Through prevention programs, reduce the disease and economic burden of diabetes, and improve the quality of life for all persons who have or are at risk for diabetes.
Diabetes poses a significant public health challenge for the
United States. Some 800,000 new cases are diagnosed each year, or 2,200 per
day.[1], [2] The changing
demographic patterns in the United States are expected to increase the number
of people who are at risk for diabetes and who eventually develop the disease.
Diabetes is a chronic disease that usually manifests itself as one of two major
types: type 1, mainly occurring in children and adolescents 18 years and
younger, in which the body does not produce insulin and thus insulin
administration is required to sustain life; or type 2, occurring usually in
adults over 30 years of age, in which the body’s tissues become unable to use
its own limited amount of insulin effectively. While all persons with diabetes
require self-management training, treatment for type 2 diabetes usually
consists of a combination of physical activity, proper nutrition, oral tablets,
and insulin. Previously, type 1 diabetes has been referred to as juvenile or
insulin-dependent diabetes and type 2 diabetes as adult-onset or noninsulin
dependent diabetes.
The occurrence of diabetes, especially type 2 diabetes, as
well as associated diabetes complications, is increasing in the United States.
1, 2
, [3] The number of persons with diabetes
has increased steadily over the past decade; presently, 10.5 million persons
have been diagnosed with diabetes, while 5.5 million persons are estimated to
have the disease but are undiagnosed. This increase in the number of cases of
diabetes has occurred particularly within certain racial and ethnic groups.[4] Over
the past decade, diabetes has remained the seventh leading cause of death in
the United States, primarily from diabetes-associated cardiovascular disease.
While premenopausal nondiabetic women usually are at less risk of cardiovascular
disease than men, the presence of diabetes in women is associated with a three-
to four-fold increase in coronary heart disease compared to nondiabetic
females.[5]
In the United States, diabetes is the leading cause of nontraumatic amputations
(approximately 57,000 per year or 150 per day); blindness among working-aged
adults (approximately 20,000 per year or 60 per day); and end-stage renal
disease (ESRD) (approximately 28,000 per year or 70 per day).[6] (See Focus Area 4. Chronic Kidney
Disease and Focus Area 28. Vision and Hearing.)
These and other health problems associated with diabetes
contribute to an impaired quality of life and substantial disability among
people with diabetes.[7] Diabetes is a costly disease;
estimates of the total attributable costs of diabetes are around $100 billion
($43 billion direct; $45 billion indirect).[8], [9] Hospitalizations for
diabetes-associated cardiovascular disease account for the largest component of
the direct costs. However, diabetes management is occurring increasingly in the
outpatient setting, and more people with diabetes are using nursing home facilities.
8, 9
Diabetes is a major clinical and public health challenge
within certain racial and ethnic groups where both new cases of diabetes and
the risk of associated complications are great.4,
[10]
These realities are especially disturbing given the
validated efficacy and economic benefits of secondary prevention (controlling
glucose, lipid, and blood pressure levels) and tertiary prevention (screening
for early diabetes complications [eye, foot, and kidney abnormalities],
followed by appropriate treatment and prevention strategies).[11], [12], [13], [14], [15], [16], [17]
For many reasons, however, these scientifically and economically justified
prevention programs are not used routinely in daily clinical management of
persons with diabetes.[18], [19], [20]
Diabetes is thus a “wasteful” disease. Strategies that would lessen the burden
of this disease are not used regularly, resulting in unnecessary illness,
disability, death, and expense.
The toll of diabetes on the health status of people in the
United States is expected to worsen before it improves, especially in
vulnerable, high-risk populations—African Americans, Hispanics, American
Indians or Alaska Natives, Asians or other Pacific Islanders, elderly persons,
and economically disadvantaged persons. Several factors account for this
chronic disease epidemic, including behavioral elements (improper nutrition,
for example, increased fat consumption; decreased physical activity; obesity);
demographic changes (aging, increased growth of at-risk populations); improved
ascertainment and surveillance systems that more completely capture the actual
burden of diabetes; and the relative weakness of interventions to change
individual, community, or organizational behaviors.1, 3, 7,
[21]
Several other interrelated factors influence the present and future burden of diabetes, including genetics,
cultural and community traditions, and socioeconomic status (SES). In addition,
unanticipated scientific breakthroughs, the characteristics of the health care
system, and the level of patient knowledge and empowerment all have a great
impact on the disease burden associated with diabetes.
Personal behaviors. “Westernization,” which includes
a diet high in fat and processed foods as well as total calories, has been
associated with a greater number of overweight persons in the United States
when compared to a decade ago, especially within certain racial and ethnic
groups, for example, African American females.[22],
[23]
Obesity, improper nutrition (including increased ingestion of fats and
processed foods), and lack of physical activity are occurring in persons under
age 15 years. These behaviors and conditions may explain the increasing diagnosis
of type 2 diabetes in teenagers.[24], [25] Increased television watching
associated with diminished physical activity also may contribute to the
emergence of type 2 diabetes in youth.24,
25, [26],
[27]
Demographics. Diabetes is most common in persons over age 60 years.[28]
Increased insulin resistance and gradual deterioration in the function of
insulin-producing cells may account for this phenomenon. As the population in
the United States ages, especially as the number of persons aged 60 years and
older grows, an increase in the number of people with diabetes is expected.
