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Scientific Data Documentation
Diabetes Supplement, 1991ABSTRACT General Information Diabetes Surveillance, 1991 The Division of Diabetes Translation National Center for Chronic Disease Prevention and Health Promotion Acknowledgments Editor: Linda S. Geiss Contributors: Frank DeStefano, Barbara L. Dougherty, Mark S. Eberhardt, Earl S. Ford, Robert R. German, William H. Herman, Merilyn G. Goldschmid,, Jeffrey M. Newman, David R. Olson, Todd W. Pierce, Stephen J. Sepe, John M. Stevenson, Frank Vinicor, Scott F. Wetterhall, Julie C. Will Secretarial support: Myra A. Montalbano Description Public health surveillance is the ongoing and systematic collection, analysis, and dissemination of health data for public health action. Surveillance data are important for formulating policy, identifying high-risk groups, targeting interventions, and evaluating progress in disease prevention and control. Diabetes mellitus is a major cause of morbidity and premature mortality in the United States, and surveillance is essential for developing and evaluating public health strategies to reduce the burden associated with diabetes and for monitoring progress toward the national health objectives for the year 2000. In 1990, the Division of Diabetes Translation (DDT), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, established a framework for an ongoing surveillance system to compile national data on diabetes and its complications. In establishing this framework, DDT identified and evaluated data sources providing periodic and representative data on the disease burden associated with diabetes and its complications in the United States. These data sources, which included vital statistics, the National Health Interview Survey, the National Hospital Discharge Survey, and Medicare claims data for end-stage renal disease, were analyzed to estimate diabetes prevalence and incidence, mortality, hospitalization, cardiovascular disease, lower extremity amputation, diabetic ketoacidosis, and end-stage renal disease. The results of these analyses were reported in Chapters 2 through 8 of DDT's first surveillance report, Diabetes Surveillance, 1980-1987. The current report reprints Chapters 2 through 8 from the first report. These chapters describe methods and operational definitions and discuss the implications of the findings. The update sections of each chapter briefly highlights and, in some cases, slightly modifies these findings in light of one additional year of hospitalization data, two additional years of mortality, prevalence, and incidence data, and three additional years of Medicare data on end-stage renal disease. In addition, Medicare data on end- stage renal disease for years 1980-1986 have been updated. The 1991 report also contains a new chapter,"Disability," which addresses that important aspect of the disease burden of diabetes. We evaluated temporal trends by age, sex, and race. For most topics, we could only evaluate race-specific results for whites and blacks because racial designation for other groups was not adequate or because the number of persons in the sample was not sufficient to calculate stable estimates. Where possible, we provide data by region of the country or state. Regional estimates are classified according to the four major Bureau of the Census regions (Figure 1.1). State-specific data could only be obtained for mortality and end-stage renal disease. Since we generally limit the presentation of detailed results to specific subgroups for which we are able to obtain relatively stable estimates, the extent of subgroup information varies by data source. This report contains a section of detailed data tables upon which we base discussions of the disease burden of diabetes. In these detailed tables, totals may not equal the sum of the individual cell counts because of unknowns, rounding, or the presentation of race-specific results for whites and blacks only. In most instances, we calculated rates based on two different denominators. First, rates were calculated using the resident population of the United States as the denominator. These general population rates indicate the disease burden of diabetes in the U.S. population and are useful for comparison with the disease burden of other diseases and conditions. The general population rates are also useful for assessing the prevalence of diabetes and its complications and for estimating health care needs. Second, we calculated rates using estimates of the number of persons known to have diabetes in the United States as the denominator. These diabetic population rates are affected by differences in diabetes prevalence among different age, sex, or race groups and indicate the risk of various complications among persons with diabetes. They are useful for comparing complication rates among subgroups of people with diabetes. In several analyses, we standardized the results. For rates based on the general population denominators, we standardized the rates to the 1980 resident population of the United States (Tables 1.1-1.7). For