Prevalence of Diagnosed Diabetes Among American Indians/Alaskan Natives -- United States, 1996

Since the early 1960s, diabetes has disproportionately affected American Indians/Alaskan Natives (AIs/ANs) compared with other populations (1,2). Diabetes is a major cause of morbidity (such as blindness, kidney failure, lower-extremity amputation, and cardiovascular disease) and premature mortality in this population (3). To update information about the prevalence of diabetes among AIs/ANs, data were analyzed from the Indian Health Service (IHS) national outpatient database for 1996 and were compared with the prevalence of diabetes among non-Hispanic whites in the United States. This report presents the findings of this analysis, which indicate that the prevalence of diabetes among AIs/ANs remains high and is approximately three times the prevalence among non-Hispanic whites.

Outpatient data were reported from 141 of the 166 service units in four geographic groups of tribes *; 25 service units (representing 11% of the population served by IHS) were excluded because the reported data were incomplete. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 250.0-250.9 were used to identify persons with diabetes. The outpatient database includes unduplicated case reports of persons who attended the service unit one or more times during 1996 and for whom there was a diagnostic code of diabetes. The number of persons residing within the IHS service units were estimated from the U.S. census and birth and death rates. Approximately 60% of the estimated 2.3 million AIs/ANs residing in the United States are eligible to receive IHS services and use IHS medical facilities (4). The prevalence of diabetes in the United States was estimated from the 1995 National Health Interview Survey (NHIS) (5). Prevalence estimates were adjusted for age by the direct method using the 1980 U.S. population as the standard.

In 1996, an estimated 63,400 AIs/ANs who receive care from IHS had diabetes; 98.3% were aged greater than or equal to 20 years. Of those aged greater than or equal to 20 years, 49.7% were aged 45-64 years; 59.0% were women. The prevalence of diabetes increased with age -- from 3.5% for persons aged 20-44 years to 21.5% for persons aged greater than or equal to 65 years. The overall crude prevalence for those aged greater than or equal to 20 years was 9.0% (Table_1). The prevalence was greater among women (10.1%) than men (7.7%). The age-specific prevalence among AI/AN women was higher than among men, but the age-specific prevalence among non-Hispanic white men was higher than among women.

Among AIs/ANs aged 20-44 years and 45-64 years, the prevalence of diabetes was more than three times that among non-Hispanic whites in the NHIS (3.5% versus 0.9% {95% confidence interval (CI)=0.6%-1.2%} for persons aged 20-44 years and 19.0% versus 5.2% {95% CI=4.2%-6.2%} for persons aged 45-64 years). Among persons aged greater than or equal to 65 years, the prevalence among AIs/ANs (21.5%) was approximately twice that among non-Hispanic whites (11.4% {95% CI=9.7%-13.1%}). The age-adjusted prevalence among persons aged greater than or equal to 20 years was 2.8 times that among non-Hispanic whites in the same age group (10.9% versus 3.9% {95% CI=3.5%-4.3%}).

The prevalence of diabetes varied by tribal group -- 12.7% among the Plains tribes, 10.5% among the Southwestern tribes, 9.3% among the Woodland tribes, and 4.5% among the Pacific Coastal tribes. The age-adjusted prevalence of diabetes ranged from 1.5 to 4.1 times the prevalence among non-Hispanic whites. Among the tribes of the Plains and the Southwest, the age-adjusted prevalence of diabetes (15.9% and 13.5%, respectively) was greater than that for the total IHS population and was more than three times that among non-Hispanic whites.

Reported by: Diabetes Program, Indian Health Service. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Diabetes is a serious disease associated with severe morbidity and premature death that affects approximately 9% of AI/AN adults. In persons with type 1 or type 2 diabetes, aggressive glycemic control may prevent or delay diabetes-related complications such as retinopathy, nephropathy, or neuropathy (6,7). Interventions that promote healthy behaviors may prevent or delay the onset of diabetes in persons at risk for developing type 2 diabetes (also known as noninsulin-dependent or adult-onset diabetes) (8). As with other chronic disease prevention interventions, diabetes prevention efforts need to be ongoing and long-term before the impact on morbidity and mortality can be measured.

The findings in this analysis have at least four limitations. First, estimates of the AI/AN population are inaccurate because U.S. census estimates do not account for migration between service units and previously have underreported the number of AIs/ANs. Second, these data account only for those persons who are eligible to receive IHS services and use IHS medical facilities. The higher age-specific prevalence of diabetes among AI/AN women may be due to women seeking health care more frequently than men (4). Moreover, the data represent diagnosed cases of diabetes being treated and underestimate the true prevalence. Data from the Navajo Health and Nutrition Survey showed that one third of Navajo adults with diabetes had not had diabetes diagnosed (9). Third, under the Indian Self-Determination Act **, an increasing number of service units are becoming IHS sites operated by tribal governments that may choose not to report diabetes cases to the IHS outpatient database. Finally, 11% of the total IHS population was excluded from this analysis because of incomplete data.

