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Data Sources, References, and Methods for Estimates of Diabetes

Treating Diabetes

1. 2004–2006 National Health Interview Survey (NHIS), National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhis.htm.

Methods: The percent distribution of the type of treatment among civilian, noninstitutionalized adults aged 18 years or older with diagnosed diabetes was calculated using treatment questions from the 2004–2006 NHIS.

Pre-diabetes: Impaired Glucose Tolerance (IGT) and Impaired Fasting Glucose (IFG)

1. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183–1197.

2. Coutinho M, Gerstein HC, Wang Y, Yusuf S. The relationship between glucose and incident cardiovascular events. A metaregression analysis of published data from 20 studies of 95,783 individuals followed for 12.4 years. Diabetes Care. 1999; 22:233–240.

3. Meigs JB, Nathan DM, D’Agostino RB Sr, Wilson PW; Framingham Offspring Study. Fasting and postchallenge glycemia and cardiovascular disease risk: the Framingham Offspring Study. Diabetes Care. 2002;10:1845–1850.

4. Smith NL, Barzilay JI, Shaffer D, Savage PJ, Heckbert SR, Kuller LH, Kronmal RA, Resnick HE, Psaty BM. Fasting and 2-hour postchallenge serum glucose measures and risk of incident cardiovascular events in the elderly: the Cardiovascular Health Study. Archives of Internal Medicine. 2002;162:209–216.

5. Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, Wiedmeyer HM, Byrd-Holt DD. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey (NHANES III) 1988–1994. Diabetes Care. 1998;21(4):518–524.

6. NHANES III 1988–1994, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhanes.htm.

Methods: The prevalences of IGT, IFG, and pre-diabetes in the civilian noninstitutionalized population were estimated using 1988–1994 NHANES III data. People previously diagnosed with diabetes and those with undiagnosed diabetes—i.e., without a history of diabetes but with a fasting plasma glucose of 126 or more—were excluded from the prevalence counts of IGT, IFG, and pre-diabetes. Persons were classified as having IGT if they had 2-hour plasma glucose values of 140 to 199 mg/dL after an oral glucose tolerance test. They were classified as having IFG if they had fasting plasma glucose values of 100 to 125 mg/dL—regardless of their 2-hour plasma glucose values. Those with IGT or IFG or both were classified as having pre-diabetes.

Prevalence of IFG in People Younger than 20 Years of Age, United States

1. Williams DE, Cadwell BL, Cheng YJ, Cowie CC, Gregg EW, Geiss LS, Engelgau MM, Venkat Narayan KM, Imperatore G. Prevalence of impaired fasting glucose and its relationship with cardiovascular disease risk factors in US adolescents, 1999–2000. Pediatrics. 2005;116;1122–1126.

Prevalence of IFG in People Aged 20 Years or Older, United States, 2007

1. Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, Saydah SH, Williams DE, Geiss LS, Gregg EW. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: NHANES 1999–2002. Diabetes Care. 2006;29(6):1263–1268.

2. NHANES 2003–2006, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhanes.htm.

3. U.S. Census Bureau, resident population estimates for 11/1/2007. Available at: www.census.gov/popest/national/asrh/2006_nat_res.html.

Methods: The prevalence of IFG in the civilian noninstitutionalized population was estimated using 2003–2006 NHANES data. Persons were classified as having IFG if they had fasting plasma glucose values of 100 to 125 mg/dL. Persons previously diagnosed with diabetes and those with undiagnosed diabetes—i.e., without a history of diabetes but with a fasting plasma glucose of 126 or more—were excluded from the case counts of IFG. The 2007 estimated number of those aged 20 years or older with IFG is the sum of the numbers derived by applying the age-race-sex-specific estimates of IFG prevalence from the 2003–2006 NHANES to the corresponding age-race-sex-specific estimates of the 2007 resident population. IGT prevalence was not estimated because NHANES did not include glucose tolerance test measurements in 2003–2004. IFG prevalence by race are age and sex adjusted by the direct method based on 2000 U.S. standard population.

