N C D i a b e t e s P r e v e n t i o n a n d C o n t r o l P r o g r a m Fa c t S h e e t
The Burden of Diabetes
in North Carolina: Brief 2013 Report
Highlights
• 10.9 percent or 788,000 adults in North Carolina had diabetes in 20111.
• Another 512,000 adults were diagnosed with pre-diabetes.
• One in 10 pregnant women has gestational diabetes in the state.
• Lifestyle factors such as overweight/obesity, lack of physical activity and
unhealthy eating habits are contributing to the diabetes epidemic in the state.
• High blood sugar levels in diabetic patients cause problems with other body
functions such as heart, kidneys, nerves, feet, eyes and gums. Having diabetes also
increases the risk for skin and digestive problems.
• Diabetes is the 7th leading cause of death among North Carolinians.
• Diabetes disparities are prevalent and costly in the state. Minorities in
North Carolina have higher diabetes prevalence, lower quality care, and suffer
more from diabetes complications.
Some adults are more likely to have diabetes
Gender
Males had slightly higher diabetes prevalence than females (10.9% vs. 10.8%).
Age
Diabetes prevalence increases with age. One in every five adults age 55 and older had diabetes
in the state. People aged 65 and older had the highest diabetes prevalence (23.2%).
Race
Diabetes prevalence was highest in African-Americans at 13.8 percent, compared to 10.4 percent
in whites.
Education
Adults with less than a high school diploma (17.8%) or high school/GED (11.9%) were more
likely to have diabetes than those with a college degree (6.0%).
Income
Adults with household incomes more than $75,000 were less likely to have diabetes compared to
adults with incomes less than $15,000 (5.5% vs.16.7%).
Disability Status
Adults with diabetes reported disability status three times more than adults without diabetes
(22.0% vs.7.3%).
Table1. Diabetes Prevalence in North Carolina, 2011
Demographic Characteristic
Weighted Number of adults
Prevalence Rate (%)
95% C.I.*
Upper 95% CI
Total Diabetes
Gender
Male
White
Black
Other minority
Female
White
Black
Other minority
Race/Ethnicity **
White
Black
Other minority
Hispanic
Yes
No
Age
18-44
45-64
65+
Education**
< H.S.
H.S. or G.E.D
Some post-H.S.
College Graduate
Household Income**
Less than $15,000
$15,000-24,999
$25,000-34,999
$35,000-49,999
$50,000-74,999
$75,000+
Disability Status**
Yes
No
NC Regions**
788,000a
10.9
10.0
11.7
273,000
82,000
23,000
11.1
12.3
6.5
9.6
9.2
3.1
12.6
15.4
9.9
260,000
121,000
23,000
9.8
15.0
8.6
8.6
12.3
5.3
10.9
17.8
11.8
533,000
203,000
45,000
10.4
13.8
7.4
9.5
11.7
5.0
11.3
15.8
9.8
36,000
747,000
7.2
11.1
4.6
10.2
9.8
11.9
108,000
375,000
293,000
3.1
15.3
23.2
2.3
13.7
21.1
3.9
17.0
25.4
215,000
246,000
224,000
103,000
17.8
11.9
10.0
6.0
15.1
10.3
8.5
5.0
20.6
13.4
11.4
6.9
138,000
162,000
94,000
115,000
63,000
78,000
16.7
12.3
14.0
12.4
7.2
5.5
13.9
10.1
11.1
9.8
5.4
4.2
19.5
14.4
17.0
15.1
9.0
6.7
376,000
375,000
22.0
7.3
19.9
6.4
24.1
8.1
Eastern NC
239,000
451,000
98,000
11.7
10.5
10.7
10.1
9.4
9.0
13.3
11.6
12.4
Piedmont
Western NC
*C.I. denotes Confidence Interval BRFSS 2011, North Carolina State Center for Health Statistics
**Includes both sexes. Rounded to the nearest thousand.
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Diabetes Risk Factors
Patients with diabetes have modifiable risk factors such as obesity, lack of physical activity, and
unhealthy eating that contribute to complications including heart disease, kidney disease, eye
problems and nerve disease.
