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Surveillance for Diabetes Mellitus -- United States, 1980-1989

Abstract Problem/Condition: In the United States, diabetes mellitus is the most important cause of lower-extremity amputation and end-stage renal disease; the major cause of blindness among working-age adults; a major cause of disability, premature mortality, congenital malformations, perinatal mortality, and health-care costs; and an important risk factor for the development of many other acute and chronic conditions (e.g., diabetic ketoacidosis, ischemic heart disease, stroke). Surveillance data describing diabetes and its complications are critical to increasing recognition of the public health burden of diabetes, formulating health-care policy, identifying high-risk groups, developing strategies to reduce the burden of this disease, and evaluating progress in disease prevention and control.

Reporting Period Covered: In this report, data are summarized from CDC's diabetes surveillance system; trends in diabetes and its complications are evaluated by age, sex, and race for the years 1980-1989.

Description of System: CDC has established an ongoing and evolving surveillance system to analyze and compile periodic, representative data on the disease burden of diabetes and its complications in the United States. Data sources currently include vital statistics, the National Health Interview Survey, the National Hospital Discharge Survey, and Medicare claims data for end-stage renal disease.

Results and Interpretation: In 1989, approximately 6.7 million persons in the United States reported that they had diabetes mellitus, and a similar number probably had this disabling chronic disease without being aware of it. The disease burden of diabetes and its complications is large and is likely to increase as the population grows older. Effective primary, secondary, and tertiary prevention strategies are needed, and these efforts need to be intensified among groups at highest risk, including blacks. Important gaps exist in periodic and representative data for describing the disease burden.

Actions Taken: CDC is assisting diabetes control programs in 26 states and one territory. These programs attempt to reduce the burden of diabetes by preventing blindness, lower-extremity amputations, cardiovascular disease, and adverse outcomes of pregnancy among persons with diabetes. Because of important limitations in measuring the burden of diabetes, CDC is exploring sources of surveillance data for blindness, adverse outcomes of pregnancy, and the public health burden of diabetes among minority groups.

INTRODUCTION

In the United States, diabetes mellitus is the most frequent cause of blindness among working-age adults; the most important cause of nontraumatic lower-extremity amputation (LEA) and end-stage renal disease (ESRD); a major cause of congenital malformations, perinatal mortality, disability, premature mortality, and increased health-care costs; and an important risk factor for the development of many other acute (e.g., diabetic ketoacidosis {DKA}) and chronic conditions (e.g., ischemic heart disease {IHD}, stroke) (1-3). Diabetes and its complications shorten life span, limit normal daily activities, create disability, increase use of health-care services, and impose an economic burden on persons who have the disease.

Surveillance data describing the magnitude of the disease burden of diabetes and its complications can be used to identify high-risk groups, develop strategies to reduce the burden associated with diabetes, help formulate health-care policy, and evaluate progress in disease prevention and control. CDC has established an ongoing diabetes surveillance system to compile and analyze periodic, representative data on the disease burden associated with diabetes and its complications in the United States. Data sources for the surveillance system include vital statistics, the National Health Interview Survey (NHIS), the National Hospital Discharge Survey (NHDS), and Medicare claims data. These data are analyzed to estimate diabetes incidence, prevalence, mortality, DKA, ESRD, cardiovascular disease (CVD), LEA, hospitalization, and disability. The results of these analyses for the period 1980-1989 are summarized in this report and presented in greater detail in Diabetes Surveillance, 1991.*

DATA ANALYSIS

For this report, trends were evaluated in diabetes and its complications by age, sex, and race. The presentation of results was generally limited to specific subgroups for which relatively stable estimates could be obtained. In most circumstances, race-specific results were evaluated only for whites and blacks because the number of persons in the sample surveys analyzed was not sufficient for stable estimates to be calculated for other racial groups.