Prevention or Delay of Diabetes

1. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine. 2002;346(6):393–403.

2. The Diabetes Prevention Program Research Group. Costs associated with the primary prevention of type 2 diabetes mellitus in the Diabetes Prevention Program. Diabetes Care. 2003;26:36–47.

3. Diabetes Prevention Program Research Group. Within-trial cost-effectiveness of lifestyle intervention or metformin for the primary prevention of type 2 diabetes. Diabetes Care. 2003;26(9):2518–2523.

4. Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P, Hamman RF, Ackermann RT, Engelgau MM, Ratner RE. Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Annals of Internal Medicine. 2005;142:323–332.

Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007

1. Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, Saydah SH, Williams DE, Geiss LS, Gregg EW. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: NHANES 1999–2002. Diabetes Care. 2006;29(6):1263–1268.

2. NHANES 2003–2006, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhanes.htm.

3. 2004–2006 NHIS, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhis.htm.

4. U.S. Census Bureau, resident population estimates for 11/1/2007. Available at: www.census.gov/popest/national/asrh/2006_nat_res.html.

Methods: The total number of people with diabetes is the sum of the estimated number of those aged 20 years or older with diagnosed and undiagnosed diabetes in 2007—see next section for calculation methods—and the estimated number of those younger than 20 years with diagnosed diabetes in 2007—see section after next section on diagnosed diabetes among people under 20 years of age for calculation methods. The percentage of the population with diabetes is the estimated total number with diabetes in 2007 divided by the estimated 2007 U.S. resident population.

The total number of persons with diagnosed diabetes in 2007 is the sum of the estimated numbers of those younger than 20 years and those aged 20 years or older with diagnosed diabetes.

Information about how NHANES data can be used to estimate diagnosed, undiagnosed, and total prevalence of diabetes is available in the Cowie et al. reference listed above.

Prevalence of Diagnosed and Undiagnosed Diabetes among People Aged 20 Years or Older, United States, 2007

1. Cowie CC, Rust KF, Byrd-Holt DD, Eberhardt MS, Flegal KM, Engelgau MM, Saydah SH, Williams DE, Geiss LS, Gregg EW. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: NHANES 1999–2002. Diabetes Care. 2006;29(6):1263–1268.

2. NHANES 2003–2006, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhanes.htm.

3. U.S. Census Bureau, resident population estimates for 11/1/2007. Available at: www.census.gov/popest/national/asrh/2006_nat_res.html.

Methods:

Aged 20 years or older
The 2007 estimated number of those aged 20 years or older with diagnosed and undiagnosed diabetes is the sum of the numbers derived by applying the age-race-sex-specific estimates of total diabetes prevalence—both diagnosed and undiagnosed—from the 2003–2006 NHANES to 2007 resident population estimates. The percentage of the population with diabetes aged 20 years or older is this estimated number divided by the estimated 2007 U.S. resident population aged 20 years or older. Information on the use of NHANES data to measure diabetes prevalence—including diagnosed and undiagnosed diabetes—is available from the Cowie et al. reference listed above.

Aged 60 years or older
The 2007 estimated number of those aged 60 years or older with diabetes was derived by applying race-sex-specific estimates of total diabetes prevalence—both diagnosed and undiagnosed diabetes—in this age group from the 2003–2006 NHANES to 2007 resident population estimates. The percentage of the population with diabetes aged 60 years or older is this estimated number divided by the estimated 2007 U.S. resident population aged 60 years or older.

Men and women
The 2007 estimated number of men and women aged 20 years or older with diabetes is the sum of the sex-specific numbers derived by applying age-race-sex-specific estimates of total diabetes prevalence—both diagnosed and undiagnosed diabetes—from the 2003–2006 NHANES to 2007 resident population estimates. The percentage of men and women with diabetes are these estimated numbers divided by the sex-specific estimated 2007 U.S. resident population aged 20 years or older.