While studies indicate that aging itself may not be a major factor in the
substantial increase in the number of persons with diabetes,21
present and future prevention strategies for diabetes will be associated with a
greater lifespan for persons with diabetes.[29]
Other changes in the U.S. population can be expected to
affect the number of persons with diabetes. By 2050, almost half of the population
will be other than white (53 percent white, 24 percent Hispanic, 14 percent
African American, and 8 percent Asian).[30]
Because these racial and ethnic groups are at greater risk for diabetes and
associated complications, and because of rising levels of obesity and physical
inactivity in the general population, the number of persons with diabetes is
expected to continue to increase into the first few decades of the 21st
century.[31]
Ascertainment. Known as the “hidden” disease,
diabetes is undiagnosed in an estimated 5 million persons.[32], [33]
In addition, complications and health services associated with diabetes
frequently are not recorded on death certificates,[34], [35]
hospital discharge forms,[36]
emergency department paperwork, and other documents. Much of this “missing”
burden of diabetes now is being captured due to improved surveillance and data
systems,[37] including boxes on data forms to indicate
the presence of diabetes and screening programs for undiagnosed diabetes in
high-risk persons.32
Thus, the real—but previously undocumented—burden of diabetes is becoming
better recognized.
Limitations in programs to change behaviors. Scientific
evidence indicates that secondary and tertiary prevention programs are
effective in reducing the burden of diabetes. Yet changing the behaviors of
persons with diabetes, health care providers, or other individuals or
organizations involved in diabetes health care (for example, health maintenance
organizations and employers) is difficult. Although many factors account for
these challenges,[38] more effective
interventions will need to be developed and implemented to improve the practice
of diabetes care. Several other factors influence the present and future burden
of diabetes, including genetics, culture, SES, scientific discoveries, and the
characteristics of both chronic diseases and the health care system.
Both
type 1 and type 2 diabetes have a significant genetic component.[39], [40]
For type 1 diabetes, genetic markers that indicate a greater risk for this condition have been identified; they are
sensitive but not specific. Type 2 diabetes, especially in vulnerable racial
and ethnic groups, may be associated with a “thrifty gene.”40, [41]
Family and twin studies demonstrate considerable influence of genetics for type
2 diabetes, but a specific genetic marker for the common variety of type 2
diabetes has not been identified. The degree to which such genetic indicators
can be both validated and clinically available will determine the effectiveness
of primary prevention trials.[42], [43]
Personal
behaviors are influenced by beliefs and attitudes, and these are greatly
affected by community and cultural traditions.[44], [45]
In many racial and ethnic communities, fatalism, use of alternative medicine, desirability of rural living conditions,
lack of economic resources, and other factors will influence significantly both
availability of health care and the capabilities of persons with diabetes in
handling their own care. Thirteen percent of the total U.S. population speak a
language at home other than English. Cultural and linguistic factors affect
interactions with health care providers and the system. The degree to which
diabetes prevention strategies recognize and incorporate these traditions will
largely determine program effectiveness.[46], [47]
The public health and medical communities increasingly are recognizing the influence
of SES in the occurrence of new cases and progression of chronic diseases.[48], [49],
[50]
Chronic diseases, such as diabetes, reflect the social fabric of our society:
the degree to which employment, financial security, feelings of safety, education,
and the availability of health care are addressed and improved within the
United States will influence the likelihood of developing type 2 diabetes as
well as effectively managing both types of diabetes.[51]
For example, unemployment without access to health insurance will substantially
limit attention to and expenditures for preventive health practices.
Because
acute infectious diseases were the dominant health threats during the first
half of the 20th century, a dichotomous view of health developed: for example,
people were either alive or dead, vaccinated or not vaccinated. Death and
length of life were the most important markers of disease burden and program
effectiveness during those years. Chronic diseases, such as diabetes, pose
different challenges because qualitative terms such as “doing better” are valid
indicators of health improvement, as are measures of quality of life and
disability. Further, a variety of nonphysician health professionals (for
example, nurses or pharmacists) and nonhealth care professionals (for example,
faith or community leaders, employers) can be involved in critical decisions
affecting chronic diseases. Diabetes, like other chronic conditions, is long
term and is affected by the environment where people live, work, and play. For
diseases like diabetes, the accurate measurement of quality of life as an
indicator of program effectiveness and the incorporation of nonhealth
professionals at work or worship on the health team will influence the
successes of preventive treatment programs.
37,
45,
46
The
rapidity and utility of scientific discoveries also will influence the control of
the diabetes burden. In all aspects of scientific investigation, important
observations about diabetes will continue to occur. These scientific results
will greatly influence diabetes prevention and management,[52], [53], [54]
but any scientific study that is not translated and used in daily practice
ultimately is “wasted.”10, [55]
The
availability of a responsive and effective health care system will determine
access to quality care, especially in secondary and tertiary prevention.[56], [57]
With the emergence of managed care, a person with diabetes theoretically could
receive effective, economical, and planned preventive care that would minimize
the diabetes burden.[58]
Several additional changes need to occur within the managed care setting, however,
to maximize fully this theoretical opportunity for persons with diabetes,
including managed care (1) not denying access to potentially expensive
patients, (2) allowing adequate time for health professionals to interact with
patients, and (3) ensuring patient protection rights.
In
addition, the apparent movement toward primary care will affect diabetes management
and outcomes. At present, about 90 percent of all persons with diabetes receive
continuous care from the primary care community. This is highly unlikely to
change. Thus, the degree that improved relationships can be established be-tween
diabetes specialists and primary care health providers will determine the
quality of diabetes care.[59]
People
with diabetes spend a small percentage of their time in contact with health
professionals. In addition to family, friends, and work colleagues, individual
patient knowledge, beliefs, and attitudes affect diabetes management and
outcomes. The ability to understand and influence individual, community, and organizational
behaviors will influence significantly the success of preventive programs in
diabetes.[60], [61], [62]
Gaps
exist among racial and ethnic groups in the rate of diabetes and its associated
complications in the United States. Certain racial and ethnic communities,
including African Americans, Hispanics, American Indians, and certain Pacific
Islander and Asian American populations as well as economically disadvantaged
or older people, suffer disproportionately compared to white populations. For
example, the relative number of persons with diabetes in African American, Hispanic,
and American Indian communities is one to five times greater than in white
communities.4
Deaths from diabetes are 2 times higher in the African American population than
they are in the white population, and diabetes-associated renal failure is 2.5
times higher in the African American population than it is in the Hispanic
population.1,
6, 7
Particularly
within certain racial and ethnic groups, there are four potential individual
reasons for the greater burden of diabetes:
Greater
number of cases of diabetes. If diabetes is more common, then more
amputations, death, and other complications from diabetes would be expected.