Diabetes incidence and prevalence rates and some diabetes mortality rates were calculated by using estimates of the resident population of the United States as the denominator. These rates were standardized by age according to the direct method, with the 1980 United States resident population as the standard population. LEA and ESRD incidence, disability prevalence, rates of hospital discharge, and some mortality rates were calculated by using estimates of the number of persons known to have diabetes as the denominator. These rates for diabetic populations indicate the risk of various complications among persons with diabetes and are useful for comparing complication rates among subgroups of persons with diabetes. Rates for the diabetic population were age standardized according to the direct method, with the 1980 United States population of persons with diabetes as the standard population.

Most of the data are based on samples of the population and are thus estimates, with margins of error due to both sampling and nonsampling error. Because of these margins of error, estimates may fluctuate from year to year.

DATA SOURCES Incidence and Prevalence Data

Data Source: National Health Interview Survey The incidence and prevalence of self-reported diabetes were determined from the 1980-1989 NHIS, conducted by CDC's National Center for Health Statistics (NCHS). The NHIS, which has been conducted since 1957, is an annual household survey of approximately 120,000 civilian, noninstitutionalized United States residents. The survey provides information on the health of the United States population, including information on the prevalence and incidence of disease, the extent of disability, and the utilization of health-care services. The NHIS has a multistage probability design (4).

Each year, a one-sixth subsample of NHIS respondents is asked whether anyone in the family has had diabetes in the past 12 months. If a household member has diabetes, the date of diagnosis is ascertained. In this report, diabetes prevalence was defined as the number of persons with diabetes. Diabetes incidence was defined as the number of persons who were diagnosed within the previous 12 months. Three-year moving averages were used to improve the precision of all estimates of incidence and of prevalence estimates among blacks.

Data Limitations: The NHIS underestimates the true prevalence of diabetes. About half of persons with diabetes are not aware that they have the disease (5). NHIS proxy respondents (i.e., household members responding for absent adult members) are also likely to underreport diabetes (5). In addition, the NHIS sample does not include persons in institutional settings, who are more likely to have diabetes than are noninstitutionalized persons. Mortality Data

Data Source: Multiple-Cause-of-Death Data NCHS compiles and codes information on all deaths in the United States and releases annual multiple-cause-of-death data tapes. Data on these tapes include decedents' age, race, sex, and state of residence; the underlying cause of death; and contributing causes of death. Up to 20 causes of death for each decedent are coded according to the International Classification of Diseases, Ninth Revision (ICD-9).

Data tapes for the years 1980-1988 were used to extract information on deaths associated with diabetes (ICD-9 code 250) and to examine trends in diabetes as the underlying cause of death and as any listed cause of death. Among deaths for which diabetes was a listed cause, the analysis also examined deaths for which the corresponding underlying cause was DKA (ICD-9 code 250.1), major CVD (ICD-9 390-448), IHD (ICD-9 codes 410-414), or stroke (ICD-9 codes 430-434, 436-438).

Data Limitation: Diabetes is underreported on death certificates. Among persons known to have diabetes, only about 40% have diabetes listed as a cause of death and only 10% have diabetes recorded as the underlying cause of death (6,7). However, since underreporting is consistent over time and does not vary by race and sex, differences in temporal trends and relative differences between these groups are not likely to be attributable to reporting artifacts (8). Hospitalization Data

Data Source: National Hospital Discharge Survey Data from the 1980-1988 NHDS (9), also conducted by CDC's NCHS, were used to estimate diabetes-related hospital discharges. NHDS collects data on hospital discharges from a sample of short-stay, nonfederal hospitals in the United States. Data collected include information on patients' age, race, sex, and length of stay, up to seven diagnoses (one primary and six secondary diagnoses), and four surgical procedures.

The analysis estimated hospital discharges for which diabetes was the primary diagnosis (ICD-9 code 250) and for which diabetes was listed as any diagnosis. Among discharges with diabetes as a secondary diagnosis, discharges for which the primary diagnosis was DKA (ICD-9 code 250.1), major CVD (ICD-9 390-448), IHD (ICD-9 codes 410-414), or stroke (ICD-9 codes 430-434, 436-438) were estimated.

