1. The Impact of Diabetes Mellitus in the United States
Epidemiology, Costs, and
Future Projections
This slide set provides an overview of the impact of type 1 and type 2 diabetes mellitus in the United States, focusing on epidemiology, costs—both direct and indirect—and the projected burden of diabetes, including globally

2. Table of Contents Section Slide No. 3-34 Epidemiology 35-43 Costs
Future Projections
43-49
Three specific areas are reviewed in this slide set
Epidemiology
Costs
Future Projections
National Diabetes Statistics, 2011 used estimates derived from various data systems of the Centers for Disease Control and Prevention (CDC), the Indian Health Service’s (IHS’s) National Patient Information Reporting System (NPIRS), the U.S. Renal Data System of the National Institutes of Health (NIH), the U.S. Census Bureau, and published studies
The estimated percentages and the total number of people with diabetes and prediabetes were derived from National Health and Nutritional Examination Survey (NHANES), National Health Interview Survey, 2009 IHS data, and 2010 U.S. resident population estimates
The diabetes and prediabetes estimates from NHANES were applied to the 2010 U.S. resident population estimates to derive the estimated number of adults with diabetes or prediabetes
Detailed information about the data sources, methods, and references are available at

3. Section 1
Section 1, Epidemiology, provides an overview of the number of people in the United States affected by diabetes, including:
Racial/ethnic differences
Diagnosed and undiagnosed diabetes
New cases
County-level US estimates
Number of Americans with diabetes
Annual age-adjusted incidence
Prevalence of overweight and obesity in adults with diabetes
Diabetes in youth (SEARCH)
Prediabetes
Gestational diabetes
Complications of diabetes
Deaths among people with diabetes
epidemiology

4. Epidemiology of Diabetes
Diabetes affects 25.8 million people of all ages
8.3% of the U.S. population
Diagnosed: 18.8 million
Undiagnosed: 7.0 million
Leading cause of kidney failure, nontraumatic lower-limb amputation, new cases of blindness among adults
Major cause of heart disease and stroke
Seventh leading cause of death
National Diabetes Statistics, 2011 provides an overview of the epidemiology of diabetes in the United States
Diabetes affects 25.8 million people of all ages, or 8.3% of the population
Of that number, about one-third, or 7.0 million, have diabetes that is undiagnosed
18.8 million have a diagnosis of diabetes
Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputation, and new cases of blindness among adults
Diabetes is also a major cause of heart disease and stroke and is the seventh leading cause of death
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

5. Diagnosed and Undiagnosed Diabetes in 2010
~1.9 million people ≥20 years of age newly diagnosed; 215,000 were <20 years
Of the 25.6 million (11.3%) ≥20 years
Men: 13.0 million (11.8%)
Women: 12.6 million (10.8%)
Non-Hispanic whites: 15.7 million (10.2%)
Non-Hispanic blacks: 4.9 million (18.7%)
>65 years, 10.9 million (26.9%)
An estimated 1.9 million people 20 years of age or older were newly diagnosed with diabetes in 2010; in addition, type 1 or type 2 diabetes was diagnosed in 215,000 people younger than 20 years of age, or about one-quarter of 1% of this age group
25.6 million (11.3%) of all people aged 20 years or older have diabetes, both diagnosed and undiagnosed
Men represented 11.8% (13.0 million) and women, 10.8% (12.6 million)
Of all non-Hispanic whites ages 20 years or older, 15.7 million (10.2%) have diabetes, as do 4.9 million, or 18.7%, of all non-Hispanic blacks ages 20 and older
Approximately one-quarter of those with diabetes, or 10.9 million people, were ages 65 years or older
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

6. Racial/Ethnic Differences in Diagnosed Diabetes
2007–2009 national survey data for people ages 20 years or older
Race/Ethnicity %
Non-Hispanic whites
7.1
Asian Americans
8.4
Hispanics/Latinos
Cuban Americans
Central and South Americans
Mexican Americans
Puerto Ricans
11.8
7.6
13.3
13.8
Non-Hispanic blacks
12.6
After adjusting for population age differences, 2007–2009 national survey data for people ages 20 years or older indicated the percentage of racial/ethnic populations with a diagnosis of diabetes
As indicated on this slide, Puerto Ricans, at 13.8% and Mexican Americans, at 13.3%, represented the populations with the highest percentage of diagnosed diabetes
Non-Hispanic white had the lowest percentage, 7.1%
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

7. Diagnosed and Undiagnosed Diabetes
The estimated percentage of people in the United States from age 20 years or older living with diabetes (diagnosed and undiagnosed) is summarized on this slide
As the population ages, an increasing percentage is living with diabetes
20-44 years: 3.7%
45-64 years: 13.7%
≥65 years: 26.9%
Source: National Health and Nutrition Examination Survey
Source: National Health and Nutrition Examination Survey
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