Greater
seriousness of diabetes. If hyperglycemia or other serious comorbid
conditions, such as high blood pressure or elevated blood lipids, are present
in certain racial and ethnic groups, a greater diabetes-related disease burden
will occur. Many other factors could be involved, including genetics and excess
weight. Greater seriousness of diabetes can be determined by comparing, for example,
death or amputation rates for specific racial and ethnic diabetic groups with
those rates in the general diabetic population.
Inadequate
access to proper diabetes prevention and control programs. If proven
diabetes services, such as self-management training programs or eye-retina
examinations, are not a part of routine diabetes care, then effective programs
to reduce the burden of diabetes will not be accessed and used. These essential
diabetes services often are provided by specialists. Unfortunately, many
diabetes at-risk groups reside in medically underserved areas or are without adequate
insurance and thus do not receive these types of preventive services.
Improper
quality of care. If diabetes management services are available, but the
quality of that service is inadequate, prevention programs would not be
effective in reducing the burden of diabetes.
Identifying
the reasons for disparities in diabetes health outcomes is important in
tailoring programs to those specific areas where deficiencies exist. Collection
of racial and ethnic health services data for all health activities is critical
to designate the reason for the greater disease burden.
Opportunities
to meet the challenges of diabetes lie in four transition points in the natural
history of this disease and the preventive interventions that target them:
primary prevention, screening and early diagnosis, access, and quality of care
(secondary and tertiary prevention).[63]
The
transition points and associated public health interventions are as follows:
n |
Transition Point 1: From No Diabetes to Diabetes Present (although not recognized).
Intervention, Primary Prevention. |
n |
Transition Point 2: From Diabetes Not Recognized to Diabetes Recognized (but preventive
diabetes care not provided). Intervention, Screening/Early Diagnosis. |
n |
Transition Point 3: From No Care to Diabetes Care Applied. Intervention, Access. |
n |
Transition Point 4: From Improper Care to Proper Care. Intervention, Quality of Care.
(Secondary and Tertiary Prevention—for example, glucose control and decreasing diabetes complications.) |
Each
transition point represents a diabetes prevention and control opportunity that
is contained in the diabetes objectives of Healthy People 2010. Objectives are
categorized as: (1) diabetes education, (2) burden of disease (new cases,
existing cases, undiagnosed diabetes, death, pregnancy complications), (3)
macrovascular, microvascular, and metabolic complications, (4) laboratory
services (lipids, glycosylated hemoglobin, microalbumin measurements), (5) health
provider services (eye, foot, and dental examinations), and (6) patient
protection behaviors (aspirin, self-blood-glucose-monitoring). These objectives
measure both the processes and outcomes of preventive diabetes programs.
To
improve the quality of diabetes care, the Diabetes Quality Improvement Project
(DQIP)—a joint public/private effort—has identified a set of measures to track
critical performance measures of diabetes management. Through the Quality Interagency
Coordination (QuIC) task force, Federal agencies with health care responsibilities
are collaborating to use DQIP to better focus efforts to improve diabetes care.
In
Healthy People 2000, five diabetes-related objectives were included in a group of
objectives addressing chronic conditions linked by their potential impact on
quality of life and disability. Of these five objectives, eye examinations is
moving toward the 2000 target. Death from diabetes, nonretinal diabetes
complications, new cases of diabetes, and the number of existing cases all are
moving away from the 2000 targets. Diabetes education is increasing in
frequency among persons with diabetes.
These
changes in direction need to be considered carefully with regard to significance,
causes, and implications. The greater number of new cases of ESRD among persons
with diabetes may in part be due to “ascertainment”; that is, persons with
diabetes were not in the past but now are allowed access to ESRD treatment programs.
Similarly, while new cases of type 2 diabetes truly may be increasing in
association with obesity and inactivity, a higher number of cases of diabetes
also may reflect increased efforts to screen for previously undiagnosed
diabetes as well as decreased deaths from such conditions as diabetic acidosis
or amputations. Thus, an increased number of existing cases of type 2 diabetes
may in part reflect successes in other types of diabetes prevention programs.
Note: Unless
otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000
Review, 1998–99.
Diabetes
Goal: Through prevention programs, reduce the disease and
economic burden of diabetes, and improve the quality of life for all persons
who have or are at risk for diabetes.
|
Number
|
Objective Short Title
|
|
5-1
|
Diabetes education
|
|
5-2
|
New cases of diabetes
|
|
5-3
|
Overall cases of diagnosed diabetes
|
|
5-4
|
Diagnosis of diabetes
|
|
5-5
|
Diabetes deaths
|
|
5-6
|
Diabetes-related deaths
|
|
5-7
|
Cardiovascular disease deaths in
persons with diabetes
|
|
5-8
|
Gestational diabetes
|
|
5-9
|
Foot ulcers
|
|
5-10
|
Lower extremity amputations
|
|
5-11
|
Annual urinary microalbumin
measurement
|
|
5-12
|
Annual glycosylated hemoglobin
measurement
|
|
5-13
|
Annual dilated eye examinations
|
|
5-14
|
Annual foot examinations
|
|
5-15
|
Annual dental examinations
|
|
5-16
|
Aspirin therapy
|
|
5-17
|
Self-blood-glucose-monitoring
|
Target: 60
percent.