NHDS data were also used to examine the incidence of LEA. Incident cases were defined as discharges having diabetes as a listed diagnosis and an LEA (ICD-9 procedure code 84.1). Discharges with traumatic amputation procedural codes (ICD-9 procedure codes 895-897) were excluded.

Data Limitation: Hospitalizations related to diabetes may be underestimated by approximately 40% (10). Since NHDS samples hospital discharges and not persons, NHDS hospital discharge rates for diabetes-related diseases and procedures are influenced by persons who are hospitalized more than once for the same condition and hence may be sampled more than once. End-Stage Renal Disease Data

Data Source: Management and Medical Information System, ESRD Program, Bureau of Data Management and Strategy, Health Care Financing Administration

ESRD is renal insufficiency requiring dialysis or kidney transplantation for survival. Because greater than 90% of ESRD treatment in the United States is reimbursed by Medicare's ESRD program, 1980-1989 data from Medicare's medical information system were used to examine the incidence of ESRD attributed to diabetes mellitus (ESRD-DM). ESRD-DM incidence was defined as cases for which treatment was initiated for ESRD and for which diabetes was the primary cause of renal failure.

Data Limitations: Because ESRD-DM incidence was defined in terms of initiation of ESRD treatment, changes in incidence may be due to changes both in disease incidence and treatment practices. The latter may be influenced by changes in treatment availability and in the definition of treatment eligibility (11). In addition, the ascertainment of incident cases was incomplete, since Medicare reimburses only about 90% of ESRD treatment. Disability Data

Data Source: National Health Interview Survey Indicators of disability among persons with diabetes were derived from the 1983-1989 NHIS. Two of the major indicators of disability used in the NHIS are activity limitation and activity restriction. Activity limitation reflects a long-term reduction in activity resulting from one or more chronic diseases or impairments. Reduction in activity is measured in terms of activities normal for a person's age and sex group: "ordinary play" for children less than 5 years of age, "going to school" for children 5-17 years of age, "working at a job or business" or "keeping house" for persons 18-69 years of age, and independent performance of basic life activities (e.g., bathing, eating, shopping) for persons greater than or equal to 70 years of age. Persons can be categorized as being a) unable to perform their major activity, b) able to perform their major activity but limited in the kind or amount of this activity, c) not limited in major activity but limited in other activities, and d) not limited in activity. This analysis examined persons unable to perform major activity (category a), limited in major activity (categories a-b), and limited in activity (categories a-c). Three-year moving averages were used to improve precision of the estimates.

The other major indicator of disability used in NHIS is activity restriction. This indicator refers to a reduction in activity due to either short-term or long-term conditions. Activity restriction is measured as school-loss days (for children ages 5- 17), work-loss days (for currently employed persons ages 18-69), restricted-activity days (days in which persons limit their usual activities), and bed-rest days (inpatient hospital days and days in which a person stayed in bed for more than half a day because of illness or injury). The total number of restricted-activity days is the total number of days that a person experiences at least one of the above types of days. Because of small sample sizes, this analysis presents data in 3-year moving averages for total restricted-activity days and bed-rest days only.

Data Limitations: Although NHIS provides a stable source of annual estimates of disability, it does not sample the institutionalized United States population. Therefore, estimates of disability derived from NHIS underestimate the total amount of disability associated with diabetes.

Because NHIS changed the way it measured disability indicators in 1982, analysis of these indicators was limited to the years 1983-1989. Population Data

Data Sources:1980 Census estimates, 1981-1989 intercensal estimates, and National Health Interview Survey

Census estimates for 1980 and intercensal estimates for subsequent years were used to calculate rates (12). Estimates of the diabetic population (derived from NHIS) were used to calculate rates among persons with diabetes.

Data Limitations: For limitations of NHIS, see the above discussion of limitations under Incidence and Prevalence Data.