8. New Cases of Diagnosed Diabetes
About 1.9 million people ages 20 years or older were newly diagnosed with diabetes in 2010, with the largest increase in the years age group
20-44 years: 465,000
45-64 years: 1,052,000
≥65 years: 390,000
Source: National Health and Nutrition Examination Survey estimates projected to the year 2010
Source: National Health and Nutrition Examination Survey estimates projected to the year 2010
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

9. County-Level Estimates of Diagnosed Diabetes (%), Adults ≥20 years, 2008
The prevalence of diagnosed diabetes by county was estimated using data from the Center for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) and data from the US Census Bureau’s Population Estimates Program
The BRFSS is an ongoing, monthly, state-based telephone survey of the adult population
The survey provides state-specific information on behavioral risk factors and preventive health practices. Respondents were considered to have diabetes if they responded "yes" to the question, "Has a doctor ever told you that you have diabetes?”
Estimates were restricted to adults 20 years of age or older to be consistent with population estimates from the U.S. Census Bureau
The county-level estimates for the 3,141 counties or county equivalents (eg, parish, borough) in the 50 US states and the District of Columbia were based on indirect model-dependent estimates, which employs a statistical model that “borrows strength” in making an estimate for one county from BRFSS data collected in other counties
Bayesian multilevel modeling techniques were used to obtain these estimates, and separate models were developed for each of the four census regions: West, Midwest, Northeast and South
Percent
0 – 6.5
6.6 – 8.0
8.1 – 9.4
9.5 – 11.1
≥ 11.2
Reference
Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available at:

10. Number of Americans with Diagnosed Diabetes, 1980-2009
This slide highlights the number of civilian, noninstitutionalized persons with diagnosed diabetes in the United States from
From 1980 through 2009, the number of Americans with diabetes has more than tripled, from 5.6 million to 19.7 million
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey
Reference
Centers for Disease Control and Prevention. Number (in millions) of civilian, non-Institutionalized persons with diagnosed diabetes, United States, 1980–2009. Available at:

11. Annual, Age-Adjusted Incidence Rate of Diagnosed Diabetes*, 2005-2007
This report is the first to provide state-specific incidence rates for diagnosed diabetes among adults and the first to describe geographic patterns in diabetes incidence
To assess geographic distribution of diagnosed diabetes and examine state-specific changes, the Centers for Disease Control and Prevention (CDC) analyzed data from Behavioral Risk Factor Surveillance System (BRFSS) surveys for and
BRFSS is a state-based, random-digit-dialed, landline telephone survey of the US civilian noninstitutionalized population aged >18 years and is conducted in all 50 states, DC, Guam, Puerto Rico, and the US Virgin Islands ; persons with diagnosed diabetes were defined as those who answered "yes" to the question, "Have you ever been told by a doctor that you have diabetes?”
By US Census region, average age-adjusted incidence was greatest in the South (10.5 per 1,000, CI = ), followed by the Northeast (8.6, CI = ), West (8.5, CI = ), and Midwest (7.4, CI = )
By state, age-adjusted incidence ranged from 5.0 per 1,000 population (CI = ) in Minnesota to 12.8 (CI = ) in Puerto Rico. The 10 states in the highest quartile of age-adjusted diabetes incidence ( per 1,000 population) included 9 of the 16 states in the South region: Alabama, Florida, Georgia, Kentucky, Louisiana, South Carolina, Tennessee, Texas, and West Virginia; the other state in the highest quartile was Arizona
For 33 states with ≥2 years of data in both periods, age-adjusted incidence was 90% higher overall for (9.1 per 1,000 population) vs (4.8); states with the greatest number of annual new cases were California (approximately 208,000), Texas (156,000), and Florida (139,000); age-adjusted incidence of diabetes increased 90%, from 4.8 per 1,000 in to 9.1 in
MMWR. 2008;57(43):
Reference
Centers for Disease Control and Prevention. State-specific incidence of diabetes among adults—participating states, and MMWR. 2008;57(43):