Baseline: 45
percent of persons with diabetes received formal diabetes
education in 1998 (age adjusted to the year 2000 standard population).
Target setting
method: Better than the best.
Data source: National
Health Interview Survey (NHIS), CDC, NCHS.
|
Persons With Diabetes,
1998
|
Diabetes
Education
|
|
Percent
|
|
TOTAL
|
45
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DSU
|
|
Native Hawaiian and other Pacific Islander
|
DSU
|
|
Black or African American
|
45
|
|
White
|
46
|
|
|
|
Hispanic or Latino
|
34
|
|
Not Hispanic or Latino
|
47
|
|
Black or African American
|
46
|
|
White
|
48
|
|
Gender
|
|
Female
|
49
|
|
Male
|
42
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
26
|
|
High school graduate
|
43
|
|
At
least some college
|
56
|
|
Geographic location
|
|
Urban
|
49
|
|
Rural
|
37
|
|
Disability status
|
|
Persons
with activity limitation
|
DNA
|
|
Persons without activity limitations
|
DNA
|
|
Select populations
|
|
Age groups(not age adjusted)
|
|
Under
18 years
|
DNC
|
|
18
to 44 years
|
48
|
|
45
to 64 years
|
47
|
|
65
to 74 years
|
40
|
|
75
years and older
|
27
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Diabetes patient education
is viewed uniformly as effective and economical in the ultimate prevention of
long-term complications from diabetes. An individual with diabetes spends less
than 1 percent of his or her time in contact with the health care system and on
a daily basis must make a variety of critical decisions about diabetes. An
informed and motivated patient is essential in managing the disease and
reducing the risk of complications (for example, foot ulcers, hypoglycemia, and
hypertension).[64], [65]
Target: 2.5
new cases per 1,000 population per year.
Baseline: 3.5
new cases of diabetes per 1,000 population (3-year average)
occurred in 1994–96 (age adjusted to the year 2000 standard population).
Target setting
method: Better than the best (retain year 2000 target).
Data source: National
Health Interview Survey (NHIS), CDC, NCHS.
|
Total Population,
1994–96
|
New Cases of
Diabetes
|
|
Rate per 1,000
|
|
TOTAL
|
3.5
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DSU
|
|
Native Hawaiian and other
Pacific
Islander
|
DSU
|
|
Black or African American
|
5.7
|
|
White
|
3.2
|
|
|
|
Hispanic or Latino
|
5.7
|
|
Not Hispanic or Latino
|
3.3
|
|
Black or African American
|
5.9
|
|
White
|
3.0
|
|
Gender
|
|
Female
|
3.9
|
|
Male
|
3.1
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
6.9
|
|
High school graduate
|
4.5
|
|
At least some college
|
4.3
|
|
Geographic location
|
|
Urban
|
3.5
|
|
Rural
|
3.7
|
|
Disability status
|
|
Persons with activity limitations
|
6.4
|
|
Persons without activity limitations
|
2.5
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
Under
18 years
|
DSU
|
|
18
to 44 years
|
2.0
|
|
45
to 64 years
|
6.9
|
|
65
to 74 years
|
9.3
|
|
75
years and older
|
9.4
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 25
overall cases per 1,000 population.
Baseline: 40
overall cases (including new and existing cases) of diabetes per 1,000
population occurred in 1997 (age adjusted to the year 2000 standard population).
Target setting
method: Better than the best (retain year 2000 target).
Data source:
National Health Interview Survey (NHIS), CDC, NCHS.
|
Total Population, 1997
|
Overall Cases of
Diagnosed Diabetes
|
|
Rate per 1,000
|
|
TOTAL
|
40
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DSU
|
|
Native Hawaiian and other Pacific lslander
|
DSU
|
|
Black or African American
|
74
|
|
White
|
36
|
|
|
|
Hispanic or Latino
|
61
|
|
Not Hispanic or Latino
|
38
|
|
Black or African American
|
74
|
|
White
|
34
|
|
Gender
|
|
Female
|
40
|
|
Male
|
39
|
|
Education
level (aged 25 years and
older)
|
|
Less
than high school
|
95
|
|
High
school graduate
|
58
|
|
At
least some college
|
44
|
|
Geographic location
|
|
Urban
|
40
|
|
Rural
|
38
|
|
Disability status
|
|
Persons
with disabilities
|
87
|
|
Persons
without disabilities
|
28
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
Under
18 years
|
DSU
|
|
18
to 44 years
|
15
|
|
45
to 64 years
|
76
|
|
65
to 74 years
|
143
|
|
75
years and older
|
117
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 80
percent.
Baseline: 68
percent of adults aged 20 years and older with diabetes had been diagnosed in
1988–94 (age adjusted to the year 2000 standard population).
Target setting method:
Better than the best.
Data source: National
Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
|
Adults Aged 20 Years and
Older
With Diabetes, 1988–94 (unless noted)
|
Persons Whose Diabetes
Has Been Diagnosed
|
|
Percent
|
|
TOTAL
|
68
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DNC
|
|
Native Hawaiian and other Pacific lslander
|
DNC
|
|
Black or African American
|
68
|
|
White
|
68
|
|
|
|
Hispanic
or Latino
|
DSU
|
|
Mexican American
|
55
|
|
Not Hispanic or Latino
|
71
|
|
Black or African American
|
67
|
|
White
|
73
|
|
Gender
|
|
Female
|
68
|
|
Male
|
66
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
64
|
|
High school graduate
|
66
|
|
At least some college
|
56
|
|
Geographic location
|
|
Urban
|
64
|
|
Rural
|
71
|
|
Disability status
|
|
Persons with disabilities
|
66
(1991–94)
|
|
Persons without disabilities
|
69
(1991–94)
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
20
to 44 years
|
67
|
|
45
to 64 years
|
62
|
|
65
to 74 years
|
70
|
|
75
years and older
|
70
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Diabetes is increasingly
common in the United States and the world. Many factors could be contributing
to this “chronic disease epidemic,” including an increase in new cases, a
decrease in deaths, and improvements in detection.1,
2,
3,
21, 63 Given the seriousness and costs
associated with diabetes and the complexities of the disease, factors that
account for the increasing frequency of diabetes should be identified.
