Testimony of Frank Vinicor, M.D., M.P.H.

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CENTERS FOR DISEASE CONTROL AND PREVENTION

Department of Health and Human Services

Field Hearing

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

CDC

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.

Background

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 pregnancy.

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 minority communities.

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 younger individuals.

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 problem.

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 poor nutrition).

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 devastating.

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 over time.

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 programs:

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 2010

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.

Conclusion

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.

Last revised: October 1, 2001