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CENTERS FOR DISEASE CONTROL AND PREVENTION
Department of Health and Human Services
Diabetes in American Indians:
The Public Health Problem and the Response--Challenges and Opportunities
Testimony before the
Senate Finance Committee Chairman
Max Baucus (D-MT)
Frank Vinicor, M.D., M.P.H.
Diabetes Program Director
August 13, 2001
Good morning Mr. Chairman. My name is Frank Vinicor. I am the Director of
the Centers for Disease Control and Prevention's (CDC) Diabetes Program. I am
pleased to appear before you on behalf of the CDC, to discuss the seriousness of the
diabetes problem in the American Indian population, and to share with you some
information about the activities of CDC's diabetes program. This hearing offers an
important opportunity for the panelists to explore other collaborative strategies, and to
recommend policies and programs that can have a positive impact on diabetes control
and prevention in Indian Country.
Diabetes is a serious, widespread and costly chronic disease, affecting not just
16 million individuals in the United States, but millions of families and communities.
Between 1990 - 1998, diabetes prevalence among adults increased 33 percent in the
U.S., growing fastest among adults aged 30-39. CDC estimates that the number of
Americans with diagnosed diabetes will increase from 11 million to 30 million between
2000 and 2050.
Alarmingly, type 2 diabetes, an illness once thought to afflict only adults, is
now being found in children and adolescents. Because these children have acquired
type 2 diabetes so very young, they will have more years of disease burden and a higher
probability of developing serious diabetes-related complications at a younger age-
complications that will threaten their life expectancy, reduce their quality of life, and
lower their productivity during the prime years of their lifetime.
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, as well as problems with
Diabetes is classified into two main types: type 1 diabetes, which is an
autoimmune disease that most often appears in childhood or adolescence, and type 2,
which accounts for approximately 90 - 95 percent of all people with known diabetes
(10.5 million) and 100 percent of all persons with undiagnosed diabetes (5.5 million).
This type of diabetes most often appears after the age 40, however, type 2 diabetes is
now being diagnosed more frequently among children and adolescents, especially in
The risk of developing type 2 diabetes is associated with modifiable risk factors
such as obesity, physical inactivity, and exposure to abnormal metabolism in utero. My
remarks will focus on type 2 diabetes.
Today, through the diligence of science and research, and the constancy of
surveillance, we know a lot about diabetes- and that knowledge base is expanding
rapidly. We know that diabetes is the leading cause of leg and foot amputations, kidney
failure, and blindness among working age adults. We know that each day, more than
2000 Americans will be diagnosed with diabetes; 150 will have a limb amputated; 75
people will go blind; and, 70 will develop end-stage renal failure: all of these
complications due to diabetes, and most of them preventable.
We know that diabetes contributes to nearly 200,000 deaths each year, and costs
this nation nearly $100 billion annually in direct health care and indirect costs such as
lost productivity. It is the seventh leading cause of death in the general population, and
most relevant to today's discussions, diabetes disproportionately affects racial and
ethnic minority populations.
Diabetes in American Indians
Diabetes is the fourth leading cause of death among American Indians and
Alaskan Natives. Recently, CDC reported that diabetes rates among American Indians
and Alaska Natives rose by 29 percent from 1990 to 1997. To develop the report, CDC,
in collaboration with the Indian Health Service (IHS), examined outpatient data
collected over an eight year period from most of the 541 IHS and tribal health facilities.
The number of diagnosed cases of diabetes among American Indians and Alaska
Natives rose from about 43,000 to 64,500. Although women were more likely to have
diagnosed diabetes than men in terms of absolute numbers, the increase among men
was higher (37 percent) than the increase among women (25 percent).
Substantial increases were observed among all age groups and in all geographic
regions of the U.S. for American Indians. While prevalence of diabetes varies among
different tribal nations, the increase in prevalence for those under age 45 was 10 times
greater than for the same age group in the general U.S. population. However, it is more
important to note that the percent increase in diabetes prevalence between 1990-97 was
highest among younger age groups, particularly among American Indians and Alaska
Natives aged 15-19 (41 percent) and 20-24 (36 percent). After adding one more year of
data to the trends, using the same methodology, the percent increase in diabetes
prevalence among American Indians and Alaska Native teens changed from 41 percent
to 68 percent.