Non-Hispanic whites and non-Hispanic blacks
The 2007 estimated numbers of non-Hispanic whites and the number of non-Hispanic blacks aged 20 years or older with diabetes are the sums of the non-Hispanic race-specific numbers derived by applying non-Hispanic age-race-sex-specific estimates of total diabetes prevalence—both diagnosed and undiagnosed diabetes—from the 2003–2006 NHANES to 2007 resident population estimates. The percentages of non-Hispanic whites and non-Hispanic blacks with diabetes are these estimated numbers divided by the non-Hispanic race-specific estimates of the 2007 U.S. resident population aged 20 years or older.

Graph of prevalence by age group
The age-specific prevalences of diagnosed and undiagnosed diabetes in people aged 20 years or older were obtained by applying age-race-sex-specific estimates of total diabetes prevalence—both diagnosed and undiagnosed diabetes—from the 2003–2006 NHANES to 2007 resident population estimates. The derived age-specific counts were then divided by the estimated 2007 U.S. resident population to obtain the 2007 age-specific percentages.

Prevalence of Diagnosed Diabetes in People Younger than 20 Years of Age, United States, 2007

1. 2004–2006 NHIS, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhis.htm.

2. U.S. Census Bureau, resident population estimates for 11/1/2007. Available at: www.census.gov/popest/national/asrh/2006_nat_res.html.

Methods: The number of persons under 20 years of age with diagnosed diabetes in 2007 was estimated by applying the 2004–2006 NHIS prevalence estimate of diagnosed diabetes in the civilian, noninstitutionalized population younger than 20 years to the 2007 resident population estimate of this age group. The percentage of persons under 20 years of age with diagnosed diabetes in 2007 was assumed to be the same as the 2004–2006 NHIS estimate. Estimates of undiagnosed diabetes for persons younger than 20 years are not available.

Race and Ethnic Differences in Prevalence of Diagnosed Diabetes

1. Acton KJ, Burrows NR, Geiss LS, Thompson T. Diabetes prevalence among American Indians and Alaska Natives and the overall population—United States, 1994–2002. Morbidity and Mortality Weekly Report. 2003;52(30);702–704.

2. Burrows NR, Geiss LS, Engelgau MM, Acton KJ. Prevalence of diabetes among Native Americans and Alaska Natives, 1990–1997: an increasing burden. Diabetes Care. 2000;23(12):1786–1790.

3. 2004–2006 NHIS, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhanes.htm.

4. Indian Health Service (IHS), 2005 outpatient database.

Methods: All estimates presented are for persons aged 20 years or older. Rates were age-adjusted by the direct method based on the 2000 U.S. standard population. With the exception of the prevalence among American Indians and Alaska Natives (AIANs), race/ethnicity-specific prevalences of diagnosed diabetes were calculated using the 2004–2006 NHIS, also available at www.cdc.gov/nchs/nhis.htm. The estimated diagnosed diabetes prevalence for the Native Hawaiian and other Pacific Islander population was not included because the NHIS estimate for this group is considered unreliable due to a small sample size.

The prevalence of diagnosed diabetes among AIANs was derived from the 2005 user population database of the IHS. The IHS operates a health-services system delivered directly through IHS facilities, purchased by IHS through contractual agreements with private providers, or delivered through tribally operated programs and urban Indian health programs. Approximately 60 percent of the nearly 3 million AIANs residing in the United States live in IHS health-care delivery areas, are eligible to receive IHS services, and use IHS medical facilities. Diabetes cases among AIANs aged 20 years or older were identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD–9–CM) diagnostic codes 250.0–250.9 from the IHS patient care computerized system for 2005. The patient care database includes unduplicated case reports for persons who attended an IHS service unit one or more times during 2005. Prevalence was calculated by using the AIAN population that received health-care services at IHS, tribal, or urban facilities at least once during the preceding 3 years.

Sufficient data are not available to derive estimates of the total prevalence of diabetes—both diagnosed and undiagnosed diabetes—for many U.S. minority populations. However, national estimates of diagnosed diabetes are available for some but not all minority groups to allow racial and ethnic comparisons. Resources to obtain data for minority groups at the state or local level include the Behavioral Risk Factor Surveillance System at www.cdc.gov/brfss/stateinfo.htm and the California Health Interview Survey at www.chis.ucla.edu.

