Diabetes is approaching epidemic proportions in the United States. More than 18 million Americans today have diabetes. Approximately 41 million Americans have pre-diabetes,8 which means they are at high risk for developing type 2 diabetes.9 For people with diabetes, blood glucose (sugar) levels are elevated either because the body cannot make adequate amounts of the hormone insulin and/or its cells do not respond to insulin.10
Over the past half century, there has been a four- to eight-fold increase in the prevalence of diagnosed cases of diabetes in the U.S.11 In 2002, the prevalence of diagnosed diabetes among people aged 20 years or older was 8.7 percent and among 60 years or older was 18.3 percent.12 From 1997 through 2002, the number of new cases of diagnosed diabetes per year increased from 878,000 to 1,291,000 (a 47 percent increase).13 Projections of diabetes for future years are not encouraging (Figure 1). A 165 percent increase in the number of persons with diabetes in the U.S. is projected through 2050, with a rise from 11 million to 29 million diagnosed persons of all ages.14 Without preventive action, one in every three children born in the year 2000 will develop diabetes in their lifetime.15
In addition, minority populations are disproportionately affected by diabetes (Figure 2). On average Blacks, Hispanics, and American Indians and Alaska Natives are more likely (1.6 to 2.3 times as likely) to have diabetes than non-Hispanic Whites.16 Rates of diabetes-related deaths are higher among Blacks, American Indians, and Hispanics than for Whites,17 and diabetes is the 5th leading cause of death for Asian and Pacific Islanders.18 Certain minority groups also have much higher rates of diabetes-related complications, in some cases as much as 50 percent more than the diabetes population. For example, Blacks are more likely to have serious complications from diabetes, such as end-stage renal disease and lower extremity amputations.19
Costs of diabetes are high in both human and economic terms. While estimating the national costs for diabetes over time is difficult because of changes in the U.S. population and changes in the cost of health care services, evidence suggests that these costs are high and rising. The American Diabetes Association (ADA) estimated the national cost of diabetes for 2002 to be approximately $132 billion: $92 billion for direct medical expenditures and $40 billion for indirect costs, such as lost work days, restricted activity days, and mortality and permanent disability due to diabetes.20 Research from the Centers for Disease Control and Prevention (CDC) indicates that people with diabetes miss 8.3 days per year from work, compared to 1.7 days for people without diabetes.21 In the same ADA study, it is projected that the annual costs of diabetes (in 2002 dollars) could rise to $156 billion by 2010 and to $192 billion in 2020. By 2020, direct medical costs are estimated to increase to $138 billion and indirect costs from lost productivity could increase to $54 billion.22
Figure 1. Prevalence of Diagnosed and Projected Diagnosed Diabetes Cases in the United States, 1960-2050
SOURCE: Data for 1960–1998 from the National Health Interview Survey, National Center for Health Statistics (NCHS). Centers for Disease Control and Prevention (CDC) projected data for 2000–2050 from the Behavioral Risk Factor Surveillance System, Division of Diabetes Translation, CDC. (Note: The “Diagnosed cases” arrow refers to the section of the figure that includes diagnosed cases of diabetes versus the section that includes projected cases. The line graph and not the line arrow indicate the number of diagnosed cases.)
Figure 2. Age-Adjusted Total Prevalence of Diabetes in People Aged 20 Years or Older, by Race/Ethnicity: United States, 2002
SOURCE: 1999-2001 National Health Interview Survey and 1999-2000 National Health and Nutrition Examination Survey estimates projected to year 2002. 2002 outpatient database of the Indian. (Note: Whites refers to non-Hispanic Whites, and Blacks refers to non-Hispanic Blacks).
*AI/AN who receive care from the IHS.
8 Pre-diabetes is a condition defined by impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both.
9 CDC, op.cit.
11 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Atlanta, GA, U.S. Department of Health and Human Services. Available at: http:www.cdc.gov/diabetes/statistics/index.htm; and Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non-insulin-dependent diabetes, in Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennette Ph (eds). (1995). Diabetes in America, 2nd ed. Bethesda, MD: National Institutes of Health.