RESULTS Prevalence and Incidence of Diabetes

In 1989, about 6.7 million persons in the United States (2.7% of the population) reported that they had diabetes. Although the prevalence of diabetes has increased since 1959, the overall rate of increase in the 1980s has slowed and reached a plateau (Table 1). Diabetes prevalence as estimated from NHIS data increased by 67% from 1959 through 1966, by 41% from 1966 through 1973, by 21% from 1973 through 1980, and by 4% from 1980 through 1989.

During the 1980s, the age-standardized prevalence of diabetes was higher among blacks than whites (Figure 1). Black males were the only group to show a marked increase (28%) in prevalence during the period 1980-1989. In 1989, the age-standardized prevalence of diabetes among blacks, regardless of sex, was approximately twice that for whites.

The number of new diabetes cases (i.e., diabetes incidence) averaged 648,000 per year. The incidence of diabetes increased in the early 1980s and then reached a plateau (Table 2). The lowest rates occurred among persons less than 45 years of age. Mortality Diabetes Mortality in the General Population

The annual number of deaths for which diabetes was listed as the underlying cause increased from 34,851 in 1980 to 40,368 in 1988. From 1982 through 1988, the age-standardized mortality rates for both black males and black females increased (by 23% and 11%, respectively) (Figure 2). The rates for white males and white females remained relatively constant.

The annual number of deaths for which diabetes was listed as any cause of mortality (diabetes-related deaths) increased from 135,931 in 1980 to 157,265 in 1988. Race-sex temporal trends in age-standardized diabetes-related mortality were similar to those for diabetes as an underlying cause; mortality increased 21% among black males (from 77.7 to 89.4 per 100,000) and 15% among black females (from 94.5 to 102.0 per 100,000). Diabetes-related mortality rates remained relatively constant for white males and white females.

From 1980 through 1988, diabetes-related mortality rates and mortality rates for diabetes as an underlying cause of death increased with age; the highest rates occurred among persons greater than or equal to 85 years of age. Diabetes Mortality in the Diabetic Population

When age-standardized mortality rates were calculated by using the number of persons known to have diabetes as the denominator, race-sex trends in age-standardized mortality were less clear. Age-standardized rates for diabetes as the underlying cause of death were lower in 1988 than in 1980 for white males, black males, and black females (Figure 3). White females were the only group whose rates were higher in 1988 than in 1980. Of the four race-sex groups examined, black males had the highest age-standardized rates.

Race-sex trends for diabetes-related mortality rates were similar to those for diabetes as the underlying cause of death. The highest age-standardized rates occurred among white males. Hospitalizations

In 1988, diabetes was the primary diagnosis for 454,000 hospital discharges; it occurred as any one of seven listed diagnoses for 2.8 million hospital discharges. Age-standardized rates of hospital discharges for which diabetes was listed as the primary diagnosis increased slightly from 1980 through 1983 but then decreased and reached a plateau (Table 3). Age-specific rates were highest among persons less than 45 years of age. The next highest rates were found among persons greater than or equal to 75 years of age. The age groups of 45-64 years and 65-74 years had similar rates, which were the lowest in the analysis. Age-standardized rates were higher for blacks than whites, and black males had the highest rates (Figure 4).

In general, the diabetic population's age-standardized rates of hospital discharges that listed diabetes as a primary or secondary diagnosis showed temporal trends similar to those for diabetes as a primary diagnosis. However, age-specific rates increased with age. Among black females with diabetes, age-standardized rates increased 27% from 1983 through 1988 (from 324 to 411 per 1,000). Cardiovascular Disease

In 1988, more than half of all diabetes-related deaths had major CVD listed as the underlying cause (n=80,876). Of these deaths from CVD, 61% (n=49,433) were attributable to IHD and 14% (n=11,653) to stroke. Age-specific rates for these diseases increase dramatically with age (Table 4). Among persons with diabetes, age-standardized mortality rates attributable to CVD, IHD, and stroke were lower in 1988 than in 1980; most of the decline occurred from 1983 through 1984. The declines for these 2 years were apparent among persons with diabetes who were greater than or equal to 65 years of age. CVD mortality among persons with diabetes who were less than 45 years of age tended to increase rather than decrease.

