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Statement on : Diabetes by Frank Vinicor, M.D.
Director, Division of Diabetes Translation
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Introduction

Thank you Mr. Chairman and Members of Congress, for the opportunity to testify before you today about the Centers for Disease Control and Prevention's mission to translate research into daily public health practice and reduce the burden of diabetes in the United States . I am Frank Vinicor, Director of the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion.

Diabetes is one of the most serious, common and costly chronic diseases affecting Americans. Nearly 16 million people in the United States have diabetes, with approximately 800,000 new cases each year or 2,200 new cases each day. According to the American Diabetes Association, it is the seventh leading cause of death in the U.S., totaling an estimated $98 billion each year in indirect and direct costs. Americans with diabetes face shortened life spans and roughly one-hundred thousand individuals suffer preventable acute and chronic complications such as kidney failure, blindness and lower extremity amputations each year. It contributes heavily to heart disease, birth defects, sexual impotence, incontinence, and other serious health problems. More than half of all persons with diabetes are women, among which older women and racial and ethnic minority women are disproportionately affected.

Diabetes is a chronic disease due to insulin deficiency and/or resistance to insulin action and associated with hyperglycemia (elevated blood glucose levels). Over time, without proper preventive treatment, organ complications related to diabetes develop, including heart, nerve, foot, eye, and kidney damage and problems with pregnancy also occur. Type 2 is the most common form of diabetes in the United States and the world, especially in minority communities and in elderly persons. In the United States , approximately 95 percent of all persons with diagnosed diabetes (10.5 million) and 100 percent of undiagnosed (5.5 million) diabetes likely have type 2 diabetes.

The Burden of Diabetes in Hispanics

Diabetes disproportionately affects racial and ethnic minority populations in the U.S. Among the adult minority populations, 10.8 percent of non-Hispanic blacks, 10.6 percent of Mexican Americans, and nearly 10 percent of American Indians and Alaskan Natives have diabetes. Hispanic/Latino Americans and non-Hispanic blacks are about twice as likely and American Indians and Alaskan Natives almost three times as likely to have diabetes as non-Hispanic whites of similar age. CDC data indicates that six percent of Hispanic adults in the United States and Puerto Rico have been diagnosed with diabetes -- twice the rate of Caucasian Americans -- while another six percent have undiagnosed diabetes. The CDC's report of this data is significant in that it is the first to provide diabetes prevalence among all Hispanics in the United States and Puerto Rico.

Thus, we know that diabetes is two to three times more common in Mexican American and Puerto Rican adults than in non-Hispanic Caucasians. One in every four Mexican Americans and Puerto Ricans aged 45 or older has diabetes. The prevalence of diabetes in Cuban Americans is lower, but still higher than that in non-Hispanic Caucasians. One in every six Cuban Americans over the age of 45 has diabetes.

There are several factors accounting for the diabetes epidemic in the U.S., including demographic changes (aging, increased growth of at-risk populations); behavioral elements (improper nutrition, decreasing physical activity, obesity); improved surveillance systems that more completely capture the extant burden of diabetes; and our present limited ability to change behaviors. Particularly within racial and ethnic minority communities, there are four potential individual reasons for the greater burden of diabetes:

• Greater prevalence of diabetes. If diabetes is more common, then greater mortality, amputations, and complications from diabetes would be expected.

• Greater seriousness of diabetes. Greater degrees of hyperglycemia or other serious co-morbid conditions (e.g., hypertension, hyperlipidemia) would result in greater diabetes-related burden. Many factors could be involved, including genetics and weight. Greater seriousness of diabetes can be determined by comparing, for example, mortality or amputation rates of persons with diabetes with those rates in the general population.

• Inadequate access to proper diabetes prevention and control programs. If diabetes services, such as education and eye evaluation, are not available, then efficacious programs to reduce the burden of diabetes will not be accessed and used. Many diabetes "at-risk" groups reside in medically under served areas and/or are not insured.

• Improper quality of care. If diabetes management services are available, but the quality of that service is inadequate, prevention programs would not be effective.

CDC Programmatic Activities

Resoundingly, diabetes is a major clinical and public health challenge. CDC responds to this challenge by focusing on three essential tasks - to know what the burden of diabetes is; to know why the burden is so high; and, to do something about it.