[66],
[67],
[68],
[69]
Target: 45
deaths per 100,000 population.
Baseline: 75
deaths per 100,000 population were related to diabetes in 1997 (age adjusted to
the year 2000 standard population).
Target setting
method: 43 percent improvement.
Data source: National
Vital Statistics System (NVSS), CDC, NCHS.
|
Total Population, 1997
|
Diabetes
Deaths
|
|
Rate per 100,000
|
|
TOTAL
|
75
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
107
|
|
Asian or Pacific Islander
|
62
|
|
Asian
|
DNC
|
|
Native Hawaiian and other Pacific Islander
|
DNC
|
|
Black or African American
|
130
|
|
White
|
70
|
|
|
|
Hispanic or Latino
|
86
|
|
Mexican
American
|
115
|
|
Puerto
Rican
|
87
|
|
Cuban
|
39
|
|
Not Hispanic or Latino
|
74
|
|
Black or African American
|
133
|
|
White
|
68
|
|
Gender
|
|
Female
|
67
|
|
Male
|
87
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
48
|
|
High school graduate
|
38
|
|
At least some college
|
17
|
|
Select populations
|
|
Age groups
|
|
Under
45 years
|
3
|
|
45
to 64 years
|
64
|
|
65
to 74 years
|
281
|
|
75
years and older
|
673
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 7.8
deaths per 1,000 persons with diabetes.
Baseline: 8.8
deaths per 1,000 persons with diabetes listed anywhere on the death certificate
occurred in 1997 (age adjusted to the year 2000 standard
population).
Target setting
method: 11 percent improvement.
Data sources: National
Vital Statistics System (NVSS), CDC, NCHS; National Health Interview Survey
(NHIS), CDC, NCHS.
|
Persons With Diabetes, 1997
|
Diabetes-Related
Deaths
|
|
Rate per 1,000
|
|
TOTAL
|
8.8
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
3.3
|
|
Asian or Pacific Islander
|
5.4
|
|
Asian
|
6.3
|
|
Native Hawaiian and other
Pacific
Islander
|
2.5
|
|
Black or African American
|
8.1
|
|
White
|
8.9
|
|
|
|
Hispanic or Latino
|
7.4
|
|
Not Hispanic or Latino
|
8.9
|
|
Black or African American
|
8.1
|
|
White
|
9.0
|
|
Gender
|
|
Female
|
8.6
|
|
Male
|
9.5
|
|
Education level (aged 25 to 64 years)
|
|
Less than high school
|
4.7
|
|
High school graduate
|
7.3
|
|
At least some college
|
3.4
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
Under
45 years
|
2.0
|
|
45
to 64 years
|
7.7
|
|
65 to 74 years
|
20.1
|
|
75
years and older
|
73.4
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 309
deaths per 100,000 persons with diabetes.
Baseline: 343
deaths from cardiovascular disease per 100,000 persons with diabetes occurred
in 1997 (age adjusted to the year 2000 standard population).
Target setting
method: 10 percent improvement.
Data sources: National
Vital Statistics System (NVSS), CDC, NCHS; National Health Interview Survey
(NHIS), CDC, NCHS.
|
Persons With Diabetes,
1997
|
Cardiovascular Disease
Deaths
|
|
Rate per 100,000
|
|
TOTAL
|
343
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
93
|
|
Asian or Pacific Islander
|
223
|
|
Asian
|
263
|
|
Native Hawaiian and other
Pacific
Islander
|
113
|
|
Black or African American
|
283
|
|
White
|
359
|
|
|
|
Hispanic or Latino
|
270
|
|
Not Hispanic or Latino
|
351
|
|
Black or African American
|
284
|
|
White
|
367
|
|
Gender
|
|
Female
|
339
|
|
Male
|
363
|
|
Education level (aged 25 to 64 years)
|
|
Less than high school
|
145
|
|
High school graduate
|
247
|
|
At least some college
|
125
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
Under
age 45 years
|
38
|
|
45
to 64 years
|
306
|
|
65
to 74 years
|
850
|
|
75
years and older
|
3,222
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Persons with diabetes
experience death rates two to four times greater than nondiabetic persons,
especially from cardiovascular disease. Other causes of death include renal
failure, diabetic acidosis, and infection. Studies have clearly indicated that
secondary prevention[70], [71], [72], [73] and tertiary prevention[74], [75], [76], [77] can reduce overall cardiac-related
illness, disability, and death. Death rates and their significance, however,
are complicated by how accurately and completely diabetes is recorded on death
certificates.34, 35 Thus, attention to both prevention behaviors
to delay or prevent death, as well as death rates themselves, should be
examined carefully.70, 71, 72, 73, 74, 75, 76, 77, [78],
[79],
[80],
[81]
Potential data
source: National Vital Statistics System (NVSS), CDC, NCHS.
Studies
of diabetes and pregnancy are consistent in their conclusions that proper
prepregnancy and pregnancy glycemia control and careful perinatal obstetrical
monitoring are associated with reduction in perinatal death and congenital abnormalities.
More recently, the importance of good fetal and neonatal nutrition in general,
as well as in persons with diabetes, has been emphasized.[82], [83],
[84],
[85],
[86],
[87]
Potential data
source: National Health and Nutrition Examination Survey (NHANES), CDC,
NCHS.