Reasons for the dramatic increase in prevalence may include increased diabetes
incidence, or better case ascertainment, or both. Population-based studies that include
regular screening for diabetes, such as those among the Pima Indians, which was
conducted by the NIDDK Phoenix Epidemiology and Clinical Research Branch,
indicate that the increase in prevalence may be due to a true increase in incidence. In
short, this means that the number of new cases of diabetes is increasing fastest among
Increasing obesity is clearly contributing to increases in diabetes and decreased
physical activity is also very likely to be a significant risk factor. From around 1980 to
1990, there was almost a 40 percent increase in obesity (defined as a body mass index
(BMI) of 30+ kg/m2) among adults aged 20 or more years in the general population.
Among all children ages six to seventeen, the prevalence of overweight increased
almost 30 percent during that decade. As among children and adolescents in the
general population, prevalence of overweight and obesity has steadily increased among
American Indian children over the past decades. One study suggested that the increase
in weight and in frequency of exposure to diabetes in utero among Pima Indian children
with subsequent poor beta cell function, account for most of the recent increase in
diabetes prevalence in this population. Moreover, low levels of physical activity are
also a problem among American Indian children and this is further adding to the obesity
Because the risk of developing diabetes is associated with exposure to abnormal
metabolism in utero, the large increases among the younger age groups over a
relatively short span of time are extremely alarming. Any increases in prevalence
among the child-bearing population may turn into a vicious cycle (i.e. diabetes in the
mother during pregnancy would result in poor nutrition for the fetus, and ultimately
diabetes at an even younger age of the offspring - thus exposing even more fetuses to
In 1998, around 70,000 American Indians and Alaska Natives were estimated to
have diagnosed diabetes; today, we would conservatively project that number to be
around 80,000. These estimates are based solely on outpatient data of American
Indians and Alaska Natives using IHS and tribal health facilities, or about 60 percent of
the total Native American population in the U.S. If Native Americans not using IHS
and tribal health facilities are factored in, the estimated number of diagnosed diabetes
could easily rise to over 100,000; and, if the number of persons with undiagnosed
diabetes were included, we could conservatively estimate the number of Native
Americans with diabetes to be over 130,000.
In Montana, approximately 12 percent of adult American Indians reported
having diagnosed diabetes in 1999. This is two to three times higher than the state's
adult non-Indian population.
Addressing the Diabetes Problem
Clearly, we know a lot about the burden of diabetes- the health, social, medical
and economic costs and their implications. Without question, the diabetes burden in the
U.S. and in Indian Country is increasing at an alarming rate, however, our knowledge
about preventing diabetes complications, and even the onset of the disease itself, is
wide, solid and also growing. Through significant advances in diabetes research, we
know that improving nutrition or maintaining normal body weight, increasing physical
activity, controlling blood glucose levels and improving access to proper medical
treatment can delay, or stop, the onset and progression of diabetes complications.
Applying our knowledge could prevent much of the suffering caused by the devastating
complications from diabetes. And now, there is strong evidence that prevention or delay
of the onset of diabetes is possible if we can develop effective strategies and
interventions targeting weight loss or preventing obesity, increased physical activity,
and improved nutrition.
Just last week, the National Institutes of Health reported the results of the
largest-ever clinical study on diabetes prevention. The Diabetes Prevention Program
(DPP), which included a significant number of American Indian participants, found that
participants randomly assigned to intensive lifestyle intervention reduced their risk of
getting type 2 diabetes by 58 percent. On average, this group maintained their physical
activity at 30 minutes per day, usually with walking or other moderate intensity
exercise, and lost five to seven percent of their body weight.
The same study found that treatment with the oral diabetes drug metformin
(Glucophage®) also reduces diabetes risk, though less dramatically, in people at high
risk for type 2 diabetes. Participants randomized to treatment with metformin reduced
their risk of getting type 2 diabetes by 31 percent.
In short, we have an impressive 'mountain of knowledge' and we have a sizable,
and growing 'mountain of need'. How do we connect these two mountains to ensure
that all people with diabetes benefit? We build a bridge-a bridge to provide public
health approaches to help everyone with diabetes, and especially those most affected
by, and at greatest risk for, the disease.
CDC's National Diabetes Program
CDC translates scientific breakthroughs in diabetes control and prevention into
practical programs for application in health care and community-based settings. The
diabetes program has three major aims: to know what the burden of diabetes is (through
public health surveillance); to understand why the burden is so high (through applied
research); and to do something about it (through programs that respond to the problem
and increase awareness).
