The Burden of Diabetes in North Carolina: Brief 2013 Report

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1 NC Diabetes Prevention and Control Program Fact Sheet The Burden of Diabetes in North Carolina: Brief 2013 Report Highlights 10.9 percent or 788,000 adults in North Carolina had diabetes in Another 512,000 adults were diagnosed with pre-diabetes. One in 10 pregnant women has gestational diabetes in the state. Lifestyle factors such as overweight/obesity, lack of physical activity and unhealthy eating habits are contributing to the diabetes epidemic in the state. High blood sugar levels in diabetic patients cause problems with other body functions such as heart, kidneys, nerves, feet, eyes and gums. Having diabetes also increases the risk for skin and digestive problems. Diabetes is the 7th leading cause of death among North Carolinians. Diabetes disparities are prevalent and costly in the state. Minorities in North Carolina have higher diabetes prevalence, lower quality care, and suffer more from diabetes complications. Some adults are more likely to have diabetes Gender Males had slightly higher diabetes prevalence than females (10.9% vs. 10.8%). Age Race Education Income Disability Status Diabetes prevalence increases with age. One in every five adults age 55 and older had diabetes in the state. People aged 65 and older had the highest diabetes prevalence (23.2%). Diabetes prevalence was highest in African-Americans at 13.8 percent, compared to 10.4 percent in whites. Adults with less than a high school diploma (17.8%) or high school/ged (11.9%) were more likely to have diabetes than those with a college degree (6.0%). Adults with household incomes more than $75,000 were less likely to have diabetes compared to adults with incomes less than $15,000 (5.5% vs.16.7%). Adults with diabetes reported disability status three times more than adults without diabetes (22.0% vs.7.3%).

2 Table1. Diabetes Prevalence in North Carolina, 2011 Demographic Characteristic Weighted Number of adults Prevalence Rate (%) 95% C.I.* Upper 95% CI Total Diabetes 788,000a Gender Male White 273, Black 82, Other minority 23, Female White 260, Black 121, Other minority 23, Race/Ethnicity ** White 533, Black 203, Other minority 45, Hispanic Yes 36, No 747, Age , , , Education** < H.S. 215, H.S. or G.E.D 246, Some post-h.s. 224, College Graduate 103, Household Income** Less than $15, , $15,000-24, , $25,000-34,999 94, $35,000-49, , $50,000-74,999 63, $75, , Disability Status** Yes 376, No 375, NC Regions** Eastern NC 239, Piedmont 451, Western NC 98, *C.I. denotes Confidence Interval BRFSS 2011, North Carolina State Center for Health Statistics **Includes both sexes. Rounded to the nearest thousand. NC Diabetes Prevention and Control Fact Sheet 2 The Burden of Diabetes in North Carolina BRIEF 2013 Report

3 Diabetes Risk Factors Patients with diabetes have modifiable risk factors such as obesity, lack of physical activity, and unhealthy eating that contribute to complications including heart disease, kidney disease, eye problems and nerve disease. Overweight/Obesity: In 2011, 65.1 percent of North Carolina residents were considered overweight or obese based on Body Mass Index (BMI). People with diabetes are twice as likely to be obese compared to people without diabetes (54.6% vs. 26%). Obese adults are four times more likely to have diabetes than adults with normal weight (54.6% vs. 12.9%). If obesity continues to increase at the same rate, it could contribute to 1.2 million new cases of diabetes by 2030 in the state. However, if the BMI was lowered by 5 percent in next 20 years, type 2 diabetes could be prevented in 261,785 people in North Carolina 2. Poor eating habits: Eating processed foods and oversized portions have increased obesity and diabetes in the state. More than 87 percent of adults with diabetes did not consume five or more servings of fruits, vegetables or beans daily in Eating balanced meals, making healthy food choices, understanding portion sizes, and learning the best times to eat are important to manage diabetes. Lack of exercise: Vigorous exercise not only helps in weight loss but also improves insulin sensitivity and heart health. It is never too late to increase physical activity. Swedish National Diabetes Register found that higher levels of leisure-time physical activity cut the risk of cardiovascular and all-cause mortality by two-thirds in people with type 2 diabetes 3. Forty percent of diabetic patients did not participate in any physical activity such as running, walking, gardening, and golf in North Carolina in More than 60 percent did not meet aerobic activity recommendation. About 83 percent did not meet muscle strengthening activity recommendation. NC Diabetes Prevention and Control Fact Sheet 3 The Burden of Diabetes in North Carolina BRIEF 2013 Report