See the Census glossary for the definition of U.S. racial/ethnic minority groups http://factfinder.census.gov/home/en/epss/glossary_a.html

Incidence of Diagnosed Diabetes among People Aged 20 Years or Older, United States, 2007

1. 2004–2006 NHIS, National Center for Health Statistics, Centers for Disease Control and Prevention. Available at: www.cdc.gov/nchs/nhis.htm.

2. U.S. Census Bureau, resident population estimates for 11/1/2007. Available at: www.census.gov/popest/national/asrh/2006_nat_res.html.

Methods: Age-specific estimates of the incidence of diagnosed diabetes in the civilian, noninstitutionalized population aged 20 years or older from the 2004–2006 NHIS were applied to 2007 estimates of the U.S. resident population without diabetes diagnosed in the past year to calculate the number of new cases of diabetes. Incidence was calculated from data on respondents’ age at diagnosis and age at interview. Adults who reported being diagnosed with diabetes were asked at what age they were diagnosed. The number of years each person had been diagnosed with diabetes was calculated by subtracting the age at which they were diagnosed from their current age. Adults who had a value of zero were identified as having been diagnosed with diabetes within the last year. In addition, it was assumed that half of the adults who had a value of one were classified as having been diagnosed with diabetes within the last year.

Incidence of Diagnosed Diabetes in People Younger than 20 Years of Age, United States, 2002–2003

1. SEARCH Study Group. SEARCH for Diabetes in Youth: a multicenter study of the prevalence, incidence and classification of diabetes mellitus in youth. Controlled Clinical Trials. 2004;25(5):458–471.

2. Writing Group for the SEARCH for Diabetes in Youth Study Group, Dabelea D, Bell RA, D’Agostino RB Jr, Imperatore G, Johansen JM, Linder B, Liu LL, Loots B, Marcovina S, Mayer-Davis EJ, Pettitt DJ, Waitzfelder B. Incidence of diabetes in youth in the United States. Journal of the American Medical Association. 2007;297(24):2716–2724. Available at http://jama.ama-assn.org/cgi/content/full/297/24/2716.

Methods: SEARCH for Diabetes in Youth is a multicenter observational study to examine diabetes at eight locations throughout the United States—more than 5 million, or 6 percent, of all American children younger than 20 years, which is not nationally representative. However, the SEARCH sites were selected for their ability to reach minority populations, making this study group the largest and most racially and geographically diverse group ever involved in a youth diabetes study. It entails conducting population-based ascertainment of cases of physician-diagnosed diabetes in youth younger than 20 years of age—see www.cdc.gov/diabetes/pubs/factsheets/search.htm. New diabetes cases occurring in 2002 and 2003 were identified: a) in geographically defined populations in Ohio, Washington, South Carolina, and Colorado; b) among health plan enrollees in Hawaii through Hawaii Medical Service Association, Med-Quest, Kaiser Permanente Hawaii; and in California through Kaiser Permanente Southern California, excluding San Diego; and c) among American Indian populations in Arizona and New Mexico. The population under observation included noninstitutionalized, civilian youth younger than 20 years of age in the years 2002 and 2003. The population denominator included 10,031,888 persons. Race/ethnicity-specific estimates were pooled across sites using five categories: non-Hispanic white (NHW), Hispanic (H), African American (AA), Asian Pacific Islander (API), and American Indian (AI). The annual total number of new cases of diabetes in persons under 20 years of age was estimated by applying the age-, sex-, and racial/ethnic group-specific incidence estimates from SEARCH to the age-, sex-, and racial/ethnic group-specific U.S. population using bridged-race postcensal population estimates of the July 1 U.S. resident population. Data used in the bullets and the figure were derived from the Journal of the American Medical Association issue listed above.

