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Self-Reported Prevalence of Diabetes Among Hispanics -- United States, 1994-1997

Diabetes disproportionately affects the Hispanic population in the United States (1). Most diabetes studies that focused on Hispanics have been conducted among Mexican Americans (1) and have found that approximately one out of every 10 persons aged greater than or equal to 20 years has diabetes (2). However, the U.S. Hispanic population comprises many ethnically distinct groups that tend to be regionally concentrated (3). CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to assess the prevalence of diabetes among Hispanic adults in the United States and Puerto Rico. This report presents the findings of this analysis, which indicate that the prevalence of diabetes among U.S. Hispanics is approximately twice the prevalence among non-Hispanic whites and varies by geographic location and education.

The BRFSS is a state-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized adult (aged greater than or equal to 18 years) population conducted in the 50 states, the District of Columbia, Puerto Rico, and other U.S. territories. Respondents were considered to have diabetes if they answered "yes" to the question, "Has a doctor ever told you that you have diabetes?" Women who were told that they had diabetes only during pregnancy were classified as not having diabetes. All respondents who reported being of Hispanic origin were considered to be Hispanic and all respondents who reported being white and not of Hispanic origin were considered to be non-Hispanic white. Because of the small number of Hispanics in the annual BRFSS surveys, data were aggregated for 1994-1997 for the 50 states and the District of Columbia and were combined into three U.S. census regions (Table_1). For Puerto Rico, data from the 1996 and 1997 BRFSS were used. Data were weighted to reflect the age, sex, and racial/ ethnic distribution of the noninstitutionalized population of the United States and Puerto Rico. The prevalence of diabetes and 95% confidence intervals (CIs) were estimated for the total population and for each sex/ethnic group by age, education, and geographic location. To allow comparisons between groups, data were age-adjusted by the direct method using the 1980 U.S. population. The Mantel-Haenszel chi-square test was used to assess whether differences in diabetes prevalence were statistically significant. Logistic regression analyses were used to assess the association of diabetes prevalence with Hispanic origin and with geographic location after controlling for age, sex, and education.

Overall, 6.0% (95% CI=5.5%-6.4%) of Hispanic adults in the United States and Puerto Rico had been told by a doctor that they had diabetes (Table_1). Among Hispanic and non-Hispanic white adults, the prevalence of diabetes increased with age (pless than 0.05) and was higher among Hispanic adults than among non-Hispanic white adults in each age group (pless than 0.05). Overall, the age-adjusted prevalence of diabetes among Hispanic adults was twice that of non-Hispanic white adults (8.0% versus 4.0%; pless than 0.001).

The age-adjusted prevalence of diabetes among Hispanic men and women was not significantly different (8.4% versus 7.7%; p=0.18), but was higher among non-Hispanic white men than among women (4.1% versus 3.8%; pless than 0.05). Regardless of ethnicity, the age-adjusted prevalence of diabetes was higher among persons without a high school education than among persons with at least a high school education (9.8% versus 6.5% among Hispanic adults and 5.9% versus 3.6% among non-Hispanic white adults; pless than 0.001). Among persons with at least a high school education, men had a higher age-adjusted prevalence of diabetes than women (7.6% versus 5.6% among Hispanic adults and 3.9% versus 3.4% among non-Hispanic white adults; pless than 0.05).

The prevalence of diabetes among Hispanic adults varied by geographic location: 10.7% (95% CI=9.6%-11.7%) in Puerto Rico, 5.8% (95% CI=5.1%-6.6%) in the West/Southwest, 4.9% (95% CI=4.0%-5.7%) in the South/Southeast, and 4.1% (95% CI=3.4%-4.7%) in the Northeast/Midwest. * Compared with non-Hispanic white adults in the United States, Hispanic adults in Puerto Rico were 2.9 times (95% CI=2.6-3.2) and Hispanic adults in the West/Southwest were two times (95% CI=1.7-2.3) more likely to have diabetes. Hispanic adults in the Northeast/Midwest and the South/Southeast were 1.4 times (95% CI=1.2-1.6) more likely to have diabetes than non-Hispanic white adults in the United States. After controlling for age, sex, education, and geographic location, Hispanic adults remained 1.8 times (95% CI=1.6-1.9) more likely to have diabetes than non-Hispanic white adults.