As described earlier, CDC released a report earlier this year which provided diabetes prevalence among all Hispanics in the United States and Puerto Rico. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess the prevalence. The BRFSS and its diabetes module, CDC's cornerstone for diabetes surveillance activities in states, provide state-specific information on diabetes prevalence, risk factors, and preventive care practices. The number of states using the BRFSS diabetes module increased from 22 in 1994 to 39 in 1997. BRFSS data have been used to describe the gap between optimal diabetes care and the care actually received by people with diabetes. CDC intends to expand the BRFSS's capacity to perform surveillance of diabetes in minority populations. Three recently funded projects focused on one or more geographically defined minority populations and are assessing the technical factors related to the feasibility of using the BRFSS to conduct diabetes surveillance.

CDC is also monitoring the disturbing trend in type 2 diabetes diagnoses in children and adolescents. A statistically significant increase in prevalence of type 2 diabetes was found among American Indian adolescents and children. Meanwhile, there are increases in case reports of type 2 diabetes among Mexican-American, African-American and white youth throughout the U.S. Young people affected tend to be 10 to 19 years old with a strong family history of type 2 diabetes. They are more likely to be girls than boys; to be African American, Hispanic or American Indian than of other racial or ethnic groups; and obese rather than normal weight. CDC is providing national leadership to increase awareness of type 2 diabetes in children, to determine the size of the problem, and to stimulate new efforts to prevent and treat the disease. Thus far, CDC has convened several meetings to bring together pediatric endocrinologists, epidemiologists, and public health professionals.

This year, CDC initiated a multi-center, 5-year study to conduct research within managed care organizations that will evaluate and improve the health care and health status of people with diabetes. The Translating Research into Action for Diabetes (TRIAD) study will be recruiting substantial numbers of Hispanic-Americans in an effort to 1) better understand the current levels of quality of care and health status of Hispanic-Americans; and 2) better understand the barriers to improved care and health status for Hispanics covered by managed care. Approximately 1500 Hispanic-Americans will be recruited into the TRIAD study, coming primarily from health plans in Texas, California, and New Jersey.

CDC is committed to the federal effort to eliminate the disparity in the diabetes burden among racial and ethnic minorities. CDC is leading the effort to develop the nation's Healthy People 2010 Objectives which offer a blueprint for achieving significant reductions in preventable death and disability, enhanced quality of life, and greatly reduced disparities in health status of populations in our society. In addition, CDC, along with the National Institutes of Health (NIH), co-chairs the Diabetes Work Group of the U.S. Department of Health and Human Services' Health Disparities Initiative. The workgroup assessed the best ways to translate what we know about preventing and controlling diabetes, identified ways to address the gaps in what we know, and developed strategies to eliminate the disparity in the burden of diabetes among selected racial and ethnic minority populations, including Hispanics.

CDC's efforts to eliminate the diabetes disparity in Hispanics are focused on improving what we know about the burden of diabetes in this population, developing national strategies and state-based diabetes control programs to respond to the challenge, and building partnerships to help inform our efforts and broaden our impact.

CDC joins with state and territorial health departments and other partners to focus efforts on all populations at increased risk for diabetes and its complications. CDC provides leadership for a coordinated, multifaceted program to effect changes and improvements in systems that care for and support people with diabetes. CDC's national program goals are to increase awareness and education about diabetes, promote early detection of diabetes and treatment of its complications, improve quality of care, and enhance access to diabetes care by improving and expanding services. Priority is on reaching high-risk and disproportionately burdened populations.

CDC funds state-based diabetes control programs in all 50 states, the District of Columbia, and eight U.S.-affiliated island jurisdictions. A two-tiered funding level enables 34 states to operate core capacity-building diabetes programs and 16 states (with more substantive support) to operate comprehensive capacity-building programs. Core programs do not operate state-wide but serve as a framework on which states build more comprehensive programs.

CDC, specifically in response to the high incidence of diabetes among Hispanics/Latinos in the U.S., launched the National Hispanic/Latino Diabetes Initiative for Action, (Hispanic/Latino DIA). This initiative focuses on developing appropriate diabetes prevention strategies for Hispanic/Latino communities. This initiative promotes inter-disciplinary, culturally-relevant approaches for preventing diabetes and its complications in the U.S. and territorial Hispanic/Latino communities. In August 1997, CDC received a list of strategic options from our Expert Consultant group culminating a two-year planning process on how to effectively reach and reduce the burden of diabetes within Latino populations. CDC developed a formal response to the workgroup product and initiated several key efforts.