4 Pre-diabetes: People with pre-diabetes a condition in which blood glucose levels are higher than normal but not high enough to be classified as diabetes are at increased risk for developing type 2 diabetes. The Diabetes Prevention Program (DPP) study showed that people with pre-diabetes who exercised moderately for 30 minutes a day and lost 5 to 7 percent of their body weight through modest dietary changes were able to cut their odds of getting diabetes by 58 percent. In North Carolina, 7.9 percent or 512,000 adults were estimated to have diagnosed pre-diabetes in Pre-diabetes rates were highest among blacks (9.3%), compared to whites (7.8%) in the state. Women had higher levels of diagnosed pre-diabetes, compared to men (10.3% vs. 5.4%). One in 10 ten adults who were diagnosed with pre-diabetes was 55 and older. Figure 1. Selected Risk Factor prevalence by Diabetes status in North Carolina, BRFSS 2011 Gestational Diabetes: Gestational Diabetes occurs in some pregnant women who never had diabetes before but have high blood glucose levels during pregnancy. Although gestational diabetes goes away after delivery in majority of cases, 5 to 10 percent of women develop type 2 diabetes immediately. Women with gestational diabetes have percent chance of developing type 2 diabetes in the next years. Among Medicaid enrollees in North Carolina in FY 2011, 10,059 women had gestational diabetes. Pregnancy Risk Assessment and Monitoring System (PRAMS) showed that one in 10 pregnant women in North Carolina had gestational diabetes in 2009 (10.5%) 4. NC Diabetes Prevention and Control Fact Sheet 4 The Burden of Diabetes in North Carolina BRIEF 2013 Report

5 Environmental Chemicals and Toxins: People who are exposed to highest levels of environmental toxins have a much higher risk of diabetes. Toxins block the function of receptors in cells which leads to insulin resistance and diabetes. Toxins slow down metabolism, increase glucose, cholesterol, and fatty liver, and slow down thyroid function. The National Health and Nutrition Examination Survey (NHANES) found a strong correlation between diabetes and blood levels of six common persistent organic pollutants (POPS); polychlorinated dibenso-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and two organochlorines used as pesticides. According to Journal of the American Medical Association, bisphenol A, a petrochemical that lines water bottles and canned food containers, increases a person s risk of diabetes, heart disease and abnormal liver function caused by insulin resistance 6. And another study showed that arsenic exposure increases the risk of diabetes 7. Exposure to chemicals and toxins causes obesity and diabetes, independent of calorie intake or exercise. Diabetes Complications Cardiovascular Disease (CVD): People with diabetes are three times more likely to report cardiovascular disease (history of heart attack or coronary heart disease or stroke) than people without diabetes (24.3% vs. 7.3%) 1. Blood Pressure: People with diabetes reported almost three times more high blood pressure than people without diabetes (72.9% vs. 27.5%). Blood Cholesterol: People with diabetes were twice as likely to report high blood cholesterol as people without diabetes (67.6% vs. 34.1%). Kidney Disease: Diabetes is the leading cause of kidney failure. People with diabetes have almost four times more kidney disease prevalence than people without diabetes (6.4% vs. 1.7%). Cancer: People with diabetes are almost three times more likely to have cancer than people without diabetes in North Carolina (13.8% vs. 5.6%). Diabetes and increased fasting glucose are independently associated with an increased risk for a variety of cancers. It is estimated that colon cancer risk is 38 percent higher among people with diabetes than people without the disease 8. About 40 percent of the years of life lost from diabetes can be attributed to nonvascular conditions, including about 10 percent to death from cancer. NC Diabetes Prevention and Control Fact Sheet 5 The Burden of Diabetes in North Carolina BRIEF 2013 Report