Effective intervention strategies are needed to control diabetes and its complications among AIs/ANs. CDC provides technical assistance to the IHS Diabetes Program for surveillance of diabetes and its complications. CDC and the National Institute of Diabetes and Digestive and Kidney Disease of the National Institutes of Health are conducting the Diabetes Prevention Program, a clinical trial to evaluate three diabetes prevention interventions -- including a program to increase exercise and reduce body weight -- in four American Indian communities. CDC and IHS are collaborating to establish the National Diabetes Prevention Center in Gallup, New Mexico, that will 1) provide guidance and technical support in diabetes prevention and control strategies to AI/AN communities throughout the United States and 2) develop, evaluate, and disseminate culturally appropriate community-based interventions. IHS also has granted $30 million to tribal governments in 1998 to help develop and implement innovative interventions to prevent diabetes and its complications.

November is National Diabetes Awareness Month. Additional information about diabetes is available from CDC, telephone (toll-free) (877) 232-3422 ({877} CDC-DIAB); e-mail ccdinfo@cdc.gov; or the World-Wide Web site http://www.cdc.gov/diabetes; by mail to the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC, 4770 Buford Highway NE, Atlanta, GA 30341-3717; and from state and territorial diabetes control programs. Information about the National Diabetes Education Program, a nationwide partner-based initiative of CDC and the National Institutes of Health (NIH), is available from NIH, telephone (800) 438-5383, and from CDC.

References

1. Bennett PH, Burch TA, Miller M. Diabetes mellitus in American (Pima) Indians. Lancet 1971; 2:125-8.

2. Valway S, Freeman W, Kaufman S, Welty T, Helgerson SD, Gohdes D. Prevalence of diagnosed diabetes among American Indians and Alaska Natives, 1987. Diabetes Care 1993;16(suppl 1):271-6.

3. Gohdes D. Diabetes in North American Indians and Alaska Natives. In: Harris MI, Cowie CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, eds. Diabetes in America. 2nd ed. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1995; DHHS publication no. (NIH)95-1468.

4. Indian Health Service. Trends in Indian health, 1996. Rockville, Maryland: US Department of Health and Human Services, Indian Health Service, Office of Planning, Evaluation, and Legislation, Division of Program Statistics, 1997.

5. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-1994. Hyattsville, Maryland: US Department of Health and Human Ser-vices, Public Health Service, CDC, National Center for Health Statistics, 1989. (Vital and Health Statistics; vol 2, no. 110).

6. DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus: The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86.

7. U.K. Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:839-55.

8. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537-44.

9. Will JC, Strauss KF, Mendlein JM, Ballew C, White LL, Peter DG. Diabetes mellitus among Navajo Indians: findings from the Navajo Health and Nutrition Survey. J Nutrition 1997;127 (suppl):2106-13.

* The scope of each geographic group of tribes is as follows: Woodland tribes -- Alabama, Connecticut, Florida, Kansas, Louisiana, Maine, Michigan, Minnesota, Mississippi, New York, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, and Wisconsin; Plains tribes -- Iowa, Montana, Nebraska, North Dakota, South Dakota, and Wyoming; Southwestern tribes -- Arizona, Colorado, Nevada, New Mexico, and Utah; and Pacific Coastal tribes -- Alaska, California, Idaho, Oregon, and Washington. 

** Public Law 93-638.

TABLE 1. Prevalence* of diagnosed diabetes among American Indians/Alaskan
Natives+ and non-Hispanic whites& aged >=20 years, by age and sex -- United States,
1996
=======================================================================================================
                            Men                        Women                          All
                  ------------------------     ------------------------     -------------------------
                  American                     American                     American
                  Indians/                     Indians/                     Indians/
Age group          Alaskan    Non-Hispanic      Alaskan    Non-Hispanic      Alaskan     Non-Hispanic
 (yrs)             Natives          whites      Natives          whites      Natives           whites
------------------------------------------------------------------------------------------------------
20-44                3.1          0.6             3.8          1.3             3.5           0.9
45-64               16.7          5.4            21.1          5.1            19.0           5.2
  >=65              19.1         11.8            23.3         11.2            21.5          11.4

  >=20               7.7          3.9            10.1          4.5             9.0           4.2

Age-adjusted@        9.7          3.8            12.0          4.0            10.9           3.9
------------------------------------------------------------------------------------------------------
* Per 100 persons.
+ American Indians/Alaskan Natives in the 1996 Indian Health Service (IHS) Patient Comprehen-
  sive Care file; excludes data from 25 (representing 11% of the population served by IHS) of
  the 166 IHS service units because the data were incomplete.
& Non-Hispanic whites in the 1995 National Health Interview Survey.
@ To the 1980 U.S. population.
=======================================================================================================

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