Target: 1.8
lower extremity amputations per 1,000 persons with diabetes per year.
Baseline: 4.1
lower extremity amputations per 1,000 persons with diabetes
occurred in 1997 (age adjusted to the year 2000 standard population).
Target setting
method: 55 percent improvement.
Data sources: National
Hospital Discharge Survey (NHDS), CDC, NCHS;
National Health Interview Survey (NHIS), CDC, NCHS.
|
Persons With Diabetes,
1997
|
Lower Extremity
Amputations
|
|
Rate per 1,000
|
|
TOTAL
|
4.1
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DNC
|
|
Native Hawaiian and other Pacific lslander
|
DNC
|
|
Black or African American
|
4.8
|
|
White
|
2.6
|
|
|
|
Hispanic or Latino
|
DSU
|
|
Not Hispanic or Latino
|
DSU
|
|
Black or African American
|
DSU
|
|
White
|
DSU
|
Gender
|
|
Female
|
6.0
|
|
Male
|
2.4
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
DNC
|
|
High school graduate
|
DNC
|
|
At least some college
|
DNC
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
Under 65 years
|
6.4
|
|
65 to 74 years
|
8.6
|
|
75 years and older
|
14.2
|
DNA = Data have not been
analyzed. DNC = Data are not collected. DSU = Data are statistically
unreliable.
Note: Age adjusted to the year 2000 standard population.
Potential data
source: Behavioral Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP.
Scientific
evidence documents that with secondary and tertiary prevention, microvascular
complications of diabetes can be reduced substantially. Improved quality of
life, decreased death rates, and reduced costs all can result from improved
clinical and public health diabetes prevention strategies directed at microvascular
and metabolic complications from diabetes. Monitoring the consequences of these
strategies through reductions in mid- and end-stage microvascular complications
needs to be an important component in determining the effectiveness of national
diabetes activities. In both type 1 and 2 diabetes, evidence now is established
firmly that microvascular and metabolic complications of diabetes can be
prevented through secondary (glucose[88], [89])
and tertiary (screening and early treatment of complications[90])
prevention strategies.[91], [92],
[93], [94]
Improper
nutrition, obesity, and inactivity appear to be significant risk factors for
the development of type 2 diabetes. (See Focus Area 19. Nutrition and Overweight
and Focus Area 22. Physical Activity and Fitness.) In addition, nutrition,
weight, and physical activity components are particularly critical in both
glucose management and blood pressure and lipid control in persons with
diabetes. These components are closely related to abilities to control both
micro- and macrovascular diabetic complications. Given the discouraging trends
in obesity and physical inactivity, these elements should be particularly and
carefully monitored in persons with diabetes.[95], [96], [97]
Target: 50 percent.
Baseline: 24
percent of adults aged 18 years and older with diabetes had a glycosylated hemoglobin measurement at least once a year (mean of data from 39
States in 1998; age adjusted to the year 2000 standard population).
Target setting
method: Better than the best.
Data source: Behavioral
Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP.
|
Adults Aged 18 Years and
Older
With Diabetes, 1998
|
Annual Glycosylated
Hemoglobin
Assessment
|
|
Percent
|
|
TOTAL
|
24
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
29
|
|
Asian or Pacific Islander
|
48
|
|
Asian
|
DNC
|
|
Native Hawaiian and other
Pacific
Islander
|
DNC
|
|
Black or African American
|
21
|
|
White
|
25
|
|
|
|
Hispanic or Latino
|
22
|
|
Not Hispanic or Latino
|
25
|
|
Black or African American
|
21
|
|
White
|
24
|
|
Gender
|
|
Female
|
24
|
|
Male
|
25
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
13
|
|
High school graduate
|
19
|
|
At least some college
|
31
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
18 to 44 years
|
29
|
|
45 to 64 years
|
23
|
|
65 to 74 years
|
13
|
|
75 years and older
|
11
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
During the past decade,
scientific investigations have established that controlling certain
macrovascular risk factors, such as elevated blood lipids and blood pressure,
as well as microvascular factors, such as elevated blood glucose, will result
in fewer diabetes-related complications. Further, identification of early
indicators of organ damage, for example, microalbuminuria, and proper treatment
with angiotensin-converting enzyme-inhibitors, will reduce progression to renal
failure. Diabetes-associated complications can be detected with available
laboratory and clinical measures, thus indicating the need for prevention
programs. Monitoring these clinical and laboratory measures can serve to
identify targets for intervention programs.[98], [99],
[100],
[101],
[102]
Target: 75
percent.
Baseline: 47
percent of adults aged 18 years and older with diabetes had an annual dilated
eye examination in 1998 (age adjusted to the year 2000 standard
population).
Target setting
method: Better than the best.
Data source:
National Health Interview Survey (NHIS), CDC, NCHS.
|
Adults Aged 18 Years and
Older
With Diabetes, 1998
|
Annual Dilated Eye
Examination
|
|
Percent
|
|
TOTAL
|
47
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian
or Pacific Islander
|
DSU
|
|
Asian
|
DSU
|
|
Native Hawaiian and other
Pacific
Islander
|
DSU
|
|
Black or African American
|
43
|
|
White
|
49
|
|
|
|
Hispanic or Latino
|
38
|
|
Not Hispanic or Latino
|
49
|
|
Black or African American
|
43
|
|
White
|
51
|
|
Gender
|
|
Female
|
46
|
|
Male
|
47
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
36
|
|
High school graduate
|
45
|
|
At least some college
|
61
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
18 to 44 years
|
44
|
|
45 to 64 years
|
51
|
|
65 to 74 years
|
58
|
|
75 years and older
|
60
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 75
percent.
Baseline: 55
percent of adults aged 18 years and older with diabetes had at least an annual
foot examination (mean value of data from 39 States in 1998; age adjusted to
the year 2000 standard population).