6 Figure 2. Complications by Diabetes Status in North Carolina, BRFSS 2011 *Cardiovascular Disease Hypoglycemia: Hypoglycemia, same as low blood sugar, is a common North Carolina Emergency Medical Services (EMS) shows that 40,263 emergency among people with or 43 percent of ambulance runs from July 2008 to June 2010 were diabetes. It can happen when blood potentially diabetes-related. By primary impression, almost 30 percent glucose level falls too low as people or 11,496 of diabetes-related ambulance runs were hypoglycemia-related. with diabetes take insulin or oral antidiabetic medications. It can cause sickness and even death. The research shows that achieving good glycemic control is good for minimizing the risk of micro vascular complications among people with diabetes. Hearing loss: More than one million North Carolinians have hearing loss in The major factors known to affect hearing are age, race, ethnicity, income level, noise exposure, and the use of certain medications. It is more prevalent in men compared to women. Hearing loss is twice as common in adults with diabetes compared to people without diabetes. National Health and Nutrition Examination Survey (NHANES) showed that 65.5 percent of U.S. adults (age 20 and above) with diabetes had hearing impairment 10. The study showed that 21 percent had low frequency hearing loss and 54 percent had high frequency hearing loss specifically linked to diabetes. Diabetic patients with low HDL cholesterol ( good cholesterol ), a history of coronary heart disease, peripheral neuropathy and those who report poor health are more likely to have hearing impairment. Sleep Apnea is a common and serious sleep disorder among people with diabetes Sleep apnea is associated with alterations in glucose metabolism and places patients at an increased risk of the development of type 2 diabetes. The risk factors for sleep apnea include overweight/obesity, age, crowded airway, male sex, hypertension and cardiovascular disease. The symptoms of sleep apnea are snoring, difficulty breathing at night, insomnia and excessive daytime sleepiness. NC Diabetes Prevention and Control Fact Sheet 6 The Burden of Diabetes in North Carolina BRIEF 2013 Report

7 Obstructive Sleep Apnea: Among people who have sleep apnea, 90 percent of them have Obstructive Sleep Apnea (OSA). OSA affects approximately 20 percent of the nation s adults of whom 90 percent are undiagnosed. OSA is highly prevalent in men. Two out of three men with diabetes who are 65 or older have OSA. North Carolina Hospital Discharge data shows that there were 15,000 males with OSA in In North Carolina, there were 138,464 Medicaid adults with diabetes (18+) in FY Of them, 13,612 adults were identified with a procedure code for sleep apnea. Out of them, 84 percent had OSA. It is important to treat sleep apnea as it increases risk of high blood pressure, heart failure and stroke. Lifestyle modification including weight loss, smoking cessation, Continuous Positive Airways Pressure (CPAP) treatment and surgery will help to treat the problem and reduce complications. Diabetes Control Comprehensive diabetes control includes optimal management of A1c (a measure of average blood glucose over 2-3 months), Blood pressure and Cholesterol (ABC). The ABC treatment goals for most people with diabetes are: A- A1c (blood glucose) less than 7 percent. B- Blood pressure less than 130/80 mmhg C- Cholesterol-LDL less than 100 mg/dl Preventive Care Practices Preventive care practices are essential to diabetes care. More than half of diabetes patients received preventive care services annually such as eye and foot exams in the state. Table 2 shows the percentage of North Carolina adults with diagnosed diabetes who received some of the preventive care practices in National health objectives in Healthy People 2020 (HP 2020) call for increasing the percentage of people with diabetes who are practicing these recommendations. Although North Carolina met some HP 2020 objectives such as annual eye exam, foot exam, and A1c testing, the state still needs to work on improving the percentage of people receiving diabetes self-management class and flu and pneumococcal vaccines. NC Diabetes Prevention and Control Fact Sheet 7 The Burden of Diabetes in North Carolina BRIEF 2013 Report

8 Table 2. Preventive Care Practices among people with Diabetes, North Carolina BRFSS 2011 Preventive Care Practices Prevalence Rate HP 2020 Goal Meets HP 2020 goal? Annual Eye Exam Annual Medical Foot Exam A1c tests twice per year Self-Exam of Feet (one or more times per day) Diabetes Self-Management Class X Self-Monitoring of Blood Glucose (one or more times per day) X Influenza vaccination X Pneumococcal Vaccination X Health Care Access: Health Insurance Coverage The 2011 BRFSS survey shows that people with diabetes have slightly higher rate of health insurance coverage (78.6% ) (under age 65), compared to 75.0% of people without diabetes in the state. Among people who are employed (under age 65), 88.1 percent of people with diabetes reported having health insurance compared to 81.7 percent of people without diabetes. Table 3. Prevalence of Health Insurance coverage by Selected Groups (Age <65), in North Carolina, BRFSS 2011 Demographic Group Percent Total 75.1 Male 73.1 Female 77.2 White 80.6 Black 70.2 Less than High School 48.9 High School 69.8 Post High School 79.4 College graduate 91.7 People with diabetes 78.6 People without diabetes 75.0 NC Diabetes Prevention and Control Fact Sheet 8 The Burden of Diabetes in North Carolina BRIEF 2013 Report