Overweight/Obesity:
In 2011, 65.1 percent of North Carolina residents were considered overweight or obese based on
Body Mass Index (BMI). People with diabetes are twice as likely to be obese compared to people
without diabetes (54.6% vs. 26%). Obese adults are four times more likely to have diabetes than
adults with normal weight (54.6% vs. 12.9%). If obesity continues to increase at the same rate, it
could contribute to 1.2 million new cases of diabetes by 2030 in the state. However, if the BMI was
lowered by 5 percent in next 20 years, type 2 diabetes could be prevented in 261,785 people in North
Carolina2.
Poor eating habits:
Eating processed foods and oversized portions have increased obesity and
diabetes in the state. More than 87 percent of adults with diabetes did not
consume five or more servings of fruits, vegetables or beans daily in 2011.
Eating balanced meals, making healthy food choices, understanding portion
sizes, and learning the best times to eat are important to manage diabetes.
Lack of exercise:
Vigorous exercise not only helps in weight loss but
also improves insulin sensitivity and heart health.
It is never too late to increase physical activity.
Swedish National Diabetes Register found that
higher levels of leisure-time physical activity cut
the risk of cardiovascular and all-cause mortality
by two-thirds in people with type 2 diabetes3. Forty
percent of diabetic patients did not participate
in any physical activity such as running, walking,
gardening, and golf in North Carolina in 2011.
More than 60 percent did not meet aerobic activity
recommendation. About 83 percent did not meet
muscle strengthening activity recommendation.
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Pre-diabetes:
People with pre-diabetes – a condition in which blood glucose levels are higher than normal but
not high enough to be classified as diabetes – are at increased risk for developing type 2 diabetes.
The Diabetes Prevention Program (DPP) study showed that people
with pre-diabetes who exercised moderately for 30 minutes a day
and lost 5 to 7 percent of their body weight through modest dietary
changes were able to cut their odds of getting diabetes by 58 percent.
•
In North Carolina, 7.9 percent or 512,000 adults were estimated to
have diagnosed pre-diabetes in 2011. Pre-diabetes rates were
highest among blacks (9.3%), compared to whites (7.8%) in the state.
•
Women had higher levels of diagnosed pre-diabetes, compared to men (10.3% vs. 5.4%).
•
One in 10 ten adults who were diagnosed with pre-diabetes was
55 and older.
Figure 1. Selected Risk Factor prevalence by
Diabetes status in North Carolina, BRFSS 2011
Gestational Diabetes:
Gestational Diabetes occurs in some pregnant women who never had diabetes before but have
high blood glucose levels during pregnancy. Although gestational diabetes goes away after
delivery in majority of cases, 5 to 10 percent of women develop type 2 diabetes immediately.
Women with gestational diabetes have 35-60 percent chance of developing type 2 diabetes in the
next 10-20 years.
•Among Medicaid enrollees in North Carolina in FY 2011, 10,059 women had gestational
diabetes.
•Pregnancy Risk Assessment and Monitoring System (PRAMS) showed that one in 10
pregnant women in North Carolina had gestational diabetes in 2009 (10.5%)4 .
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Environmental Chemicals and Toxins:
People who are exposed to highest levels of environmental toxins have a much higher risk of
diabetes. Toxins block the function of receptors in cells which leads to insulin resistance and
diabetes. Toxins slow down metabolism, increase glucose, cholesterol, and fatty liver, and slow
down thyroid function.
•
The National Health and Nutrition Examination
Survey (NHANES) 1999-2002 found a strong
correlation between diabetes and blood levels of six
common persistent organic pollutants (POPS);
polychlorinated dibenso-p-dioxins (PCDDs),
polychlorinated dibenzofurans (PCDFs),
polychlorinated biphenyls (PCBs), hexachlorobenzene
(HCB), and two organochlorines used as pesticides .