12. Prevalence of Overweight and Obesity Among Adults with Diabetes
CDC analysis of prevalence of overweight and obesity among U.S. adults ≥20 years with previously diagnosed diabetes
Overweight or obesity: 85.2%
Obesity: 54.8%
Women aged years had a significantly higher prevalence of obesity than women ≥65 years of age (64.7% vs 47.4%; P<0.05) during
Among men, prevalence of overweight or obesity was 86.3% and obesity, 53.0%
The Centers for Disease Control and Prevention (CDC) analyzed the prevalence of overweight and obesity among US adults aged ≥20 years with previously diagnosed diabetes by using data from two surveys: the Third National Health and Nutrition Examination Survey (NHANES III), , and NHANES
This analysis found that most adults with diagnosed diabetes were overweight or obese; during , the prevalence of overweight or obesity was 85.2%, and the prevalence of obesity was 54.8%
In NHANES III, , participants were asked, “Have you ever been told by a doctor that you have diabetes or sugar diabetes?” For women, the question was preceded by “other than during pregnancy”
In NHANES , the same questions were asked, but “doctor” was replaced with “doctor or health-care professional”
Participants who responded “yes” were categorized as having diagnosed diabetes
The body mass index (BMI) of each participant was calculated as weight in kilograms divided by height in meters squared; overweight was defined as a BMI of and obesity as a BMI of ≥30.0
For the periods (45.7%) and (54.8%), prevalence of obesity was similar among all survey participants with diagnosed diabetes
Among women in the survey, the prevalence of overweight or obesity was 84.2% and the prevalence of obesity was 58.0%
Compared with women aged ≥65 years, women aged years had a significantly higher prevalence of obesity (64.7% vs 47.4%)(P<0.05)
MMWR. 2004;53(45):
Reference
Centers for Disease Control and Prevention. Prevalence of overweight and obesity among adults with diagnosed diabetes—United States, and MMWR. 2004;53(45):

13. SEARCH for Diabetes in Youth Study Overview
Population-based, observational study of physician-diagnosed diabetes among youth <20 years of age
Initiated in 2000
Funded by CDC, NIH
Collects data from 6 centers
4 geographically based (Colorado, Ohio, South Carolina, Washington)
2 health plan-based (California, Hawaii)
SEARCH represents the largest surveillance effort on diabetes in youth conducted in the US to date
Population-based observational study of physician-diagnosed diabetes among youth <20 years of age
Provides the most comprehensive data to date on overall burden of diabetes among youth
Initiated in 2000, SEARCH is funded by the Centers for Disease Control and Prevention and the National Institutes of Health
Data are collected from 6 study centers
4 locations are geographically based: Colorado, Ohio, South Carolina, Washington
2 locations represent health plan-based members in California and Hawaii
CDC=Centers for Disease Control and Prevention; NIH=National Institutes of Health
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

14. SEARCH for Diabetes in Youth Results
6379 youth with diabetes in a population of ~3.5 million
Average age at diagnosis: 8.4 years
Average duration of diabetes: 56 months (range, months)
Estimated prevalence of U.S. youth aged years with diabetes in 2001
1.82 cases per 1000 youth (95% CI: per 1000 youth)
Cancer: 1.24 per 1000
Asthma: 120 per 1000
Diabetes is one of the leading chronic diseases in childhood and adolescence
Persons diagnosed with diabetes before 20 years of age have a markedly lower life expectancy than the general population without diabetes
SEARCH identified 6379 youth with diabetes in a population of approximately 3.5 million
Average age at diagnosis: 8.4 years
By race/ethnicity:
Non-Hispanic white: 7.8 years
Hispanic: 8.8 years
African-American: 10.0 years
Asian/Pacific Islander: 10.2 years
American Indian: 12.0 years
Average duration of diabetes: 56 months (range, months)
Age-, gender-, and racial/ethnic group-specific prevalence rates were multiplied by US population counts to estimate the total number of youth ages 0-19 years with diabetes in 2001
According to SEARCH data, the crude prevalence of total diabetes was estimated at cases per 1000 youth (95% CI: per 1000 youth)
To place this in context, 1.24 per 1,000 youth are diagnosed with cancer and 120 per with asthma
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

15. SEARCH for Diabetes in Youth Demographics, Prevalence
Characteristic
No. of cases (%)
Population denominator, n (%)
Prevalence, cases per 1000 youth (95% CI)
Total population
6379
3,499,846
1.82 ( )
Age group
0-4 y
5-9 y
10-14 y
15-19 y
255 (4.0)
1094 (17.2)
2120 (33.2)
2910 (45.6)
829,589 (23.7)
876,263 (25.0)
925,426 (26.5)
868,568 (24.8)
0.31 ( )
1.25 ( )
2.29 ( )
3.35 ( )
Gender
Male
Female
3156 (49.5)
3223 (50.5)
1,787,208 (51.1)
1,712,638 (48.9)
1.77 ( )
1.88 ( )
Race/ethnicity
NHW
Black
Hispanic
API AI
4382 (68.7)
721 (11.3)
829 (13.0)
267 (4.2)
180 (2.8)
2,025,426 (57.9)
373,599 (10.6)
641,414 (18.3)
320,403 (9.2)
139,004 (4.0)
2.16 ( )
1.93 ( )
1.29 ( )
0.83 ( )
1.29 ( )
The demographic characteristics of the SEARCH study population in 2001 and the prevalence of total diabetes mellitus are summarized on this slide
Prevalence of diabetes was observed to increase markedly as age increased
Compared with male youth, female youth had a slightly higher prevalence of diabetes mellitus
Non-Hispanic white youth accounted for a disproportionately large number of youth with diabetes
Asian-Pacific Islander (API) youth had the lowest prevalence
The prevalence estimates of 1.29 cases per 1000 Hispanic children and adolescents and 0.83 cases per 1000 API youth represent the first population-based prevalence estimate for these US subpopulations based on validated cases of diabetes
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118: Table 1.
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