Source: SEARCH for Diabetes in Youth Study.
NHW=Non-Hispanic whites; AA=African Americans; H=Hispanics; API=Asian/Pacific Islanders; AI=American Indians

Deaths among People with Diabetes, United States, 2006

1. Heron MP, Hoyert DL, Xu J, Scott C, Tejada-Vera B. Deaths: Preliminary data for 2006. National vital statistics reports; Vol. 56 No. 16. Hyattsville, MD: National Center for Health Statistics. 2008.

2. McEwen LN, Kim C, Haan M, Ghosh D, Lantz PM, Mangione CM, Safford MM, Marrero D, Thompson TJ, Herman WH; TRIAD Study Group. Diabetes reporting as a cause of death: results from the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care. 2006;29(2):247–253.

3. Saydah SH, Geiss LS, Tierney E, Benjamin SM, Engelgau M, Brancati F. Review of the performance of methods to identify diabetes cases among vital statistics, administrative, and survey data. Annals of Epidemiology. 2004;14(7):507–516.

4. Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971–1993. Diabetes Care. 1998;21:1138–1145.

5. Hu FB, Stampfer MJ, Solomon CG, Liu S, Willett WC, Speizer FE, Nathan DM, Manson JE. The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women: 20 years of follow-up. Archives of Internal Medicine. 2001;161:1717–1723.

Methods: The number of deaths with diabetes as any listed cause of death among U.S. residents was obtained from the multiple cause-of-death dataset, National Center for Health Statistics, Centers for Disease Control and Prevention.

Complications of Diabetes in the United States

Heart Disease and Stroke

1. Gorina Y, Lentzer H. Multiple causes of death in old age. Aging Trends, No. 9. Hyattsville, MD. National Center for Health Statistics, 2008. Available at: www.cdc.gov/nchs/data/ahcd/agingtrends/09causes.pdf.

Methods: Tables 1–2 in the above reference provide the data for the bullets on heart disease and stroke. A total of 174,130 death certificates in 2004 mentioned diabetes as a cause of death among people aged 65 years or older (Table 1). Among these 174,130 deaths, 117,810 (68 percent) also mentioned heart disease as a cause of death and 27,874 (16 percent) mentioned stroke (Table 2).

High Blood Pressure

1. Ong KL, Cheung B, Wong L, Wat N, Tan K, Lam K. Prevalence, treatment, and control of diagnosed diabetes in the U.S. National Health and Nutrition Examination Survey 1999–2004. Annals of Epidemiology. 2008;18:222–229.

Blindness

1. Klein R, Klein BEK. Vision disorders in diabetes. In: National Diabetes Data Group, editors. Diabetes in America, 2nd ed. Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95–1468:293–336, 1995.

2. Will JC, Geiss LS, Wetterhall SF. Diabetic retinopathy [letter]. New England Journal of Medicine. 1990;323:613.

Kidney Disease

1. United States Renal Data System, Standard Analysis Files, 2007 [data query online]. Available at: www.usrds.org/odr/xrender_home.asp.

Nervous System Disease

1. Eastman RC. Neuropathy in diabetes. In: National Diabetes Data Group, editors. Diabetes in America, 2nd ed. Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95–1468:339–348, 1995.

2. Gregg EW, Sorlie P, Paulose-Ram R, Gu Q, Eberhardt MS, Wolz M, Burt V, Curtin L, Engelgau M, Geiss L; 1999–2000 national health and nutrition examination survey. Prevalence of lower-extremity disease in the U.S. adult population >/=40 years of age with and without diabetes: NHANES 1999–2000. Diabetes Care. 2004;27:1591–1597.

Amputations

1. Centers for Disease Control and Prevention. National Diabetes Surveillance System. Available at: www.cdc.gov/diabetes/statistics/index.htm.

Dental Disease

1. Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the U.S. adult population. Community Dentistry and Oral Epidemiology. 2002;30(3):182–192.

2. Personal communication from R.H. Selwitz, D.D.S., National Institute of Dental and Craniofacial Research, Bethesda, MD, concerning unpublished data from the NHANES III 1988–1994.