Of the four race-sex groups examined, white males had the highest age-standardized mortality rates for major CVD (Figure 5). Rates for black males, however, exceeded those for white males among persons less than 45 years of age. Although the age-standardized rates for white females were higher than those for black females, black females less than 65 years of age had higher rates than white females.

In 1988, 33% (908,000) of all diabetes-related hospitalizations listed major CVD as the primary diagnosis. Of these hospitalizations for CVD, 43% (n=386,000) were for IHD and 13% (n=114,000) were for stroke. Hospital discharge rates for major CVD and IHD among persons with diabetes increased from 1980 through 1988 (Figure 6). Although the trend for stroke was less clear, the rate was higher in 1988 than in 1980. In 1988, the age-standardized hospital discharge rates were 40% higher for major CVD, 42% higher for IHD, and 29% higher for stroke than in 1980. In general, hospital discharge rates for major CVD, IHD, and stroke increased with age. The rates of increase for major CVD and IHD were greater among persons less than 45 years of age. Nontraumatic Lower-Extremity Amputation

In 1988, 55,000 hospital discharges with LEA were reported among persons with diabetes (Table 5). This number represented approximately half of all hospital discharges with LEA. The incidence of LEA among persons with diabetes was relatively stable from 1980 through 1982, increased dramatically in 1983, and then leveled off (Table 5). Rates for LEA increased with age (Table 5) and were higher among males than among females and among blacks than among whites (Figure 7). Diabetic Ketoacidosis

In 1988, DKA was the primary diagnosis for 84,000 hospital discharges. The age-standardized rates of hospital discharge for DKA increased from 1980 through 1984, decreased slightly in 1985, and then reached a plateau (Table 6). DKA hospital discharge rates were highest among persons less than 45 years of age. Among the race-sex groups examined, rates were higher among black males, followed by black females, white females, and white males. In 1988, the rate for black males was more than three times the rate for white males (26.8 vs. 7.9 per 1,000 diabetic population).

In 1988, DKA was listed as the underlying cause of 1,905 deaths. During the period 1980-1987, DKA mortality declined from 30.6 to 23.2 per 100,000 diabetic population. The rate then increased in 1988 to 27.7 per 100,000 persons with diabetes. The highest DKA mortality rates were among persons greater than or equal to 75 years of age, followed by persons less than 45 years of age. Among the race-sex groups examined, age-standardized mortality rates were highest among black males, followed by black females and then by whites, with little difference between the sexes (Figure 8). End-Stage Renal Disease

The number of new cases of ESRD-DM increased from 2,220 in 1980 to 13,332 in 1989. The age-standardized incidence rate of ESRD-DM among persons with diabetes increased more than fivefold, from 38.4 to 201.9 per 100,000 persons (Table 7). Age differences in incidence rates decreased during this decade. Rates were higher among blacks than among whites (Figure 9). Among both races, males had higher rates than females until 1986, when rates for black females began to exceed those for black males. Disability

The number of persons with diabetes who reported that they were limited in activity increased from 3.1 million in 1983 to 3.3 million in 1989, approximately half of all persons with known diabetes (Figure 10). This proportion increased with age and tended to reach a plateau after age 64. In general, age-standardized rates of being limited in activity were greater among blacks than among whites and among females than among males. From 1983 through 1989, rates decreased in all sex-race groups, except for white males.

Approximately 40% of all persons with diabetes -- and 75% of persons with diabetes who reported limitations -- reported being limited in their major activity (Figure 10). About 20% of persons with diabetes reported that they were unable to perform their major activity.