rates based on diabetic population denominators, we standardized rates to estimates of the 1980 population of persons with diabetes in the United States (Table 2.1). We were not able to distinguish persons with insulin-dependent diabetes mellitus (IDDM, or Type I diabetes) from those with non-insulin-dependent diabetes mellitus (NIDDM, or Type II diabetes) in any of the analyses. Because NIDDM is much more common after 45 years of age and because it accounts for 90% or more of patients with diabetes in the United States, the results presented for persons aged 45 and older pertain mostly to NIDDM. We are aware that each of the data sources used has limitations. These limitations are discussed within each chapter. The analysis of surveillance data can indicate general trends and differences between groups, but usually the information available is not sufficient to provide reasons for observed differences and trends. Identifying differences and trends, however, can be useful in pointing out areas and raising questions for more specific and rigorous research. We believe the data we have used are adequate for public health surveillance. They should be useful for formulating public health strategies to decrease disease burden related to diabetes and for monitoring progress toward this goal.PREVALENCE AND INCIDENCE Introduction We present data on the prevalence and incidence of diabetes in the United States during 1980-1987. The data are limited to those persons who were diagnosed and were aware they had diabetes. Prevalence is the total number of persons known to have diabetes at a particular point in time, whereas incidence is the number of persons who discovered they had diabetes for the first time during the preceding year. Incidence, in general, is a more sensitive indicator of trends related to the etiology of diabetes. Prevalence, on the other hand, is a measure of the disease burden of diabetes, which is useful for public health planning purposes. We present results by calendar year, age, sex, race, and geographic region. The estimated number of persons with diabetes presented here will be used in subsequent chapters to calculate mortality and morbidity rates among persons with the disease. Methods Incidence and prevalence of self-reported diabetes were determined from the 1980-1987 National Health Interview Surveys (NHIS). The NHIS is a national health survey which has been continuously conducted since 1957. Approximately 800 households are surveyed each week, totaling about 130,000 persons interviewed each year. Each person interviewed represents approximately 1,800 persons within the United States. The NHIS is designed as a multistage cluster sample survey. Households are selected to represent a small geographic unit, such as a county, a small group of contiguous counties, or a standard metropolitan statistical area. When information gathered from these households is combined, the health status of the civilian, non-institutionalized population in four U.S. Bureau of the Census regions can be analyzed: Northeast, North Central, South, and West. State-level data are not available from the NHIS. The NHIS questionnaire consists of two basic parts: core and supplements. The core interview is administered each year, and the supplements can change each year. Chronic disease questions, including questions about diabetes, are included on condition lists which are administered as part of the core questionnaire. A one-third sample of respondents in 1980 and 1981 were asked questions about diabetes as were a one-sixth sample of the respondents during 1982-1987. The condition list for diabetes asks the following questions: 1) "During the past 12 months, did anyone in the family have diabetes?" 2) "Who was this?" and 3) "During the past 12 months, did anyone else have diabetes?" If a person in the household has diabetes, when the person was diagnosed is ascertained. In 1987, more than 20,000 persons were asked to respond to the question regarding diabetes in their family. For each year of data analyzed, diabetes prevalence was determined by counting the number of persons in a household with diabetes and projecting the number to reflect either a regional or national estimate. Diabetes incidence was calculated by counting only those persons who reportedly discovered their diabetes during the past 12 months. We calculated incidence and prevalence rates and their relative standard errors using the SESUDAAN computer software package (Shah, 1981). In calculating annual incidence and regional prevalence rates, we found it necessary to pool three years of data to develop precise estimates. These estimates were obtained by using three-year moving averages. To interpret yearly trends, we age-adjusted the prevalence and incidence rates to remove any influence of a changing age structure of the population. The age-adjusted diabetes prevalence and incidence rates were calculated by direct standardization (Fleiss, 1981) using the 1980 U.S. resident population as the standard.Results Prevalence In 1987, 6.8 million persons in the United States were