Target setting
method: Better than the best.
Data source:
Behavioral Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP.
|
Adults Aged 18 Years and Older
With Diabetes, 1998
|
Annual
Foot
Examination
|
|
Percent
|
|
TOTAL
|
55
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
40
|
|
Asian or Pacific Islander
|
57
|
|
Asian
|
DNC
|
|
Native Hawaiian and other
Pacific
Islander
|
DNC
|
|
Black or African American
|
55
|
|
White
|
55
|
|
|
|
Hispanic or Latino
|
56
|
|
Not Hispanic or Latino
|
54
|
|
Black or African American
|
54
|
|
White
|
54
|
|
Gender
|
|
Female
|
51
|
|
Male
|
59
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
46
|
|
High school graduate
|
56
|
|
At least some college
|
59
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
18
to 44 years
|
53
|
|
45
to 64 years
|
59
|
|
65 to 74 years
|
56
|
|
75
years and older
|
51
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Health practitioner
behaviors, such as blood pressure monitoring or eye and foot examinations, are
associated with greater identification of early indicators of end-organ damage
from diabetes. These screening behaviors are necessary to initiate secondary
and tertiary prevention programs and should be monitored.[103], [104],
[105]
Target: 75
percent.
Baseline: 58
percent of persons aged 2 years and older with diagnosed diabetes saw a dentist
at least once within the preceding 12 months in 1997 (age adjusted to the year
2000 standard population).
Target setting
method: Better than the best.
Data source: National
Health Interview Survey (NHIS), CDC, NCHS.
|
Persons Aged 2 Years and Older
With Diabetes, 1997
|
Annual
Dental
Examination
|
|
Percent
|
|
TOTAL
|
58
|
|
Race
and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
56
|
|
Asian
|
DSU
|
|
Native Hawaiian or Pacific Islander
|
DSU
|
|
Black or African American
|
63
|
|
White
|
58
|
|
|
|
Hispanic or
Latino
|
32
|
|
Not Hispanic
or Latino
|
61
|
|
Black or
African American
|
63
|
|
White
|
61
|
|
Gender
|
|
Female
|
59
|
|
Male
|
57
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
40
|
|
High school graduate
|
52
|
|
At least some college
|
65
|
|
Disability status
|
|
Persons with
disabilities
|
42
|
|
Persons without
disabilities
|
66
|
|
Select populations
|
|
Age groups
(not age adjusted)
|
|
18 to 44
years
|
60
|
|
45 to 64
years
|
50
|
|
65 to 74
years
|
44
|
|
75 years and
older
|
41
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Persons with diabetes are at
increased risk for destructive periodontitis and subsequent tooth loss.[106], [107] In addition, untreated periodontitis in persons with
diabetes may complicate glycemic control.[108]
Regular dental visits provide opportunities for prevention, early detection,
and treatment of periodontal problems in persons with diabetes.
Target: 30
percent.
Baseline: 20
percent of adults aged 40 years and older with diabetes took aspirin at least
15 times per month in 1988–94 (age adjusted to the year 2000 standard
population).
Target setting
method: Better than the best.
Data source: National
Health and Nutrition Examination Survey (NHANES), CDC, NCHS.
|
Adults
Aged 40 Years and Older With
Diabetes, 1988–94
|
Took Aspirin at Least 15
Times per Month
|
|
Percent
|
|
TOTAL
|
20
|
|
Race
and ethnicity
|
|
American Indian or Alaska Native
|
DSU
|
|
Asian or Pacific Islander
|
DSU
|
|
Asian
|
DNC
|
|
Native Hawaiian and other
Pacific
Islander
|
DNC
|
|
Black
or African American
|
9
|
|
White
|
23
|
|
|
|
Hispanic
or Latino
|
DSU
|
|
Mexican American
|
8
|
|
Not Hispanic or Latino
|
DNA
|
|
Black or African American
|
8
|
|
White
|
25
|
|
Gender
|
|
Female
|
15
|
|
Male
|
27
|
|
Education level
|
|
Less
than high school
|
16
|
|
High
school graduate
|
24
|
|
At
least some college
|
22
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Target: 60
percent.
Baseline: 42
percent of adults aged 18 years and older with diabetes performed
self-blood-glucose-monitoring at least once daily (mean of data from 39 States
in 1998; age adjusted to the year 2000 standard population).
Target setting
method: Better than the best.
Data source: Behavioral
Risk Factor Surveillance System (BRFSS), CDC, NCCDPHP.
|
Adults
Aged 18 Years and Older
With Diabetes, 1998
|
Daily
Self-Blood-
Glucose-Monitoring
|
|
Percent
|
|
TOTAL
|
42
|
|
Race and ethnicity
|
|
American Indian or Alaska Native
|
53
|
|
Asian or Pacific Islander
|
30
|
|
Asian
|
DNC
|
|
Native Hawaiian and other
Pacific
Islander
|
DNC
|
|
Black or African American
|
40
|
|
White
|
43
|
|
|
|
Hispanic or Latino
|
36
|
|
Not Hispanic or Latino
|
43
|
|
Black or African American
|
37
|
|
White
|
45
|
|
Gender
|
|
Female
|
43
|
|
Male
|
41
|
|
Education level (aged 25 years and older)
|
|
Less than high school
|
38
|
|
High school graduate
|
41
|
|
At least some college
|
44
|
|
Select populations
|
|
Age groups (not age adjusted)
|
|
18
to 44 years
|
43
|
|
45
to 64 years
|
41
|
|
65
to 74 years
|
44
|
|
75
years and older
|
38
|
DNA = Data have not been analyzed. DNC = Data are not
collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.
Certain activities, ultimately chosen by individuals
themselves, are essential in the proper preventive management of diabetes.