The number of restricted-activity days among persons with diabetes increased from 199 million days in 1983 to 233 million days in 1989. During this period, persons with diabetes averaged 34 restricted-activity days per year; half of these days were bed-rest days. The average number of total restricted-activity days and bed-rest days was greater among blacks than whites (Figure 11).

DISCUSSION

Although the overall rate of increase in diabetes prevalence slowed and reached a plateau in the 1980s, the number of persons known to have diabetes increased by nearly 900,000 from 1980 through 1989. Because the prevalence of diabetes is associated with age, the number of persons with diabetes will continue to increase as the population ages, even if total population size and age-specific prevalence remain constant. Effective intervention strategies for preventing non-insulin-dependent diabetes mellitus (NIDDM), which accounts for 90%-95% of all prevalent cases, are urgently needed, particularly among groups at high risk for developing diabetes (e.g., blacks and other minority groups). These primary prevention strategies should focus on promoting healthful behaviors such as improved diet, exercise, and weight control.

Among persons with diabetes, major CVD accounted for more than half of all deaths and about one-third of all hospitalizations. Thus, the reduction of CVD risk factors among persons with diabetes could have a major effect on diabetes-related morbidity and mortality. Studies on the effectiveness of CVD risk-factor reduction among diabetic persons are needed. In the absence of such studies, prevention efforts should promote exercise, weight control, smoking prevention and cessation, hypertension prevention and blood pressure control, and lipid and glycemic control.

Temporal trends in hospital discharge rates varied by discharge diagnosis and must be interpreted with caution, because Medicare's implementation of the prospective reimbursement system in 1983 appears to have influenced hospitalization practices and disease reporting on discharge records. For example, the rate of LEA hospital discharges among persons with diabetes increased by greater than 50% in 1983. This increase was probably due to increased reporting of diabetes among those having amputations rather than to increased incidence; the inclusion of diabetes as a contributing cause for LEA results in the assignment of that discharge to a higher reimbursement group.

The incidence of ESRD-DM increased dramatically in the 1980s. This increase may have been due to increases both in the incidence of ESRD-DM and in the use of treatment. Recommendations for preventing and slowing the progression of ESRD-DM among persons with diabetes include annual monitoring for early markers of renal disease among diabetic persons, controlling hypertension, and identifying and eliminating barriers to preventive care and treatment (13).

Many persons with diabetes have some degree of disability. Efforts to describe the disease burden of diabetes (and other chronic conditions) that do not consider disability will greatly underestimate the impact and burden of diabetes and its complications. Efforts to prevent disability among persons with diabetes should incorporate strategies to reduce the burden of diabetes and its complications, including CVD risk factor reduction, health promotion, improving access to health-care services and preventive care, patient and professional education, and incorporation of consensus standards of care (14) into health-care delivery systems. Diabetes control programs in 26 states and one territory are currently using these and other strategies to reduce the morbidity and mortality associated with diabetes among high-risk groups (e.g., the medically underserved and minority groups).

Black-white differences in trend were examined because diabetes and its complications disproportionately affect blacks and other minorities (1,3). Although genetic markers have not been identified for most forms of NIDDM, which accounts for 97% of incident cases, twin studies, studies of ancestral admixture, and other studies suggest that genetic factors play a strong role in the development of NIDDM (15-17). Not only are blacks and other racial/ethnic minorities more likely to develop diabetes, they are also at greater risk for many of the complications of diabetes (11,18,19). Our surveillance data indicate that blacks have higher rates of diabetes, of mortality with diabetes and DKA as underlying causes, of hospital discharges with diabetes and DKA as primary diagnoses, of LEA and ESRD-DM incidence, and of disability. It is unknown whether this increased risk of complications reflects more severe disease, barriers to health-care services, including preventive-care services, or the combination of these and other factors. Prevention efforts should be intensified in this high-risk population.

