Current Trends Regional Variation in Diabetes Mellitus Prevalence -- United States, 1988 and 1989

To plan and implement public health programs for diabetes mellitus (DM), state health officials need to be able to measure accurately the magnitude of the disease burden of DM. Because only national and regional estimates of the prevalence of DM have been available (1), in 1988, CDC's Behavioral Risk Factor Surveillance System (BRFSS) was used to determine the state-specific prevalence of self-reported diabetes in 36 states and the District of Columbia; in 1989, two additional states participated. This report summarizes the BRFSS findings.

The BRFSS is a monthly random-digit-dialed telephone interview of adults greater than or equal to 18 years of age (2). To decrease random variation in the state-specific prevalence estimates, survey data from 1988 and 1989 were combined. The sample results were weighted to reflect the age, sex, and racial/ethnic distribution of adults in each state. To allow comparisons among states and within demographic categories, state-specific and combined results were age-standardized to the 1980 U.S. civilian population. SESUDAAN, a computer software program for analyzing complex sample survey data, was used to calculate standard errors for the prevalence estimates (3).

Respondents were asked if they had ever been told by a doctor that they had diabetes. The prevalence of self-reported diabetes ranged from 1.6% among persons aged 18-34 years to 12.5% among persons aged 65-74 years (Table 1). The age-adjusted prevalence among women was 22% higher than that among men; 91% higher among blacks than among whites; 61% higher among Hispanics than among whites; and 43% higher among other races than among whites. The prevalence of age-adjusted diabetes varied threefold among participating states, from 2.8% (95% confidence interval (CI)=2.1-3.4) in Montana to 8.7% (95% CI=7.6-9.9) in the District of Columbia (Table 2). The median level of age-adjusted prevalence of diabetes among the states was 5.0%. With the exception of Hawaii, states with the highest prevalence were east of the Mississippi River (Figure 1). Reported by: the following state BRFSS coordinators: L Eldridge, Alabama; J Contreras, Arizona; W Wright, California; M Adams, Connecticut; A Peruga, District of Columbia; S Hoecherl, Florida; J Smith, Georgia; A Villafuerte, Hawaii; J Mitten, Idaho; B Steiner, Illinois; S Joseph, Indiana; S Schoon, Iowa; K Bramblett, Kentucky; J Sheridan, Maine; A Weinstein, Maryland; L Koumjian, Massachusetts; J Thrush, Michigan; N Salem, Minnesota; J Jackson-Thompson, Missouri; M McFarland, Montana; S Spanake, Nebraska; K Zaso, L Powers, New Hampshire; L Pendley, New Mexico; J Marin, O Munshi, New York; C Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; C Becker, Pennsylvania; R Cabral, Rhode Island; M Mace, South Carolina; S Moritz, South Dakota; D Riding, Tennessee; J Fellows, Texas; L Post-Nilson, Utah; J Bowie, Virginia; K Tollestrup, Washington; D Porter, West Virginia; M Soref, Wisconsin. Div of Diabetes Translation and Office of Surveillance and Analysis, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: For 1988 and 1989, the BRFSS data indicate that age-adjusted prevalence of self-reported diabetes varied substantially by state. Although state-specific differences in diabetes incidence and/or mortality may account for the variability in disease prevalence, data are not available at the state level to examine these associations.

These prevalence estimates are based on self-reports of diabetes. Results of the second National Health and Nutrition Examination Survey, conducted in 1976-1980, indicated that the prevalence of diabetes, when based on an oral glucose tolerance test, is approximately double the prevalence estimate based on self-reports of diabetes (4). If the degree of underdiagnosis and/or underreporting of diabetes is constant across states, the differences in BRFSS prevalence estimates among states should be accurate.

The overall age-standardized prevalence of 5.1% for self-reported diabetes from the 1988 and 1989 BRFSS is higher than the overall prevalence of 3.7% reported in the 1987 National Health Interview Survey (NHIS). This difference may reflect, in part, differences in survey methodology. The BRFSS asks for information about each respondent only and is an aggregation of state probability samples; the NHIS is a survey of a national probability sample of households that asks respondents to provide information about health conditions of each household member.

Diabetes-control programs in 27 state and territorial health departments are designed to reduce the morbidity associated with diabetic complications by rapidly translating diabetes research into medical-care practices. The programs focus on four diabetic complications: diabetic eye disease, cardiovascular disease, lower-extremity amputations, and adverse pregnancy outcomes. Although the BRFSS can be used to monitor diabetes prevalence, data for monitoring trends in diabetic complications are generally not available at the state level. To address this need, the Division of Diabetes Translation (DDT) in CDC's Center for Chronic Disease Prevention and Health Promotion has entered into cooperative agreements with state health agencies in Colorado, Minnesota, and North Carolina to explore methods for developing state-based surveillance systems for diabetes and its complications.

The DDT has recently provided "synthetic" state-specific estimates of the disease burden (e.g., hospitalizations for lower-extremity amputations) from diabetes (5). For each state, tabulations include the estimated number of persons with diabetes, deaths caused by diabetes, and hospitalizations and deaths for diabetes-related conditions (e.g., cardiovascular disease, ketoacidosis, lower-extremity amputation, end-stage renal disease, and blindness). Copies of Diabetes Fact Sheets 1990 are available from the DDT, Mailstop F48, Center for Chronic Disease Prevention and Health Promotion, CDC, 1600 Clifton Road, NE, Atlanta, GA 30333.

References

1. CDC. Prevalence and incidence of diabetes mellitus--United States, 1980-1987. MMWR 1990;39:809-12.

2. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988;103:366-75.

3. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, North Carolina: Research Triangle Institute, 1981.

4. Harris MI, Hadden WC, Knowler WC, Bennett PH. Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in U.S. population aged 20-74 years. Diabetes 1987;36:523-34.

5. CDC. Diabetes fact sheets 1990. Atlanta: US Department of Health and Human Services, Public Health Service, 1990.

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