16. SEARCH for Diabetes in Youth 0-9 Years by Race/Ethnicity
Prevalence
SLIDE 1 OF 2
The next two slides illustrate the contribution of type 1, type 2, and other type of diabetes mellitus to the overall prevalence of diabetes within each of the racial/ethnic group by age
Among children 0-9 years of age, most had type 1 diabetes regardless of race/ethnicity
Type 1 diabetes mellitus accounted for ≥80% of all cases of diabetes among all 5 racial ethnic/groups, including the American Indian group
American Indian youth (13%) and Asian-Pacific Islander youth (7%) were notable for diagnosis of type 2 diabetes
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

17. SEARCH for Diabetes in Youth 10-19 Years by Race/Ethnicity
Prevalence
SLIDE 2 OF 2
Among youth age years, type 1 diabetes was frequent among non-Hispanic white, Hispanic, and African-American adolescents
Proportion of diabetes accounted for by type 2 varied across racial/ethnic groups, ranging from 6% for non-Hispanic white youth to 76% for American Indian youth; for other racial/ethnic groups, the percentage of cases of type 2 diabetes was 22% among Hispanic youth, 33% among African-American youth, and 40% among Asian-Pacific Islander youth
NHW=non-Hispanic white; AA=African-American; H=Hispanic; API=Asian/Pacific Islander; AI=American Indian
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

18. SEARCH for Diabetes in Youth Population Estimates, 2001
Estimated number of cases of diabetes mellitus, extrapolated from SEARCH data
154,369 youth (95% CI: 150, ,248)
Majority (78.7%) years of age
Non-Hispanic white: 62% of those <20 years but 71% of all children with diabetes
32,860 children <10 years of age
Non-Hispanic white: 60% of population but 77% of all children with diabetes
SEARCH results were used to estimate the number of cases of diabetes mellitus in the US in 2001
154,369 (95% CI: 150, ,248) youth had physician-diagnosed diabetes
The majority of these youth (78.7%, or 121,509) were ages years
Non-Hispanic white youth represented 62% of the US population <20 years of age but 71% of all children with diabetes
Of those 0-9 years, 32,860 youth had diabetes
Similarly, non-Hispanic white youth had a disproportionate percentage of diabetes compared with the other racial/ethnic groups: they represented 60% of the population but 77% of all children with diabetes
SEARCH for Diabetes in Youth Study Group. Pediatrics. 2006;118:
Reference
SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:

19. Prediabetes
In , based on fasting glucose or hemoglobin A1C levels, prediabetes was detected in
35% of adults ages 20 years and older
50% of adults ages 65 years and older
An estimated 79 million adults ages 30 years and older
People with prediabetes have an increased risk of developing type 2 diabetes, heart disease, and stroke
79 million adults ages 30 years and older are estimated to have prediabetes, based on fasting glucose or hemoglobin A1C levels detected in
35% were ages 20 years or older
50% were ages 65 years or older
20% of American Indians 15 years of age or older had prediabetes in
Prediabetes can lead to increased risk of developing type 2 diabetes, heart disease, and stroke
Losing weight and increased physical activity can prevent or delay type 2 diabetes in those with prediabetes; in some cases, blood glucose levels return to normal
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

20. Gestational Diabetes Range from 2%–10% of pregnancies
Postpartum, 5%–10% of women with gestational diabetes are found to have diabetes, usually type 2
Women who have had gestational diabetes have a 35%–60% chance of developing diabetes within 10–20 years
Using new diagnostic criteria, international multicenter study of gestational diabetes found 18% of pregnancies were affected
Gestational diabetes is estimated to range from 2% to 10% of pregnancies
Following pregnancy, approximately 5% to 10% of women with gestational diabetes are found to have diabetes, usually type 2
In addition, women who have had gestational diabetes have a 35% to 65% chance of developing diabetes within 10 to 20 years
New diagnostic criteria are anticipated to increase the proportion of women who are diagnosed with gestational diabetes
Using the new diagnostic criteria, an international multicenter study of gestational diabetes found 18% of pregnancies were affected by gestational diabetes
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