12 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Atlanta, GA, U.S. Department of Health and Human Services. Available at: http:www.cdc.gov/diabetes/statistics/index.htm.
13 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Incidence of diabetes. Available at: http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm. Accessed September 15, 2004.
14 Boyle JP, Honeycutt AA, Narayan KM, Hoerger TJ, Geiss LS, Chen H, Thompson TJ. (2001). Projection of diabetes burden through 2050: Impact of changing demography and disease prevalence in the U.S. Diabetes Care, 24(11), 1936-1940.
15 Narayan, op.cit.
16 Centers for Disease Control and Prevention (CDC). (2003). National diabetes fact sheet: General information and national estimates on diabetes in the United States. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf.
18 National Center for Health Statistics. (2003). 15 Leading causes of death for Asian and Pacific Islanders, 2001 Chart, Health, United States, 2003. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at http://www.omhrc.gov/healthgap/datastats_aapi1.pdf.
19 World Health Organization. Global strategy on diet, physical activity and health. Available at: http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf. Accessed May 28, 2004; Centers for Disease Control and Prevention (CDC). (2003). Diabetes surveillance, 2003. [Statistics. 2003 surveillance report]. Atlanta: National Center for Chronic Disease and Prevention and Health Promotion, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/diabetes/statistics/esrd/Fig5.htm; Agency for Healthcare Research and Quality (AHRQ). (2001). Diabetes disparities among racial and ethnic minorities. (AHRQ Pub. NO. 02-P007). Rockville, MD: AHRQ. Available at http://www.ahrq.gov/research/diabdisp.htm; and Gornic, ME, Eggers P.W, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC. (1996). Effects of race and income on mortality and use of services among Medicare beneficiaries. New England Journal of Medicine, 335(11), 791-799.
20 American Diabetes Association (ADA). Direct and indirect costs of Diabetes in the United States. (2003). Available at: http://www.diabetes.org/diabetes-statistics/cost-of-diabetes-in-us.jsp. Accessed September 15, 2004; and ADA, op.cit., Economic costs of diabetes.
21 Centers for Disease Control and Prevention (CDC). Fact sheet,Diabetesatwork.org. Available at:
22 ADA, op.cit., Economic costs of diabetes.
What Is Diabetes?
Diabetes is typically classified according to three main types—type 1 diabetes, type 2 diabetes including a related condition called pre-diabetes, and gestational diabetes.
Type 1 diabetes (previously called “juvenile diabetes”) is an autoimmune disorder in which the insulin producing beta cells are destroyed by the body’s immune system. As a result the body is unable to produce insulin. Without insulin, the body is unable to use glucose (sugar) as energy for everyday activities. Individuals with type 1 diabetes must take insulin by injection or pump every day to survive. This type of diabetes occurs in 5 percent to 10 percent of Americans who are diagnosed with diabetes. Children and adolescents are most often diagnosed with type 1 diabetes although a significant portion of those with type 1 diabetes are diagnosed as adults.
Type 2 diabetes (previously called “adult onset diabetes”) is the most common form of diabetes, accounting for about 90 percent to 95 percent of all diabetes cases. In this type of diabetes, the body does not produce enough insulin and/or the body’s cells become resistant to insulin. Insulin resistance occurs when the body’s muscle, fat, and liver cells do not respond to insulin. The pancreas tries to keep up with the demand for insulin by producing more. Since insulin helps to mobilize glucose from the blood stream into cells, excess glucose builds up in the blood stream. Many people with insulin resistance have high levels of blood glucose and high levels of insulin circulating in their blood at the same time indicating that the cells are not responding properly to insulin.