•
According to Journal of the American Medical
Association, bisphenol A, a petrochemical that lines
water bottles and canned food containers, increases a
person’s risk of diabetes, heart disease and abnormal
liver function caused by insulin resistance6. And
another study showed that arsenic exposure increases the risk of diabetes7.
• Exposure to chemicals and toxins causes obesity and diabetes, independent of calorie intake or exercise.
Diabetes Complications
• Cardiovascular Disease (CVD): People with diabetes are three times more likely to report
cardiovascular disease (history of heart attack or coronary heart disease or stroke) than people
without diabetes (24.3% vs. 7.3%)1.
•Blood Pressure: People with diabetes reported almost three
times more high blood pressure than people without diabetes
(72.9% vs. 27.5%).
•Blood Cholesterol: People with diabetes were twice as likely to
report high blood cholesterol as people without diabetes
(67.6% vs. 34.1%).
•Kidney Disease: Diabetes is the leading cause of kidney failure.
People with diabetes have almost four times more kidney
disease prevalence than people without diabetes (6.4% vs. 1.7%).
•Cancer: People with diabetes are almost three times more likely
to have cancer than people
without diabetes in North Carolina (13.8% vs. 5.6%). Diabetes and increased fasting glucose
are independently associated with an increased risk for a variety of cancers. It is estimated
that colon cancer risk is 38 percent higher among people with diabetes than people without the
disease8. About 40 percent of the years of life lost from diabetes can be attributed to
nonvascular conditions, including about 10 percent to death from cancer.
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Figure 2. Complications by Diabetes Status in
North Carolina, BRFSS 2011
*Cardiovascular Disease
•
Hypoglycemia: Hypoglycemia,
same as low blood sugar, is a common
North Carolina Emergency Medical Services (EMS) shows that 40,263
emergency among people with
or 43 percent of ambulance runs from July 2008 to June 2010 were
diabetes. It can happen when blood
potentially diabetes-related. By primary impression, almost 30 percent
glucose level falls too low as people
or 11,496 of diabetes-related ambulance runs were hypoglycemia-related.
with diabetes take insulin or oral antidiabetic medications. It can cause
sickness and even death. The research shows that achieving good glycemic control is good for minimizing the risk of micro vascular complications among people with diabetes.
•
Hearing loss: More than one million
North Carolinians have hearing loss in
20119. The major factors known to
affect hearing are age, race, ethnicity,
income level, noise exposure, and the
use of certain medications. It is more
prevalent in men compared to women.
Hearing loss is twice as common in
adults with diabetes compared to
people without diabetes.
•
National Health and Nutrition Examination Survey (NHANES) 19992004 showed that 65.5 percent of U.S. adults (age 20 and above) with
diabetes had hearing impairment 10. The study showed that 21 percent
had low frequency hearing loss and 54 percent had high frequency
hearing loss specifically linked to diabetes. Diabetic patients with
low HDL cholesterol (‘good cholesterol’), a history of coronary heart
disease, peripheral neuropathy and those who report poor health are
more likely to have hearing impairment.
Sleep Apnea is a common and serious sleep disorder among people with diabetes
Sleep apnea is associated with alterations in glucose metabolism and places patients
at an increased risk of the development of type 2 diabetes. The risk factors for sleep
apnea include overweight/obesity, age, crowded airway, male sex, hypertension and
cardiovascular disease. The symptoms of sleep apnea are snoring, difficulty breathing
at night, insomnia and excessive daytime sleepiness.
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
•
Obstructive Sleep Apnea:
Among people who have sleep
apnea, 90 percent of them have
Obstructive Sleep Apnea (OSA).
OSA affects approximately 20
percent of the nation’s adults of
whom 90 percent are undiagnosed.
OSA is highly prevalent in men.
Two out of three men with
diabetes who are 65 or older have
OSA.