21. Complications of Diabetes
Heart disease and stroke
Hypertension
Blindness, eye problems
Renal disease
Nervous system disease
Amputations
Dental disease
Complications of pregnancy
Other complications
Complications of diabetes are included on this slide; the following slides summarize those of heart disease and stroke, hypertension, blindness, eye problems, nervous system disease and amputations
In addition, periodontal disease is more common in those with diabetes
Among young adults, those with diabetes have about twice the risk of those without diabetes
Adults ages ≥45 years with poorly controlled diabetes, defined as A1C >9%, were 2.9 times more likely to have severe periodontitis than those without diabetes; the likelihood was even greater (4.6 times) among smokers with poorly controlled diabetes
About one-third of people with diabetes have severe periodontal disease consisting of loss of attachment of 5 mm of more of the gums to the teeth
Major birth defects may result in 5%-10% of pregnancies in women with poorly controlled type 1 diabetes; spontaneous abortions may occur in 15%-20%
Other complications include diabetic ketoacidosis and hyperosmolar coma in those with uncontrolled diabetes; susceptibility to other illnesses; lack of physical ability, and depression
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

22. Complications of Diabetes Heart Disease, Stroke, Hypertension
In 2004, of diabetes-related death certificates among people ages ≥65 years, 68% noted heart disease and 16%, stoke
Adults with diabetes have heart disease death rates ~2–4 times higher than those without; stroke risk is 2–4 times higher
In , of adults ages ≥20 years with self-reported diabetes, 67% had blood pressure ≥140/90 mmHg or used prescription medications for hypertension
In 2004, heart disease was noted on 68% of diabetes-related death certificates among people ages ≥65 years and stroke was noted on 16%
Adults with diabetes have death rates approximately 2-4 times higher from heart disease compared to those without diabetes
Risk for stroke is 2-4 times higher among people with diabetes
In , 67% of adults ages 20 years or older with diabetes had hypertension (≥140/90 mmHg) or used prescription medications for hypertension
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

23. Complications of Diabetes Blindness, Eye Problems
Diabetes is leading cause of new cases of blindness among adults ages 20–74 years
Of people with diabetes aged ≥40 years, 4.2 million (28.5%) had diabetic retinopathy in
655,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss
Among adults ages years, diabetes is the leading cause of new cases of blindness
In , 4.2 million people with diabetes ages 40 years and older (28.5%) had diabetic retinopathy and of these, 655,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

24. Complications of Diabetes Renal Disease
In 2008, diabetes was leading cause of kidney failure, accounting for 44% of all new cases of renal failure
48,374 people with diabetes began treatment for end-stage renal disease (ESRD)
202,290 people with ESRD due to diabetes were living on chronic dialysis or with a kidney transplant
44% of all new cases of kidney failure in 2008 were caused by diabetes
Also in 2008
48,374 began treatment for end-stage renal disease
202,290 people with ESRD due to diabetes were living on chronic dialysis or with a kidney transplant
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

25. Complications of Diabetes Nervous System Disease
~60%–70% of people have mild to severe forms of nervous system damage
Impaired sensation or pain in feet or hands
Slowed digestion of food in the stomach
Carpal tunnel syndrome
Erectile dysfunction
Severe forms are a major contributing cause of lower-extremity amputations: >60% occur in people with diabetes
60%-70% of people with diabetes have mild to severe forms of nervous system damage, including neuropathy, erectile dysfunction, or carpal tunnel syndrome
More than 60% of nontraumatic lower-limb amputations occur in those with diabetes; in 2006, approximately 65,700 nontraumatic lower-limb amputations were performed in people with diabetes
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

26. Insulin and oral medication 14%
Treatment of Diabetes
No medication 16%
Insulin only 12%
Insulin and oral medication 14%
Oral medication only 58%
Among adults with a diagnosis of diabetes, either type 1 or type 2, 12% take insulin only; 14% take both insulin and oral medication; 58% take oral medication only; and 16% do not take either insulin or oral medication
Source: National Health Interview Survey
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

27. Deaths Among People with Diabetes
In 2007, diabetes seventh leading cause of death based on death certificates
71,382 underlying cause
160,022 contributing cause
Likely to be underreported as a cause of death
Overall, risk for death among those with diabetes is about twice that of people with similar age but without diabetes
Based on US death certificates in 2007, diabetes was the seventh leading cause of death in which diabetes appeared as any-listed cause of death
This ranking is based on 71,382 death certificates that listed diabetes as the underlying cause of death and 160,022 in which diabetes was listed as a contributing cause of death
Diabetes is likely to be underreported as a cause of death; studies have found that 35%-40% of those who died had diabetes listed anywhere on the death certificate; in about 10%-15%, it was listed as the underlying cause of death
Risk for death among people with diabetes is about twice that of people of a similar age who do not have diabetes
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

28. Age Distribution of Deaths Associated with Diabetes2%
Age ,663 6%
Age ,918 1%
Age ,907 5%
Age <18
488 0%
Age ,634 6%
Age 65-69
20,656 7%
The majority of deaths attributed to diabetes occur among the elderly, with 73% of deaths occurring among people 70 years of age and older
7% of deaths occur among those years of age
Age ,791
73%
American Diabetes Association. Diabetes Care. 2008;31: Figure 4.
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