Part of CDC's mandate is to conduct public health surveillance. We have
established multiple data sources including the Behavioral Risk Factor Surveillance
System (the Diabetes Module), the National Health Interview Survey, and the National
Health and Nutrition Examination Survey to learn about disease morbidity and
mortality. CDC's surveillance activities place a high priority on increasing what we
know about the diabetes burden among special populations, such as certain racial and
ethnic minority groups and children.
CDC provides technical assistance to IHS's diabetes program on surveillance of
diabetes and its complications among American Indians and Alaskan Natives. CDC
has focused on trends in prevalence of diabetes for adults and children. This
collaboration has produced several publications, including a report on the prevalence of
diagnosed diabetes among American Indians and Alaskan Natives for 1996 which was
published in the October 30, 1998 issue of the Mortality and Morbidity Weekly Report
(MMWR), and an article describing the increasing prevalence of diabetes in American
Indians in the December 2000 issue of Diabetes Care.
It is essential that we not only understand the size of the diabetes burden but
also the reasons for this burden and the reasons for disparities among population
groups. For example, we recently found in a study conducted jointly by CDC and the
IHS, that the total number of American Indians and Alaska Natives with diabetes who
began treatment for end-stage renal disease almost doubled between 1990 and 1996
from 394 to 719. Nearly 60 percent of those cases occurred among women. Possible
factors for the increase in end-stage renal disease include an increased prevalence of
diabetes in Native American populations and increased prevalence of risk factors for
end-stage renal disease such as duration of diabetes, hypertension, and hyperglycemia.
Thus, an increased prevalence of diabetes unmasks other risk factors for renal disease
such as hypertension, and the combination of diabetes and hypertension become
CDC relies heavily upon the states to provide the essential framework for
delivering population-based diabetes prevention and control approaches. CDC funds all
50 states, Washington, D.C. and eight territories to operate state-based diabetes control
programs. The programs are required to work with partners to improve the quality of,
and increase access to diabetes care, to involve communities in improving diabetes
control, to inform and educate health professionals and people with diabetes about the
disease, and to identify high risk populations, including American Indians. These
state-based diabetes control programs are the primary implementation arm of CDC's
National Diabetes Program.
For example, in New York, programs directed to improving access to basic
diabetes care within Harlem resulted in an approximately 50 percent reduction in
hospital rates for lower extremity amputations. Within the Michigan diabetes control
program targeted to the upper peninsula, rates of lower extremity amputations due to
diabetes were reduced by approximately 55 percent, while treatment of hypertension
improved in physician's offices. In Utah, the diabetes control program directed efforts
to screening for diabetic eye disease, with an increase from approximately 30 to 67
percent in the number of diabetic subjects who had their eyes properly examined.
Finally, 43 diabetes control programs have been involved in the "Diabetes
Collaborative" of the Health Resources and Services Administration directed to over
400 community health centers. Within one year, there was an increase in obtaining an
A1C test (a test of diabetes control) within these centers from approximately 30 percent
of times a diabetic patient was seen to approximately 65 percent.
In Montana, the diabetes control program is actively working with IHS, Indian
tribes and other partner organizations in the state to improve surveillance and diabetes
care and prevention efforts at the local level, and to provide unique training to meet the
needs of Indian and non-Indian communities. The following are illustrative of the
Montana diabetes control program's activities:
Type 2 diabetes in Montana American Indian youth:
Type 2 diabetes in children was first diagnosed in American Indian youth over
two decades ago, and it is now a major health concern. The Montana diabetes control
program collaborated with the Billings IHS office to establish an ongoing surveillance
system to monitor diabetes in American Indian youth less than 20 years of age. From
1997 to 1999, 52 cases of diabetes among American Indian youth were identified: just
over half (52 percent) had type 2 diabetes- an alarmingly high number of cases. This
joint surveillance activity continues to assess changes in diabetes prevalence and care
Additionally, to address the growing concern about type 2 diabetes risk factors
among Montana's youth, the program is providing consultation and technical expertise
in health education and surveillance to support school-based diabetes screening
programs established by local tribes and the IHS.
Training health professionals and community health representatives:
The Montana program developed the "Quality Diabetes Education Initiative," a
training course to assist health care professionals to improve their diabetes education
knowledge and skills. Last year, the program conducted a two-day training course for
newly-hired diabetes outreach workers and community health representatives working
with the tribes. The training gave the newly-hired diabetes workers an increased
understanding of primary, secondary and tertiary diabetes prevention.