• National Minority Organizations: CDC awarded six cooperative agreements to build the capacity of national minority organizations to support National Diabetes Education Program (NDEP) activities. The organizations will facilitate the delivery of culturally and linguistically appropriate NDEP prevention and control messages through trusted and valued community-based delivery channels and intervention approaches. The National Hispanic Council on Aging and the National Council of LaRaza will support NDEP activities in the Hispanic/Latino community.

• Border Health Surveillance: With CDC's guidance, several state-based diabetes control programs are collaborating with the Mexican states along the U.S.-Mexico frontier and the Mexico Department of Health Minister to devise and implement strategies to reduce the burden of diabetes among persons who live along the border. Several planning meetings have been held to date. Initial efforts will focus on improving diabetes surveillance in the border region.

• University of Illinois/Prevention Center: CDC is collaborating with the University of Illinois at Chicago Research Prevention Center through its Midwest Latino Health Research, Training and Policy Center to replicate and evaluate the culturally specific diabetes empowerment educational program, Promotora de Salud (lay health worker)/ Paso a Paso. The program implements diabetes prevention research within Hispanic/Latino population stages of life -- youths, young adults, adults, and senior adults -- using a peer education model of diabetes disease prevention and health promotion. Priority will be given to the persons most at risk for diabetes: those who are obese, have a family member with diabetes, and who have been diagnosed with glucose intolerance.

• Promatora - Lay Health Workers: The project empowers participants by raising awareness among participants about their condition and building skills to manage and control diabetes. It also teaches decision and problem solving skills regarding lifestyle behaviors and encourages social support among participants.

• Spanish Health Education Materials and Media Campaigns:
  • Controle su diabetes: Una guia para su cuidado (Spanish version of Take Charge of Your Diabetes);
  • Diabetes Today Curriculum for Health Professionals and Community;
  • NDEP messages in Spanish (print, TV and radio spots);
  • Diabetes/Flu Campaign (print, TV and radio spots);
  • Building Understanding to Prevention and Control of Diabetes Among Hispanics/Latinos: An Annotated Bibliography, 1996.

The National Diabetes Education Program is leading the way in raising awareness about the seriousness of diabetes. The NDEP, which is jointly sponsored by the CDC and the NIH, has given priority to addressing the needs of minority populations including Hispanics/Latinos. Targeted awareness campaigns have been developed for Hispanics/Latinos, African Americans, American Indians, and Asian Americans/Pacific Islanders. The NDEP's Hispanic/Latino work group collaborated closely with NDEP to develop campaign messages and strategies that are culturally and linguistically appropriate. The 1998 and 1999 campaign, Rayos y Truenos, addressed fatalism as a barrier to diabetes self-management and put diabetes into context with an act of nature (thunder and lightning) which we truly cannot control. This message was found to give hope and be empowering. The goal is to influence Hispanics/Latinos with diabetes to take diabetes seriously and control it -- for life. Rayos y Truenos has won the 1998 Aesculapius Award for Excellence from the Health Improvement Institute and the 1998 Silver Mercury Award from the International Academy of Communications Arts and Sciences/MerComm, Inc. A kit with ideas and strategies for getting NDEP messages into communities has also been developed for use by NDEP's Hispanic/Latino partners. Additionally, the CDC funded 2 national minority organizations -- National Council of La Raza and the National Hispanic Council on Aging -- to extend the reach of NDEP into Hispanic/Latino communities through trusted and valued channels and messengers.

Closing

In summary, diabetes is a big problem today and will get bigger in the future. It is associated with disparities among various populations in its devastation, as well as in the application of efficacious and efficient prevention strategies. Diabetes is a wasteful disease because the strategies that would lessen the burden of diabetes are not being used widely or regularly utilized in daily care, resulting in unnecessary disability, morbidity, mortality, and cost. Advances in diabetes research have shown that improving nutrition, increasing physical activity, and access to proper medical treatment can delay or stop the onset and progression of diabetes complications. Yet, despite current knowledge, diabetes is not being managed aggressively: physician practices do not meet recommended standards of care; patients do not know how to manage their diabetes; and the health care system is poorly equipped to manage diabetes. CDC is employing its resources to translate this knowledge and improve diabetes care. CDC has learned much but still has much to learn. We are committed to expanding program activities to eliminate the disparity in the diabetes burden in the U.S.