9 Diabetes Morbidity People with diabetes are three times more likely to require hospitalization than those without the condition. There were 18,101 hospital discharges in North Carolina in 2010 with diabetes as the principal diagnosis 11. Another 196,405 people were discharged from hospitals with any mention of diabetes in the diagnosis. The cost of diabetes-related hospitalizations is a huge burden on the state. Total charges for diabetes-related hospitalizations were almost $5 billion in North Carolina in 2010 (Table 4). Table 4. Diabetes-related hospital discharges with any mention of diabetes, North Carolina, 2010 Diagnosis related to Diabetes Number of total discharges Total charges ($) Average Charge per hospital stay ($) Any mention of diabetes 196, billion $25,273 Cardiovascular Disease 48, billion 30,355 Heart Attack 33, billion 33,637 Stroke 8, million 22,624 Renal dialysis/transplant 9, million 32,766 Lower limb amputation 2, million 44,468 In North Carolina, 7.9 percent of all emergency department (ED) visits had a first or comorbid diabetes diagnosis in ED visits rate in the state with diabetes as the first or comorbid diagnosis was 36.7/1,000 person-years. Almost 80 percent of diabetes-related ED visits were made by people 45 years of age and older, and one-third of these patients were admitted to the hospital. The state or federal government was expected to pay for 63.8 percent of diabetes-related visits. Diabetes is the leading cause of death due to heart attacks and strokes, and it is the leading cause of blindness and kidney failure in the state. While diabetes is the 8th leading cause of death among whites, it is the 4th leading cause of death for blacks and Native Americans in North Carolina in There were 2,036 deaths in the state with primary diagnosis of diabetes with an age-adjusted death rate of 26.0 per 100,000 population 13. Although diabetes-related deaths have decreased over the past few years, the racial disparities still persist. African Americans and American Indians experienced almost three times higher diabetes-related death rate than whites (52.3 and 57.0 vs per 100,000 population) in 2010 ((Figure 3). Figure NC Resident Diabetes deaths per 100,000 population, Ages 15 & Over NC Diabetes Prevention and Control Fact Sheet 9 The Burden of Diabetes in North Carolina BRIEF 2013 Report

10 Diabetes projections If obesity trend continues at the same rate in North Carolina, there may be 1.2 million new cases of diabetes over the next 20 years in the state 2. CDC estimates that the number of U.S. adults with diabetes is projected to double or triple by Increases in older population and minority population, and longer lifespans contribute to the increase of diabetes. Sources Most of the data for this brief came from Behavioral Risk Factor Surveillance System (BRFSS) 2011, State Center for Health Statistics. The eighth annual F as in Fat: How Obesity Threatens America s Future 2011, a report from the Trust for America s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF). Zethelius B, Gudbjörnsdottir S, Eeg-Olofsson L, et al. Leisure time physical activity and risks of cardiovascular disease and mortality in type 2 diabetes: Report from the Swedish National Diabetes Register. European Association for the Study of Diabetes 2012 Meeting; October 2, 2012; Berlin, Germany. Presentation Pregnancy Risk Assessment Monitoring System (PRAMS), State Center for Health Statistics. Lee DH, et al. A strong dose-response relation between Serum concentrations of persistent organic pollutants and diabetes: results from the national Health and Examination Survey Diabetes Care July: 29(7): Lang IA, et al. Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults. JAMA 2008 Sept 17;300(11): , Navas-Acien A, Silbergeld EK, et al. Arsenic exposure and prevalence of type 2 diabetes in US adults; JAMA, 2008 August 20;300(7): Sanjai Sinha, Diabetes as a risk factor for cancer and other cause-specific mortality, 9/13/2012 North Carolina Division of Services for the Deaf and the Hard of Hearing, March Kathleen Bainbridge et al. Risk Factors for Hearing Impairment Among U.S. Adults with Diabetes, National Health Nutrition Examination Survey , Diabetes Care, Volume 34, July North Carolina Hospital Discharge data, State Center for Health Statistics. 12 NC DETECT Annual Report NC Death Certificates data 2010, NC State Center for Health Statistics. For more diabetes data, please see The Burden of Diabetes in North Carolina at: North Carolina Division of Public Health Diabetes Prevention and Control NC DHHS is an equal opportunity employer and provider. 02/2013 NC Diabetes Prevention and Control Fact Sheet 10 The Burden of Diabetes in North Carolina BRIEF 2013 Report

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