A related condition, called pre-diabetes, occurs when a person’s blood sugar levels are higher than normal, but not high enough for a diagnosis of diabetes. People with prediabetes have impaired fasting glucose (fasting blood sugar level is 100 to 125 milligrams per deciliter [mg/dl]) or impaired glucose tolerance (blood sugar level is 140 to 199 mg/dl after a 2-hour oral glucose tolerance test).23
People with pre-diabetes and type 2 diabetes often do not show symptoms and they do not know that they have the conditions. The Diabetes Prevention Program—a major clinical trial in 3,234 people with impaired glucose tolerance—showed that in some individuals the loss of 5 percent to 7 percent of body weight reduced their risk of developing type 2 diabetes by 58 percent.24 This study also suggested that people with pre-diabetes can prevent or delay the development of type 2 diabetes through lifestyle changes that include eating a low-calorie, low-fat diet to lose weight and getting 150 minutes of physical activity a week.25
Gestational diabetes is a form of diabetes that occurs in some women who have high blood glucose levels during pregnancy but have never had diabetes before. This type of diabetes may disappear after the pregnancy ends, but women who have had gestational diabetes have a 20 percent to 50 percent chance of developing type 2 diabetes in the next 5 to 10 years.26
23 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Insulin resistance and pre-diabetes. NIH Publication No. 04-4893. Available at: http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/index.htm. 2004.
24 Diabetes Prevention Program Research Group, op.cit.
26 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). What I need to know about gestational diabetes. NIH Pub No. 04-5129. Available at: http://diabetes.niddk.nih.gov/dm/pubs/gestational/#3. Accessed May 28, 2004.
Risk Factors for Diabetes
Diabetes occurs in people of all ages and racial and ethnic groups. Researchers do not fully understand the cause of type 1 diabetes or what can be done to prevent it. Research suggests that type 1 diabetes has a strong genetic basis that is modified by environmental factors. Certain viruses are among the factors that have been suggested, but the definitive factors have yet to be determined.27 Having a family member with type 1 diabetes puts one at higher risk for developing the disease.28 However, most type 1 diabetes patients do not have a family history of the disease. Research is currently being done to learn more about the genetic and environmental factors important in type 1 diabetes.
Research conducted to date has identified specific risk factors related to the development of type 2 diabetes, pre-diabetes, and gestational diabetes, including family history, a sedentary lifestyle, and overweight or obesity (Table 1). Maintaining a healthy weight as measured by body mass index (BMI) reduces one’s risk for developing type 2 diabetes, pre-diabetes, or gestational diabetes.29 BMI is a measure of weight in relation to height (see Figure 3). Studies have shown that BMI is significantly correlated with body fat content for most adults. For adults, a BMI less than 25 is considered a healthy weight. Regular physical activity and eating a healthy diet can help attain and maintain a healthy weight.
Table 1. Risk Factors and Associated Medical Conditions for Diabetes
SOURCES: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Am I at risk for type 2 diabetes? NIH Publication No. 04-4805. Available at: http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/. Insulin resistance and pre-diabetes. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/. What I need to know about gestational diabetes. NIH Pub No. 04-5129. Available at:
http://diabetes.niddk.nih.gov/dm/pubs/gestational/#3. Accessed May 28, 2004.
Figure 3. Body Mass Index
SOURCE: The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001
27 Graves PM, Norris JM, Pallansch MA, Gerling IC, Rewers M. (1997). The role of enterviral infections in the development of IDDM: Limitations of current approaches. Diabetes, 46: 161-168; and Salminen KK, Vuorinen T, Oikarinen S, Helminen M, Simell S, Knip M, Ilonen J, Simell O, and Hyöty H. (2004). Isolation of enterovirus strains from children with preclinical type 1 diabetes. Diabetes Medicine, 21:156-164.
28 Diabetes Research Working Group. Conquering Diabetes: Highlights of program efforts, research advances and opportunities. Available at: http://www.niddk.nih.gov/federal/dwg/2002/3summary.pdf. 2002.
29 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National diabetes statistics. NIH Publication No. 04-3892. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. 2004; and Diabetes Prevention Program Research Group, op.cit.