Reported by: 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 disproportionately affects Hispanic adults in the United States and Puerto Rico. Hispanic ethnicity may be a marker for access to health care, social and cultural factors, or genetic factors that may explain differences in diabetes prevalence. The findings in this report are similar to previous findings indicating that the age-adjusted prevalence of diabetes among Mexican Americans was twice that among non-Hispanic white adults (2) and that the prevalence of diabetes was higher among persons with less than a high school education (1). Therefore, effective intervention strategies are needed to reduce the burden of diabetes and its complications in this population. In persons with diabetes, secondary prevention measures such as improved glycemic and blood pressure control reduced the risk for developing diabetes-related complications (e.g., retinopathy, nephropathy, or neuropathy) (4,5). In addition, screening for diabetic eye disease and diabetic foot disease reduced the incidence of blindness and amputation (6,7).

The findings in this report are subject to at least three limitations. First, prevalence estimates obtained from telephone surveys may be underestimated in populations with low telephone coverage (8). Second, total prevalence is underestimated because some persons have undiagnosed diabetes. For example, the National Health and Nutrition Examination Survey III found that for every two Mexican Americans with diagnosed diabetes, one person had undiagnosed diabetes (2). In addition, populations with less than a high school education may have undiagnosed diabetes because they have poor access to health care. Finally, small sample sizes may have restricted the ability to detect true differences.

In collaboration with Hispanic organizations, CDC and the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health are developing a diabetes education campaign targeting persons of Hispanic origin. This campaign, which is part of the National Diabetes Education Program (NDEP), aims to increase public awareness of diabetes and promote self-management among persons with diabetes. CDC also is supporting two national Hispanic organizations to implement the NDEP at the local level and to develop partnerships for community interventions. In addition, CDC supports the National Hispanic/Latino Diabetes Initiative for Action to promote and evaluate interdisciplinary and culturally appropriate procedures to prevent diabetes and its complications in the U.S. Hispanic community. Under this initiative, for example, CDC published the patient-care guide, Take Charge of Your Diabetes, in Spanish after testing the publication among Hispanic persons. A copy of this guide is available from CDC in Spanish and English, telephone toll-free (877) 232-3422. Finally, CDC is working with diabetes-control programs in Arizona, California, New Mexico, and Texas to develop a community-based and culturally appropriate diabetes education program for the Hispanic population along the United States-Mexico border.

References

  1. Stern MP, Mitchell BD. Diabetes in Hispanic Americans. 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, National Institutes of Health, 1995; DHHS publication no. (NIH)95-1468.

2. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults: the Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518-24.

3. del Pinal JH. Hispanic Americans in the United States: young, dynamic, and diverse. Statistical Bulletin -- Metropolitan Insurance Companies 1996;77:2-13.

4. 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.

5. 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.

6. Ferris FL III. How effective are treatments for diabetic retinopathy? JAMA 1993;269:1290-1.

7. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: a randomized, controlled trial. Ann Intern Med 1993;119:36-41.

8. Ford ES. Characteristics of survey participants with and without a telephone: findings from the Third National Health and Nutrition Examination Survey. J Clin Epidemiol 1998;51:55-60.

* West/Southwest=Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Louisiana, Montana, Nevada, New Mexico, Oklahoma, Oregon, Texas, Utah, Washington, and Wyoming; Northeast/Midwest=Connecticut, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, South Dakota, Vermont, and Wisconsin; South/ Southeast=Alabama, Delaware, District of Columbia, Florida, Georgia, Kentucky, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.