•
North Carolina Hospital Discharge data shows that there were 15,000
males with OSA in 2010.
•
In North Carolina, there were 138,464 Medicaid adults with diabetes
(18+) in FY 2011. Of them, 13,612 adults were identified with a
procedure code for sleep apnea. Out of them, 84 percent had OSA.
•
It is important to treat sleep apnea as it increases risk of high blood
pressure, heart failure and stroke. Lifestyle modification including
weight loss, smoking cessation, Continuous Positive Airways Pressure
(CPAP) treatment and surgery will help to treat the problem and
reduce complications.
Diabetes Control
Comprehensive diabetes control includes optimal
management of A1c (a measure of average blood glucose over
2-3 months), Blood pressure and Cholesterol (ABC).
The ABC treatment goals for most people with diabetes are:
A-A1c (blood glucose) less than 7 percent.
B- Blood pressure less than 130/80 mmHg
C-Cholesterol-LDL less than 100 mg/dl
Preventive Care Practices
Preventive care practices are essential to diabetes care. More than half of diabetes patients
received preventive care services annually such as eye and foot exams in the state. Table 2
shows the percentage of North Carolina adults with diagnosed diabetes who received some
of the preventive care practices in 2011. National health objectives in Healthy People 2020
(HP 2020) call for increasing the percentage of people with diabetes who are practicing these
recommendations. Although North Carolina met some HP 2020 objectives such as annual eye
exam, foot exam, and A1c testing, the state still needs to work on improving the percentage of
people receiving diabetes self-management class and flu and pneumococcal vaccines.
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Table 2. Preventive Care Practices among people with Diabetes,
North Carolina BRFSS 2011
Preventive Care Practices
Prevalence Rate HP 2020 Goal Meets HP 2020 goal?
Annual Eye Exam
70.2
58.7
•
Annual Medical Foot Exam
79.4
74.8
•
A1c tests twice per year
75.3
71.1
•
Self-Exam of Feet (one or more times per day)
76.5
70.4
•
Diabetes Self-Management Class
52.9
62.5
X
Self-Monitoring of Blood Glucose (one or more times per day)
68.8
70.4
X
Influenza vaccination
57.6
90.0
X
Pneumococcal Vaccination
57.2
60.0
X
Health Care Access: Health Insurance Coverage
The 2011 BRFSS survey shows that people with diabetes have slightly higher rate of health
insurance coverage (78.6% ) (under age 65), compared to 75.0% of people without diabetes in
the state. Among people who are employed (under age 65), 88.1 percent of people with diabetes
reported having health insurance compared to 81.7 percent of people without diabetes.
Table 3. Prevalence of Health Insurance coverage
by Selected Groups (Age <65), in North Carolina, BRFSS 2011
Demographic Group
Total
Male
Female
Percent
75.1
73.1
77.2
White
Black
80.6
70.2
Less than High School
High School
Post High School
College graduate
48.9
69.8
79.4
91.7
People with diabetes
People without diabetes
78.6
75.0
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Diabetes Morbidity
People with diabetes are three times more likely to require hospitalization than those without the
condition. There were 18,101 hospital discharges in North Carolina in 2010 with diabetes as the
principal diagnosis11. Another 196,405 people were discharged from hospitals with any mention
of diabetes in the diagnosis. The cost of diabetes-related hospitalizations is a huge burden on the
state. Total charges for diabetes-related hospitalizations were almost $5 billion in North Carolina
in 2010 (Table 4).
Table 4. Diabetes-related hospital discharges
with any mention of diabetes, North Carolina, 2010
Diagnosis related to Diabetes Number of total discharges Total charges ($) Average Charge per hospital stay ($)
Any mention of diabetes
Cardiovascular Disease
Heart Attack
Stroke
Renal dialysis/Transplant
Lower limb amputation
196,405
48,059
33,718
8,779
9,221
2,865
4.96 billion
1.45 billion
1.13 billion
198 million
302 million
127 million
$25,273
30,355
33,637
22,624
32,766
44,468
In North Carolina, 7.9 percent of all emergency department (ED) visits had a first or comorbid
diabetes diagnosis in 2009 12. ED visits rate in the state with diabetes as the first or comorbid
diagnosis was 36.7/1,000 person-years. Almost 80 percent of diabetes-related ED visits were
made by people 45 years of age and older, and one-third of these patients were admitted to the
hospital. The state or federal government was expected to pay for 63.8 percent of diabetes-related
visits.