FUTURE DIRECTIONS

Although national data are available for many of the complications of diabetes, some important gaps remain. Diabetes is the leading cause of new cases of blindness among adults in the United States, but recent national data are not available for eye disease and blindness related to diabetes. Furthermore, although women with diabetes are known to be at increased risk for adverse outcomes of pregnancy, national data are not available for monitoring pregnancy outcomes among these women, nor are periodic, national data available on health-care practices and behaviors that could prevent many of the complications of diabetes. Periodic, representative data are also lacking for minority groups such as Hispanics and Native Americans, who are at increased risk for both diabetes and its complications. CDC is currently exploring possible data sources to address these important gaps.

References

  1. Carter Center of Emory University. Closing the gap: the problem

of diabetes mellitus in the United States. Diabetes Care 1985;8:391-406.

  1. Center for Economic Studies in Medicine. Direct and indirect

costs of diabetes in the United States in 1987. Alexandria, VA: American Diabetes Association, 1988.

3. Harris MI, Hamman RF, eds. Diabetes in America. Washington, DC: Department of Health and Human Services, NIH Publication No. 85- 1468, 1985.

4. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-94. Hyattsville, MD: National Center for Health Statistics. Vital and Health Statistics, Series 2, No. 110, 1989.

5. National Center for Health Statistics, Hadden WC, Harris MI. Prevalence of diagnosed diabetes, undiagnosed diabetes, and impaired glucose tolerance in adults 20-74 years of age, United States, 1976-80. Hyattsville, MD: National Center for Health Statistics. Vital and Health Statistics, Series 11, No. 237, 1987.

6. Harris MI, Entmacher PS. Chapter XXIX. Mortality from diabetes. In: Harris MI, Hamman RF, eds. Diabetes in America. Washington, DC: Department of Health and Human Services, NIH Publication No. 85- 1468, 1985.

7. Ochi JW, Melton LJ, Palumbo PJ, Chu-Pin C. A population-based study of diabetes mortality. Diabetes Care 1985;8:224-9.

8. Wetterhall SF, Olson DR, DeStefano F, et al. Trends in diabetes and diabetic complications, 1980-1987. Diabetes Care 1992;15:960-7.

9. Graves EJ. Detailed diagnoses and procedures, National Hospital Discharge Survey, 1988. Hyattsville, MD: National Center for Health Statistics. Vital and Health Statistics, Series 13, No. 107, 1991. 10. Ford ES, Wetterhall SF. The validity of diabetes on hospital discharge diagnoses. Diabetes 1991;40(Suppl. 1):449a. 11. CDC. Diabetes surveillance, 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1992. 12. Irwin R. Intercensal estimates of the population by age, sex, race, 1980-1989. Alexandria, VA: Demo-Detail, 1989. 13. CDC. Incidence of treatment for end-stage renal disease attributed to diabetes mellitus -- United States, 1980-1989. MMWR 1992;41:834-7. 14. CDC. The prevention and treatment of complications of diabetes: a guide for primary care practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, 1991. 15. Zimmet P, Kirk RL, Serjeantson SW, King H. Genetic and environmental influence in the epidemiology of noninsulin-dependent diabetes mellitus: a global perspective. Ann Acad Med (Singapore) 1985;14:347-53. 16. Jarret RJ. Epidemiology and public health aspects of non-insulin-dependent diabetes mellitus. Epidemiol Rev 1989;11:151-71. 17. Stern MP. Primary prevention of type II diabetes mellitus. Diabetes Care 1991;14:399-410. 18. Stern MP, Haffner SM. Type II diabetes and its complications in Mexican Americans. Diabetes Metab Rev 1990;6:29-45. 19. Harris MI. Noninsulin-dependent diabetes mellitus in black and white Americans. Diabetes Metab Rev 1990;6:71-90.

  • Diabetes Surveillance, 1991 is the second report from CDC's diabetes surveillance system. A copy of this report is available from the National Center for Chronic Disease Prevention and Health Promotion, Rhodes-1113, MS-K13, Centers for Disease Control and Prevention, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724.

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