Table_1
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TABLE 1. Percentage of self-reported diabetes among persons aged >=18 years, by sex, ethnicity, age, education, and
geographic location* -- United States, Behaviorial Risk Factor Surveillance System, 1994-1997+
===========================================================================================================================================================
                                       Men                                       Women                                    Total
                    -----------------------------------------   ---------------------------------------  ----------------------------------------
                         Hispanic         Non-Hispanic white          Hispanic       Non-Hispanic white       Hispanic        Non-Hispanic white
                    ------------------    -------------------   -------------------  ------------------  ------------------   -------------------
Characteristic        %     (95% CI&)       %       (95% CI)      %      (95% CI)      %     (95% CI)      %      (95% CI)      %       (95% CI)
-------------------------------------------------------------------------------------------------------------------------------------------------
Age group (yrs)
  18-44              1.9   ( 1.5- 2.3)     1.2    ( 1.1- 1.3)    2.7    ( 1.9- 3.6)   1.3   (1.2- 1.4)    2.3   ( 1.8- 2.8)    1.2    ( 1.1- 1.3)
  45-64             12.6   (10.7-14.6)     6.2    ( 5.9- 6.6)   11.5    (10.1-13.0)   5.7   (5.5- 6.0)   12.0   (10.8-13.3)    6.0    ( 5.7- 6.2)
   >=65             24.9   (21.0-28.8)    11.3    (10.7-11.8)   19.0    (16.4-21.5)   9.8   (9.4-10.2)   21.4   (19.2-23.6)   10.4    (10.1-10.7)
   >=18              5.7   ( 5.1- 6.3)     4.3    ( 4.1- 4.4)    6.2    ( 5.5- 6.9)   4.4   (4.3- 4.6)    6.0   ( 5.5- 6.4)    4.4    ( 4.3- 4.5)
  Age-adjusted@      8.4   ( 7.6- 9.3)     4.1    ( 4.0- 4.3)    7.7    ( 6.9- 8.4)   3.8   (3.7- 4.0)    8.0   ( 7.4- 8.5)    4.0    ( 3.9- 4.1)

Education@
   <High school      9.5   ( 8.1-10.9)     5.3    ( 4.8- 5.8)   10.1    ( 9.0-11.3)   6.5   (6.1- 7.0)    9.8   ( 8.9-10.7)    5.9    ( 5.6- 6.2)
  >=High school      7.6   ( 6.6- 8.7)     3.9    ( 3.8- 4.1)    5.6    ( 4.7- 6.5)   3.4   (3.3- 3.5)    6.5   ( 5.8- 7.2)    3.6    ( 3.5- 3.7)

Georgraphic
 location@
  West/Southwest     9.1   ( 7.6-10.5)     3.8    ( 3.5- 4.1)    8.2    ( 6.9- 9.5)   3.6   (3.4- 3.9)    8.5   ( 7.6- 9.4)    3.7    ( 3.5- 3.9)
  Northeast/
   Midwest           6.5   ( 4.9- 8.1)     4.3    ( 4.1- 4.5)    5.6    ( 4.4- 6.8)   4.0   (3.8- 4.1)    5.9   ( 5.0- 6.8)    4.1    ( 4.0- 4.3)
  South/Southeast    6.3   ( 4.5- 8.0)     4.1    ( 3.9- 4.4)    5.1    ( 4.0- 6.1)   3.9   (3.7- 4.1)    5.6   ( 4.6- 6.5)    4.0    ( 3.9- 4.1)
  Puerto Rico       11.4   ( 9.8-13.1)     NA**        --       10.4    ( 9.1-11.6)   NA        --       10.9   ( 9.8-11.9)     NA         --
-------------------------------------------------------------------------------------------------------------------------------------------------
 * West/Southwest=Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Louisiana, Montana, Nevada, New Mexico, Oklahoma, Oregon, Texas,
   Utah, Washington, and Wyoming; Northeast/Midwest=Connecticut, Illinois, Indiana, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Missouri,
   Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Pennsylvania, Rhode Island, South Dakota, Vermont, and Wisconsin; and
   South/Southeast=Alabama, Delaware, District of Columbia, Florida, Georgia, Kentucky, Maryland, Mississippi, North Carolina, South Carolina, Tennessee,
   Virginia, and West Virginia.
 + Data from the Behavioral Risk Factor Surveillance System for the United States (1994-1997) and for Puerto Rico (1996-1997).
 & Confidence interval.
 @ Age-adjusted to the 1980 U.S. population.
** No data available.
===========================================================================================================================================================

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