29. All-cause mortality rate among people with and without diabetes
With diabetes *
Without diabetes
*Rate difference between 1997/1998 and 2003/2004, –5.2; P < 0.02 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

30. CVD mortality rate among people with and without diabetes
With diabetes
Without diabetes *
*Rate difference between 1997/1998 and 2003/2004, –4.0; P < for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

31. CVD mortality rate among women with and without diabetes
Women with diabetes
Women without diabetes * †
*Rate difference – 3.5; P < 0.01 for trend; †Rate difference – 0.5, P < 0.03 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

32. All-cause mortality rate among women with and without diabetes
Women with diabetes *
Women without diabetes
*Rate difference – 5.6; P < 0.01 for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

33. CVD mortality rate among men with and without diabetes
Men with diabetes
Men without diabetes *
*Rate difference between 1997/1998 and 2003/2004, –5.2; P < for trend
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

34. All-cause mortality rate among men with and without diabetes
Men with diabetes
Men without diabetes
Rates between 1997/1998 and 2003/2004 not significantly different
Gregg et al., Diabetes Care 35: 1252—1257, 2012
Reference
National Diabetes Information Clearinghouse. National Diabetes Statistics, Available at:

35. Section 2
Section 2, Costs, examines the economic costs of diabetes, including medical expenditures, health resource use, health care expenditures, indirect costs, and mortality costs attributed to diabetes
costS

36. Economic Costs of Diabetes, 2007
Cost of Diabetes Model
Total cost of diabetes: $174 billion
$116 billion: excess medical expenditures
$27 billion to treat diabetes directly
$58 billion to treat diabetes-related chronic complications attributed to diabetes
$31 billion excess medical costs
$58 billion: reduced national productivity
Diabetes is a disease that touches almost everyone in society and nowhere is this more true than with respect to costs of diabetes
To determine the national burden of diabetes, a prevalence-based approach was used that combined the demographics of the population in 2007 with diabetes prevalence rates and other epidemiological data, health care costs, and economics data into a Cost of Diabetes Model
Data sources included national surveys and claims databases and a proprietary database containing annual medical claims for 16.3 million people in 2006
Health resource use and associated medical costs were analyzed by age, sex, type of medical condition, and health resource category
In 2007, diabetes cost the US an estimated $174 billion; $116 billion in excess medical expenditures and $58 billion in reduction in national productivity
The $116 billion in medical costs attributed to diabetes include
$27 billion for direct care of diabetes
$58 billion to treat diabetes-related chronic complications that are attributed to diabetes
$31 billion in excess medical costs
American Diabetes Association. Diabetes Care. 2008;31:
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

37. Medical Expenditures Attributed to Diabetes, 2007
Hospital inpatient care (50%)
Diabetes medication and supplies (12%)
Retail prescriptions to treat complications of diabetes (11%)
Physician office visits (11%)
The largest components of medical expenditures attributed to diabetes were
Hospital inpatient care (50% of total costs)
Diabetes medication and supplies (12%)
Retail prescriptions to treat complications of diabetes (11%), and
Physician office visits (11%)
American Diabetes Association. Diabetes Care. 2008;31:
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

38. Costs Incurred by People with a Diagnosis of Diabetes in 2007
Average annual expenditures: $11,744
$6,649 attributed to diabetes
On average, people with diagnosed diabetes have medical expenditures ~2.3 times higher than those without diabetes
~$1 in $5 health care dollars is spent caring for someone with diagnosed diabetes
~$1 in $10 health care dollars is attributed to diabetes
People with a diagnosis of diabetes incur average expenditures of $11,744 annually, of which $6,649 is attributed to diabetes
Medical expenditures for those with a diagnosis of diabetes are, on average, approximately 2.3 times higher than what expenditures would be in the absence of diabetes
For the cost categories analyzed, approximately $1 in $5 health care dollars is spent caring for someone with a diagnosis of diabetes, while approximately $1 in $10 health care dollars is attributed to the disease itself
American Diabetes Association. Diabetes Care. 2008;31:
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

39. Health Resource Use Attributed to Diabetes, 2007
Age (years)
Total*
<45
45-64
≥65
Institutional care
Hospital inpatient days
Nursing/residential facility days
2,115
1,269
7,586
11,103
14,562
43,687
24,262
56,059
Outpatient care
Office-based physician visits
Emergency visits
Hospital outpatient and freestanding ambulatory surgical center visits
Home health visits
Hospice care days
Retail prescriptions
7,353
1,499
1,307 4
15,181
26,552
1,984
2,535
8,939 22
71,295
30,808
2,084
1,888
18,449
165
88,841
64,713
5,567
5,730
27,388
192
175,317
These data illustrate the estimated health resource use attributed to diabetes by type of service, aggregated into the age categories younger than 45 years; years, and older than 65 years of age
The population group aged 65 years and older was found to use a large proportion of services, reflecting the burden diabetes places on the Medicare program
*Numbers do not necessarily sum to totals because of rounding
American Diabetes Association. Diabetes Care. 2008;31: Table 5.
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