Health Problems Related to Diabetes
Diabetes can have a significant impact on quality of life by increasing risk for a variety of complications. These include:
- Blindness—Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years, with the greatest number in adults 65 years and older (Figure 4). Retinopathy causes 12,000 to 24,000 new cases of blindness each year in people with diabetes.30
- Kidney Disease—Diabetes is the leading cause of endstage kidney disease, accounting for 43 percent of new cases each year (Figure 5).31 In 2001, nearly 43,000 people with diabetes began treatment for end-stage kidney disease and approximately 143,000 people with endstage kidney disease were living on chronic dialysis or with a kidney transplant due to diabetes.32 The rate of diabetic end-stage kidney disease is 2.6 times higher among Blacks than among Whites.33
- High Blood Pressure—About 73 percent of adults with diabetes have blood pressure greater than or equal to 140/90 mm Hg or use prescription medications for hypertension.34
- Heart Disease and Stroke—About 65 percent of deaths among people with diabetes are due to heart disease and stroke.35 Adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes. It is projected that in the year 2025, twenty-nine percent of all heart disease deaths will be due to diabetes (Figure 6). The risk for stroke is two to four times higher among people with diabetes.
- Nervous System Disease—About 60 to 70 percent of people with diabetes have mild to severe forms of nervous system damage including impaired sensation or pain in the feet or hands, carpal tunnel syndrome, slowed digestion of food in the stomach, and other nerve problems.36 Severe forms of nerve disease are a major contributing cause of lower-extremity amputations for people with diabetes.
- Dental Disease—Gum disease is more common among people with diabetes. Among young adults, those with diabetes have about twice the risk of developing gum disease as those without diabetes. Almost one third of people with diabetes have severe gum diseases.
- Amputations—More than 60 percent of nontraumatic lowerlimb amputations occur among people with diabetes.37 In 2000–2001, about 82,000 nontraumatic lowerlimb amputations were performed annually among people with diabetes.38 Blacks have higher rates of lower extremity amputations than Whites (see Figure 7).39
- Pregnancy Complications—Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5 percent to 10 percent of pregnancies and spontaneous abortions in 15 percent to 20 percent of pregnancies.40 Poorly controlled diabetes during the second and third trimesters of pregnancy can result in very large babies, posing a risk to the mother and the child during delivery.
- Other Complications—People with diabetes are more susceptible to many other illnesses and often have worse outcomes. For example, people with diabetes are more likely to die from pneumonia or the flu than people who do not have diabetes.41
Early and optimal treatment is key to prevent or delay such complications.
Figure 4. Prevalence of diabetic retinopathy among adults 40 years and older (2000)
SOURCE: National Institutes of Health, National Eye Institute data from Prevalence and Causes of Visual Impairment and Blindness Among Adults 40 Years and Older in the United States, http://www.nei.nih.gov/eyedata/.
Figure 5. Primary causes for kidney failure (1998)
SOURCE: National Institute of Diabetes and Digestive Kidney Diseases (1998). Accessed at http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm.
Glomerulonephritis is a variety of kidney disease characterized by inflammation of the capillaries.
Figure 6. Projected increase in total heart disease deaths related to increased diabetes prevalence
SOURCE: Unpublished estimates from the National Heart, Lung and Blood Institute, October 18, 2002.
Figure 7. Age-standardized Rate of Hospital Discharge for Non-traumatic Lower Extremity Amputation per 1,000 Diabetic Population, by Race, United States, 1980-2001
SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Care Statistics, data from the National Hospital Discharge Survey and Division of Health Interview Statistics, data from the National Health Interview Survey.
U.S. Bureau of the Census, census of the population and population estimates and Centers for Disease Control and Prevention, National Center for Health Statistics, bridged-race population estimates.