Diabetes is the leading cause of death due to heart attacks and strokes, and it is the leading cause
of blindness and kidney failure in the state. While diabetes is the 8th leading cause of death
among whites, it is the 4th leading cause of death for blacks and Native Americans in North
Carolina in 2010. There were 2,036 deaths in the state with primary diagnosis of diabetes with
an age-adjusted death rate of 26.0 per 100,000 population13. Although diabetes-related deaths
have decreased over the past few years, the racial disparities still persist. African Americans and
American Indians experienced almost three times higher diabetes-related death rate than whites
(52.3 and 57.0 vs. 20.7 per 100,000 population) in 2010 ((Figure 3).
Figure 3. 2010 NC Resident Diabetes deaths per 100,000 population, Ages 15 & Over
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| The Burden of Diabetes in North Carolina BRIEF 2013 Report
Diabetes projections
• If obesity trend continues at the same rate in North Carolina, there may be 1.2 million new
cases of diabetes over the next 20 years in the state 2.
• CDC estimates that the number of U.S. adults with diabetes is projected to double or triple
by 2050. Increases in older population and minority population, and longer lifespans
contribute to the increase of diabetes.
Sources
1
Most of the data for this brief came from Behavioral Risk Factor Surveillance System (BRFSS) 2011, State Center for Health Statistics.
2
The eighth annual F as in Fat: How Obesity Threatens America’s Future 2011, a report from the Trust for America’s Health (TFAH) and the Robert Wood
Johnson Foundation (RWJF).
3
Zethelius B, Gudbjörnsdottir S, Eeg-Olofsson L, et al. Leisure time physical activity and risks of cardiovascular disease and mortality in type 2 diabetes: Report from the Swedish National Diabetes Register. European Association for the Study of Diabetes 2012 Meeting; October 2, 2012; Berlin, Germany.
Presentation 54.
4
5
2009 Pregnancy Risk Assessment Monitoring System (PRAMS), State Center for Health Statistics.
Lee DH, et al. A strong dose-response relation between Serum concentrations of persistent organic pollutants and diabetes: results from the national
Health and Examination Survey 199-2002. Diabetes Care. 2006 July: 29(7):814-22.
6
Lang IA, et al. Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults. JAMA 2008 Sept
17;300(11):1303-10,
7
Navas-Acien A, Silbergeld EK, et al. Arsenic exposure and prevalence of type 2 diabetes in US adults; JAMA, 2008 August 20;300(7):814-22.
8
Sanjai Sinha, Diabetes as a risk factor for cancer and other cause-specific mortality, 9/13/2012
9
North Carolina Division of Services for the Deaf and the Hard of Hearing, March 2011.
10
Kathleen Bainbridge et al. Risk Factors for Hearing Impairment Among U.S. Adults with Diabetes, National Health Nutrition Examination Survey 1999-
2004, Diabetes Care, Volume 34, July 2011.
11
2010 North Carolina Hospital Discharge data, State Center for Health Statistics.
12
NC DETECT Annual Report 2009
13
NC Death Certificates data 2010, NC State Center for Health Statistics.
For more diabetes data, please see The Burden of Diabetes in North Carolina at:
www.ncdiabetes.org/library/_pdf/Diabetes%20Burden%20Bk.pdf
North Carolina Division of Public Health
Diabetes Prevention and Control
www.ncdhhs.gov • www.ncdiabetes.org
NC DHHS is an equal opportunity employer and provider.
02/2013
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