Complications of Pregnancy

1. Personal communication from Thomas A. Buchanan, M.D., professor, Medicine, Obstetrics and Gynecology, and Physiology and Biophysics, USC Keck School of Medicine, Los Angeles.

Other Complications

1. Fishbein H, Palumbo PJ. Acute metabolic complications in diabetes. In: National Diabetes Data Group, editors. Diabetes in America, 2nd ed. Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. NIH Publication No. 95–1468:283–291, 1995.

2. Valdez R, Narayan KM, Geiss LS, Engelgau MM. Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white U.S. adults. American Journal of Public Health. 1999;89:1715–1721.

3. Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, Narayan KM. Diabetes and physical disability among older U.S. adults. Diabetes Care. 2000;23(9):1272–1277.

4. Sinclair AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older people. Diabetes Care. 2008;31(2):233–235.

Preventing Diabetes Complications

Glucose Control

1. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. British Medical Journal. 2000;321(7258):405–412.

2. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine. 1993;329:977–986.

3. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. New England Journal of Medicine. 2005;353(25):2643–2653.

Blood Pressure Control

1. Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, Camel G, Davis BR, Frost PH, Gonzalez N, Guthrie G, Oberman A, Rutan GH, Stamler J. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. Journal of the American Medical Association. 1996;276:1886–1892.

2. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, Ménard J, Rahn KH, Wedel H, Westerling S. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;51:1755–1762.

3. UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 39). British Medical Journal. 1998;317:713–720.

4. Adler AI, Stratton IM, Neil HA, Yudkin JS, Matthews DR, Cull CA, Wright AD, Turner RC, Holman RR. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. British Medical Journal. 2000;321:412–419.

Control of Blood Lipids

1. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;344:1383–1389.

2. Downs JR, Clearfield M, Weis S, Whitney E, Shapiro DR, Beere PA, Langendorfer A, Stein EA, Kruyer W, Gotto AM. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: results of the AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention Study. Journal of the American Medical Association. 1998;279:1615–1622.

3. Sacks FM, Moyé LA, Davis BR, Cole TG, Rouleau JL, Nash DT, Pfeffer MA, Braunwald E. Relationship between plasma LDL concentrations during treatment with pravastatin and recurrent coronary events in the Cholesterol and Recurrent Events trial. Circulation. 1998;97:1446–1452.

Preventive Care Practices for Eyes, Feet, and Kidneys

1. Ferris FL 3rd. How effective are treatments for diabetic retinopathy? Journal of the American Medical Association. 1993;269:1290–1291.

2. Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P, Showstack JA. Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12:24–31.

3. Litzelman DK, Slemenda CW, Langefeld CD, Hays LM, Welch MA, Bild DE, Ford ES, Vinicor F. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. Annals of Internal Medicine. 1993;19:36–41.

4. Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, Ritz E, Atkins RC, Rohde R, Raz I; Collaborative Study Group. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. New England Journal of Medicine. 2001;345:851–860.

5. Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, Remuzzi G, Snapinn SM, Zhang Z, Shahinfar S; RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine. 2001;345:861–869.

6. Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P; Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. New England Journal of Medicine. 2001;345:870–878.

7. Hostetter TH. Prevention of end-stage renal disease due to type 2 diabetes. New England Journal of Medicine. 2001;345:910–912.

8. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. New England Journal of Medicine. 1993;29:1456–1462.

9. Kunz R, Friedrich C, Wolbers M, Mann JF. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Annals of Internal Medicine. 2008;148(1):30–48.

Estimated Diabetes Costs in the United States in 2007

1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care. 2008;31(3):596–615.

The estimated costs of diabetes in the United States were based on a study by the Lewin Group, Inc., for the American Diabetes Association and are 2007 estimates of both the direct, which is the cost of medical care and services, and indirect costs, which are the costs of short-term and permanent disability and of premature death, attributable to diabetes. This study used a specific cost-of-disease methodology to estimate the health care costs due to diabetes.

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