010 Objectives listed below. Limited data on diabetes knowledge and care practices in Mississippi are available from the diabetes module of the MS-BRFSS and the 1997 IQH/MSDH survey of primary care providers. Data are available on the following performance indicators: annual number of visits to a physician; percent of respondents who have heard of HgA1c; frequency of HgA1c checks; frequency of foot exams (or referral for a foot exam); frequency of (dilated) eye exams (or referral for an eye exam); frequency of screening for albuminuria / proteinuria; frequency of checking lipid profile/cholesterol level; percent of respondents receiving treatment with ACE inhibitors when proteinuria diagnosed.

Healthy People 2010 Objectives for diabetes(LINK) addressed by Extension Diabetes education :

• 5-1 - Increase the proportion of persons with diabetes who receive formal diabetes education.
• 5-4 - Increase the proportion of adults with diabetes whose condition has been diagnosed.
• 5-11,5-12,5-13,5-14,5-15,5-17 - Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement, a lipid profile, a urinary microalbumin measurement, a dilated eye exam, a foot health exam, and a dental exam at least once a year.
• 5-16 - Increase the proportion of adults with diabetes who take aspirin at least 15 times per month.

ⁱExpert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report. Diabetes Care1997;20:1183-97.

ⁱⁱPerman, A. Epidemiology of Diabetes in Mississippi. www.msdh.state.ms.us/documents/epi.diabetes1998.pdf

ⁱⁱⁱGeiss LS, Herman WH, Smith PJ. Mortality in Non-Insulin Dependent Diabetes. In: Harris MI,Cowie CC, Stern MP, et al (eds). Diabetes in America. 2 ed. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995;4:233-257. NIH Publication 95-1468.

^ivCook CB, Penman AD, Cobb A, Murphy T, Miller D, Horne T. Compliance with recommended diabetes standards of care among Medicare beneficiaries in four Mississippi primary care clinics. Journal of the Mississippi State Medical Association 1999;40:8-13.

^vGrundy SM, Benjamin IJ, Burke GL, et al. Diabetes and Cardiovascular Disease: A Statement for Healthcare Professionals From the American Heart Association. Circulation 1999;100:1134-1146.

^viAmerican Diabetes Association: Clinical Practice Recommendations 1999. Standards of medical care for patients with diabetes mellitus. Diabetes Care 1999;22(Suppl 1):S32-41.

Frequently Asked Questions

What are the different types of diabetes?

How is diabetes diagnosed?

What are the costs of diabetes?

Publications

What You Should Know About Diabetes IS1632