Smoking cessation, use of aspirin, and self-blood-glucose-monitoring are
representative of individual behaviors that should be periodically monitored
because each behavior is associated with a decreased likelihood of
microvascular and macrovascular complications.[109],
[110],
[111],
[112],
[113]
Aspirin therapy in persons with diabetes mellitus—especially in the presence of other
cardiovascular risk factors, such as high blood pressure, elevated blood
lipids, etc.—has been demonstrated to reduce the likelihood of a future heart attack
or stroke.113
 | |
1. |
Access to
Quality Health Services |
| |
4. |
Chronic
Kidney Disease |
| |
9. |
Family
Planning |
| |
12. |
Heart Disease
and Stroke |
|
|
|
|
| 12-1. | | Coronary heart
disease (CHD) deaths |
| 12-2. | | Knowledge of
symptoms of heart attack and importance of calling 911 |
| 12-7. | | Stroke deaths |
| 12-8. | | Knowledge of
early warning symptoms of stroke |
| 12-9. | | High blood
pressure |
| 12-10. | | High blood
pressure control |
| 12-11. | | Action to help
control blood pressure |
| 12-12. | | Blood pressure
monitoring |
| 12-13. | | Mean total
cholesterol levels |
| 12-14. | | High blood
cholesterol levels |
| 12-15. | | Blood cholesterol
screening |
| 12-16. | | LDL-cholesterol
level in CHD patients |
| |
14. |
Immunization
and Infectious Diseases |
| |
16. |
Maternal,
Infant, and Child Health |
| |
19. |
Nutrition and
Overweight |
|
|
|
|
| 19-1. | | Healthy weight in
adults |
| 19-2. | | Obesity in adults |
| 19-3. | | Overweight or
obesity in children and adolescents |
| 19-16. | | Worksite promotion
of nutrition education and weight management |
| 19-17. | | Nutrition
counseling for medical conditions |
| |
22. |
Physical
Activity and Fitness |
|
|
|
|
| 22-1. | | No leisure- time
physical activity |
| 22-2. | | Moderate physical
activity |
| 22-3. | | Vigorous physical
activity |
| 22-6. | | Moderate physical
activity in adolescents |
| 22-7. | | Vigorous physical
activity in adolescents |
| |
28. |
Vision and
Hearing |
(A listing of abbreviations and acronyms used in this
publication appears in Appendix H.)
Ascertainment: The processes and systems used to
collect information and data about a particular health condition, for example,
written surveys, telephone calls, electronic records, etc.
Comorbidity: The presence of serious health
conditions in addition to the one being examined, for example, high blood
pressure in people with diabetes mellitus.
Diabetes mellitus (diabetes): A chronic disease due
to either or both insulin deficiency and 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; problems with
pregnancy also occur. Diabetes is classified into four major categories:
Type 1 diabetes: (Previously
called insulin-dependent diabetes mellitus [IDDM] or juvenile-onset diabetes
[JODM]) represents clinically about 5 percent of all persons with diagnosed
diabetes. Its clinical onset is typically at ages under 30 years. Most often
this type of diabetes represents an autoimmune destructive disease in beta (insulin-producing)
cells of the pancreas in genetically susceptible individuals. Insulin therapy
always is required to sustain life and maintain diabetes control.
Type 2 diabetes: (Previously
called non-insulin-dependent diabetes mellitus [NIDDM] or adult-onset diabetes
[AODM]) is the most common form of diabetes in the United States and the world,
especially in certain racial and ethnic groups and in elderly persons. In the
United States, approximately 95 percent of all persons with diagnosed diabetes
(10.5 million) and almost 100 percent of all persons with undiagnosed (5.5
million) diabetes probably have type 2 diabetes.
Gestational diabetes mellitus
(GDM): Refers to the development of hyperglycemia during pregnancy in an
individual not previously known to have diabetes. Approximately 3 percent of
all pregnancies are associated with GDM. GDM identifies health risks to the
fetus and newborn and future diabetes in the mother and offspring.
Other types: Include genetic
abnormalities, pancreatic diseases, and medication use.
Complications: Microvascular—small vessel abnormalities
in the eyes and kidneys; macrovascular—large vessel abnormalities in the heart,
brain, and legs; and metabolic—abnormalities in nerves and during pregnancy.
Diabetic acidosis: A severe condition of diabetes.
Due to a lack of insulin, the body breaks down fat tissue and converts the fat
to very strong acids. The condition most often is associated with a very high
blood sugar and happens most often in poorly controlled or newly diagnosed type
1 diabetes.
Direct costs: Costs associated with an illness that
can be attributed to a medical service, procedure, medication, etc. Examples
include payment for an x ray; pharmaceutical drugs, for example, insulin;
surgery; or a clinic visit.
Formal diabetes education: Self-management training
that includes a process of initial individual patient assessment; instruction
provided or supervised by a qualified health professional; evaluation of
accumulation by the diabetic patient of appropriate knowledge, skills, and
attitudes; and ongoing reassessment and training.
Indirect costs: Those costs associated with an illness
that occur because an individual cannot work at his or her usual job due to
premature death, sickness, or disability (for example, amputation).
Prevention: Primary—stopping or delaying onset of
diabetes; secondary—early identification and stopping or delaying onset of
complications; tertiary—stopping disability from disease and its complications.
Thrifty gene: An idea which suggests that a “thrifty
gene” is present in people likely to develop type 2 diabetes. It is speculated
that thousands of years ago, people with this “thrifty gene” could store food
very efficiently and thus survive long periods of starvation. Now when
starvation is unusual, this thrifty gene tends to make people overweight and
thus prone to diabetes.
Urinary microalbumin measurement: A laboratory
procedure to detect very small quantities of protein in the urine, indicating
early kidney damage.
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