40. Indirect Costs Attributed to Diabetes, 2007
Cost component
Productivity loss
Total cost attributable to diabetes ($ billions)
Proportion of indirect costs (%)
Work days absent
15 million days
2.6 4
Reduced performance at work
120 million days
20.0 34
Reduced productivity days for those not in labor force
6 million days
0.8 1
Permanent disability
445,000 people, 107 million days
7.9 14
Mortality
284,000 deaths
26.9 46
Total
58.2
100
The number of workdays absent because of diabetes in 2007 was estimated at 15 million, at a national cost of $2.6 billion
Reduced performance at work, or “presenteeism,” was estimated at 120 million lost workdays, with an estimated national cost of $20 billion
The estimated productivity loss for those not in the labor force was equivalent to 6 million days, with a national cost of $800 million
At any given time during 2007, approximately 16 million people were unemployed and receiving Supplemental Security Income (SSI) payments due to disability
More than 1 million of these people had diabetes
More than 445,000 cases of unemployment were attributed to diabetes, equating to 107 million lost workdays at a national cost of $7.9 billion
An estimated 284,000 deaths in 2007 were attributed to diabetes (see Slide 26)
Total cost attributable to diabetes was $58.2 billion
American Diabetes Association. Diabetes Care. 2008;31: Table 14.
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

41. Mortality Costs Attributed to Diabetes, 2007
Primary cause of death
Total US deaths
Deaths attributed to diabetes
Deaths
% of total of US deaths
Value of lost productivity (millions of dollars)
Diabetes
77,000
100.0
9,520
Renal disease
43,000
25,000
57.4
2,116
Cerebrovascular disease
155,000
59,000
37.6
3,849
Cardiovascular disease
739,000
123,000
16.5
11,417
Total
NA*
284,000
26,902
An estimated 284,000 deaths in 2007 were attributed to diabetes, including:
77,000 deaths where diabetes was listed as the primary cause of death
123,000 deaths where cardiovascular disease was listed as the primary cause of death (with 16.5% of national deaths from cardiovascular disease attributed to diabetes)
59,000 deaths where cerebrovascular disease was listed as the primary cause of death; and
5,000 deaths where renal disease was listed as the primary cause of death
Taking into account the age and sex distribution of these deaths, the value of lost productivity from premature mortality is $26.9 billion
*Total comprises mortality for reasons other than those listed here
American Diabetes Association. Diabetes Care. 2008;31: Table 16.
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

42. Economic Costs of Prediabetes and Diabetes, 2007
Higher medical costs: $153 billion
Productivity loss: $65 billion
Total cost: $218 billion+
$174.4 billion for diagnosed diabetes
$18 billion for undiagnosed diabetes
$25 billion for prediabetes
$636 million for gestational diabetes
Total burden for each American, regardless of diabetes status: $700 annually
A cost of Diabetes Model was used to estimate the U.S. economic burden associated with diabetes
Combined information from peer-reviewed literature, government statistics, analysis of national survey and medical claims databases
Diabetes prevalence rates and health care use reflect the Census Bureau’s national 2007 population estimates
The Consumer Price Index (for lost productivity) and its medical component (for medical costs), was used for costs, adjusted to year 2007 dollars
National productivity loss was modeled by combining information from National Health Interview Survey data on workdays lost per year and disability rates; Centers for Disease Control and Prevention estimates on mortality by cause of death; and the literature
These revised estimates suggesting the US national economic burden is even higher: $218 billion, which includes $153 billion in higher medical costs and $65 billion in productivity loss
Specifically, the $218 billion comprises $174.4 billion for diagnosed diabetes, $18 billion for undiagnosed diabetes, $25 billion for prediabetes, and $636 million for gestational diabetes
Regardless of diabetes status, this represents an annual cost of approximately $700 for each American
Dall TM, et al. Health Affairs. 2010;29(2):
Reference
Dall TM, Zhang Y, Chen YJ, Quick WW, Yang WG, Fogli J. The economic burden of diabetes. Health Affairs. 2010;29(2):