30 CDC, National diabetes fact sheet, op.cit.
33 AHRQ, op.cit
34 CDC, National diabetes fact sheet, op.cit.
39 AHRQ, op.cit.
40 CDC, National diabetes fact sheet, op.cit.
Diabetes: A National Plan for Action
Secretary of Health and Human Services (HHS) Tommy G. Thompson has identified diabetes prevention, detection, and treatment as important components of his health agenda. Activities supporting the Secretary’s focus on diabetes include Steps to a HealthierUS: Putting Prevention First (Appendix A), the Diabetes Detection Initiative, and the Small Steps, Big Rewards, Prevent Type 2 Diabetes campaign. In addition, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, establishes coverage of a one-time “Welcome to Medicare Physical Examination” within 6 months of a beneficiary’s first coverage under Part B to encourage health promotion and disease detection. The MMA also adds coverage for cardiovascular and diabetes screening for Medicare beneficiaries. Both benefits take effect January 1, 2005. More information on MMA and Medicare benefits in general can be found at http://www.medicare.gov/ or 1-800-Medicare (1-800-633-4227). Appendix B provides additional information on diabetes benefits offered through Medicare.
Diabetes: A National Plan for Action (hereby referred to as the National Diabetes Action Plan—NDAP) is the latest initiative to address diabetes. This action plan was prompted by the Secretary’s commitment to disease prevention and health promotion. It utilizes a comprehensive action-oriented approach to identify activities to improve diabetes prevention, detection, and care.
The goals of the NDAP are to:
- Increase national awareness of diabetes, its impact, and what various stakeholders can do to prevent or manage the disease;
- Reduce the prevalence of diabetes and factors that increase the risk of diabetes;
- Promote improved detection, monitoring, and treatment of the disease; and
- Identify existing public and private efforts to facilitate coordination and to leverage existing resources for detection, prevention, and treatment of diabetes.
An advisory committee composed of senior officials within the U.S. Department of Health and Human Services (HHS) was named to direct the development of the NDAP. This committee provided recommendations to reduce the prevalence and burden of diabetes. In addition, the Secretary and his senior staff hosted several town hall “listening sessions” in different parts of the country to highlight the important steps that individuals, health care practitioners and providers, businesses, and communities can and are taking to prevent, detect, and treat diabetes and educate patients, their families, and other Americans. The first town hall meeting focused on prevention of diabetes and was held in Cincinnati, Ohio, on March 29, 2004. The second town hall focused on diabetes detection and education and was held in Little Rock, Arkansas, on June 18, 2004. The third town hall focused on diabetes treatment and was held in Seattle, Washington, on July 26, 2004. In all, more than 1,200 people attended the three town halls.
During the public comment period at these town hall meetings, individuals and those representing organizations were able to ask questions, express their views, and provide input to the national diabetes action plan. Hundreds of people shared their thoughts about the burden of diabetes and solutions for preventing or delaying the disease and its complications. The public comment period identified issues of concern to the diabetes community. These included:
- The key role that schools and teachers can play in educating students and parents about the importance of healthy behaviors (i.e. physical activity, nutrition) to reduce their risk for diabetes;
- The important role health insurance plays in the ability of people with diabetes to manage their diabetes and the need for policymakers to continue to strive to improve the health insurance system for people with diabetes and other chronic conditions;
- The need to educate and train healthcare providers in state-of-the art diabetes prevention, detection, and management strategies;
- The importance of continued research into effective and innovative prevention strategies and treatments for diabetes; and
- The need for focused prevention, detection, and treatment efforts targeted specifically to individuals at higher risk for diabetes, including Blacks, Hispanics, American Indians, Alaskan Natives, Asians and Pacific Islanders using culturally sensitive materials and messages emphasizing the importance of early detection and optimal treatment.
See Appendix C for more information on the development of the NDAP.
The remainder of this document is organized around three key components: prevention, detection, and treatment of diabetes. Within each component, action steps are provided for individuals, friends and family, health care providers, schools, the media, community organizations, health insurance providers, employers, and government agencies to improve the quality of life for people living with diabetes and reduce the burden of diabetes on the nation.