In addition to our partners at the state level, CDC is working closely with other
Federal agencies and non-governmental organizations to eliminate the preventable
burden of diabetes among American Indians. Our efforts include the following
National Diabetes Prevention Center
- Congress provided funds to CDC to support the establishment of the National
Diabetes Prevention Center (NDPC), in Gallup, New Mexico.
The NDPC is a CDC and IHS collaboration to review successful
interventions for diabetes care and prevention in American
Indian/Alaska Native populations and to support innovative,
culturally appropriate and multi-disciplinary new approaches
to care and prevention. The Tribal Leaders Diabetes Committee
has been very helpful and supportive with their advice
and guidance as we have moved forward with this project
over the past three years. We are also working in close
partnership with tribal colleges, the National Indian
Council on Aging, the American Association of Indian Physicians
and a variety of other American Indian organizations,
as well as community-centered efforts and our own state-based
diabetes control programs.
- Currently, the NDPC is focused on gathering, connecting and disseminating
information about what really works in diabetes prevention.
A series of reports about 'best practices' in information
technology, community prevention activities, educational
resources, and planning activities are underway. We are
also developing a variety of tools, resources, curriculums,
systems and data approaches
to assist in diabetes prevention efforts for all tribes.
- Under a cooperative agreement with the University of New Mexico, there is
also a local/regional project with a focus on the Navajo
Nation and Zuni Pueblo. This project is focusing on community-based
research, evaluation and diabetes prevention education.
This special project initially focused on Native American
populations and hopefully will have wide-ranging applications
for community prevention projects throughout the U.S.
National Diabetes Education Program
- The National Diabetes Education Program (NDEP), a joint initiative between
CDC and NIH, has created an extensive partnership network
to mobilize public and private sector organizations to
work with the NDEP to improve diabetes treatment. An American
Indian Workgroup was formed to assist with the development
of culturally appropriate TV, radio, and print ads for
American Indian communities. With input from tribal leaders
and community members, the campaign message became, "Control
your Diabetes for Future Generations." In addition, the
Association of American Indian Physicians (AAIP) was selected
by CDC to help disseminate campaign materials. In the
future, the Workgroup will develop a new American Indian
campaign focused on youth.
- REACH, which stands for "Racial and Ethnic
Approaches to Community Health (REACH 2010), is a CDC
demonstration project that targets six health priority
areas: infant mortality, breast and cervical cancer, cardiovascular
disease, diabetes, immunization, and HIV/STD. The purpose
of the projects is for communities to mobilize and organize
their resources in support of effective and sustainable
programs which will eliminate the health disparities of
racial and ethnic minorities. Some REACH grantees
are addressing the burden of diabetes in American Indian
communities including the Eastern Band of the Cherokee
Nation and the Oklahoma State Health Department.
Without question, the diabetes problem in this country and in Indian country is
large and continuing to increase. Experience has shown that development of the chronic
complications associated with diabetes (eye, kidney and heart disease) increases 10 -20
years after an increase in incidence of diabetes. Thus, the health care burdens caused by
diabetes, particularly in Indians, will continue to increase unless better ways are found
to prevent, postpone or reverse the disease. Yet, there are significant secondary and
tertiary prevention strategies underway, and proven primary prevention strategies soon
to be implemented that will help make a difference. We are making progress in getting
patients and providers to focus on improving blood glucose levels and regularly
examining eyes and feet, but data show that there is room for improvement.
With the results of the Diabetes Prevention Program, we now need to
aggressively take on the challenge of preventing diabetes in those at highest risk for
developing the disease. We also need to build on the early starts, such as Quest, a
school-based intervention program in American Indian communities initiated to
increase physical activity, improve diet and reduce obesity in children. This program is
an important model which can contribute to the development of other community-based
primary prevention interventions. And later this week, Secretary Thompson will spend
five days visiting Native American reservations in Michigan, Wisconsin and South
Dakota, with concern about diabetes among these tribes being one of the primary topics
of discussion. He will talk to leaders about how we can better work with tribes to
reduce diabetes on reservations.
Thank you for the opportunity to appear before you today. I would be happy to
answer any questions you may have.
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Last revised: October 1, 2001