43. Reducing the Burden of Diabetes
Burden of diabetes, complications on individuals, health care system significant
Much of the cost is preventable through
Improved diet and exercise
Prevention initiatives to reduce prevalence of diabetes, comorbidities
Improved care for people with diabetes to reduce need for costly complications
Understanding economic cost, major determinants of costs, can help inform, motivate decisions to reduce burden
The burden of diabetes and its complications on the individual and on the health care system is significant and is imposed on all sectors of society
Higher insurance premiums paid by employees, employers
Reduced earnings through productivity loss
Reduced overall quality of life for people with diabetes and their families and friends
Much of this cost is preventable through improved diet and exercise, prevention initiatives to reduce the prevalence of diabetes and its comorbidities, and improved care for people with diabetes to reduce the need for costly complications
Improved understanding of the economic cost of diabetes and the major determinations of costs helps to inform and motivate decisions that can reduce the national burden of this disease
American Diabetes Association. Diabetes Care. 2008;31:
Reference
American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care. 2008;31:

44. Future projections Section 3
Section 3, Future Projections, examines International Diabetes Federation global projections for the number of people with diabetes, as well as the number of people with diabetes ages years, 2010 and 2030, by the top 10 countries
In addition, a model provides an estimate of the future burden of diabetes through 2050
Future projections

45. IDF Global Projections for Number of People with Diabetes, 2010-2030
This slide illustrates International Diabetes Foundation (IDF) regions and global projections (in 2009) for the number of people with diabetes ages years,
In 2010, an estimated 285 million adults worldwide have diabetes, nearly 7% of the adult population
Conservative estimates predict that by 2030, 438 million people will have diabetes, almost 8% of the adult population
The greatest increases will occur in Africa and the Middle East and North Africa, followed by South-East Asia and South and Central America
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Reference
International Diabetes Foundation. IDF Diabetes Atlas, 4th ed Available at:

46. Estimated Number of People with Diabetes Worldwide, 2010 and 2030
Country/Territory
2010
Millions
2030 1
India
50.8
87.0 2
China
43.2
62.6 3
USA
26.8
36.0 4
Russian Federation
9.6
Pakistan
13.8 5
Brazil
7.6
12.7 6
Germany
7.5
Indonesia
12.0 7
7.1
Mexico
11.9 8
Japan
Bangladesh
10.4 9
7.0
10.3 10
6.8
Egypt
8.6
In 2009, the International Diabetes Federation estimated the number of people with diabetes ages years in 2010 and 2030 by top 10 country (or territory)
India, China, and the United States had the greatest number of people with diabetes in 2010, and these countries are expected not only to maintain this ranking but see their population of those with diabetes increase by more than 65 million
IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.
Reference
International Diabetes Foundation. IDF Diabetes Atlas, 4th ed Available at:

47. Modeling the Future U.S. Burden of Diabetes Through 2050
Constructed system of dynamic equations
Initial prevalence (percentage of population with diagnosed/undiagnosed diabetes)
Incidence (percentage of population with newly diagnosed diabetes)
Migration
Mortality
Prevalence of prediabetes
Equations used to model future burden of diabetes on U.S. adults through 2050
Accurate projections of the burden of diabetes are essential to help determine future health care needs and costs
Boyle et al used data on prediabetes and diabetes prevalence in the US, forecasted incidence, and U.S. Census projections of migration and mortality to construct a series of dynamic models to project the future burden of diabetes among U.S. adults through the year 2050
Boyle JP, et al. Popul Health Metr. 2010;8:29.
Reference
Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29.

48. Annual U.S. Diabetes Burden in 2050
By 2050, prevalence of total diabetes (diagnosed and undiagnosed) is projected to increase from 1 in 10 adults to between 1 in 5 and 1 in 3 adults
Incidence: from 8 in 1000 to 15 in 1000
Largely attributed to three key factors
Aging of the U.S. population
Increasing size of higher-risk minority populations
Declining mortality among those with diabetes
Results indicate that by the year 2050, the prevalence of total diabetes, both diagnosed and undiagnosed, is projected to increase from 1 in 10 U.S. adults to between 1 in 5 and 1 in 3 adults
The annual incidence of new cases of diagnosed diabetes is projected to increase from 8 cases per 1000 in 2008 to approximately 15 cases per 1000 by the year 2050
The projected increases are largely attributed to three key demographic factors
The aging of the US population
Increasing size of higher-risk minority populations in the population; and
Declining mortality among people with diabetes
Boyle JP, et al. Popul Health Metr. 2010;8:29.
Reference
Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29.

49. Total U.S. Adult Population Diabetes Prevalence Projections
This figure illustrates projections of total diabetes prevalence as a percentage of the total U.S. adult population for four scenarios
Low incidence projections and r1=1.77, r2=2.11; low incidence projections and r1=1.00 and r2=4.08; middle incidence projections and r1=1.77, r2=2.11; middle incidence projections and r1=1.00, r2=4.08
[Data not shown]
Total diabetes prevalence is projected to increase from 14% of the U.S. adult population in to as high as 33% in 2050, based on the following scenarios:
Low incidence, high mortality: to 21%
Middle incidence: to 25% to 28%
High incidence, low mortality: to 33%
Boyle JP, et al. Popul Health Metr. 2010;8:29.
Reference
Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29.