known to have diabetes (Table 2.1). From 1980 to 1987, the number of persons with diabetes increased by more than one million (Figure 2.1). Population subgroups with the greatest relative increases between 1980 and 1987 in the number of persons diagnosed with diabetes were the following: 1) those persons younger than age 45 years (35% increase); 2) those aged 75 years and older (39% increase); 3) white males (33% increase); and 4) black females (24% increase) (Tables 2.1-2.5). The large increase among white males was attributable to almost a doubling of diagnosed diabetes among the youngest age group (less than 45 years). Meanwhile, the large increase among black females was from a doubling of diagnosed diabetes in the 75 years and older age group. Although the numbers fluctuated from year to year, the overall trend in the various groups was toward an increased number of persons diagnosed with diabetes. From 1980 to 1987, the prevalence rate of diabetes in the United States increased (Figure 2.2, Table 2.1). The increase cannot be attributed to differences in age structure of the population from year to year. The age-adjusted prevalence rate was stable from 1980-1982, dipped slightly in 1983, and then increased steadily up to 1986. Trends in prevalence rates were similar to the trends noted among numbers of persons with diabetes. Black females and white males had the largest increases in diabetes prevalence rates (Figure 2.3, Tables 2.2-2.5). These increases resulted from the large increases in diagnosed diabetes among young white males and older black females. In general, the prevalence rate of diabetes increased with increasing age (Tables 2.1-2.5). In 1987, black females had the highest age-specific rates, and about one in four black women 75 years or older had diabetes (Figure 2.4). In 1987, the North Central region had the lowest age-adjusted prevalence rate of the four regions (Table 2.6). From 1980 to 1987, the prevalence rate increased in all regions except the North Central (Figure 2.5). The greatest overall increases in the prevalence rate occurred in the Northeast and West (17%-18%). We present average prevalence rates during 1980-1987 by race, sex, and age for the different regions (Tables 2.7-2.10). The highest age-adjusted prevalence rates among white males occurred in the Northeast region (Table 2.7). This resulted from high rates among men aged 65 years and older. Among white females, the highest age-adjusted rate occurred in the South (Table 2.8). This increase occurred because of higher rates among women less than age 65 years. For black males, the highest diabetes rates occurred in the West--the rates were especially high among black men 45 through 74 years old (Table 2.9). The second highest age-adjusted rate for black males occurred in the Northeast region as a result of high rates in persons aged 65 years and older. Among black females, the highest rates occurred in the North Central and South regions (Table 2.10). The South had prevalence rates of approximately 200 per 1,000 black women aged 65 years and older. Incidence We present the incidence rates of diabetes for various population subgroups (Tables 2.11-2.15). The rate of new diabetes cases in the total population increased from 1980 to 1983 and then leveled off (Figure 2.6). Among white females the incidence rate increased during 1980-1987, whereas among white males the rate decreased (Figure 2.7). We did not conduct separate analyses of black males and females because sample sizes were too small. The lowest age-specific incidence rates in all years occurred among persons aged 0-44 years (Table 2.11). In 1986 and 1987, the incidence rate was highest among those 65 years or older, whereas in previous years the incidence rate among 45- to 64-year-old persons was similar to or higher than the rate among persons aged 65 years and older. There was no definite temporal trend apparent for persons less than 65 years old. Among those persons 65 years old and older, however, the incidence rate tended to increase, from slightly more than 5.6 per 1,000 in the early 1980s to more than 8 per 1,000 in 1986 and 1987. The increasing incidence rate in the oldest age group was most evident in females, among whom the rate increased from 6.3 per 1,000 in 1980 to 10.6 per 1,000 in 1987 (Table 2.13). Discussion During 1980-1987, the number of persons known to have diabetes increased by more than 1 million, such that by 1987 nearly 7 million persons in the United States knew that they had diabetes. This increase was related to both growth in the United States population and an increase in the prevalence rate of diabetes. The prevalence rate of diabetes has been increasing since 1959, but the rate of increase appears to be leveling off. Prevalence rates estimated from NHIS data from 1959 to 1987 have shown the following increases: 1) 67% from 1959 to 1966; 2) 41% from 1966 to 1973; 3) 21% from 1973 to 1980; and 4) 9% from 1980 to 1987. During 1980-1987, diabetes prevalence rates were higher among blacks than whites. Black males had a rate 1.4 times higher than white males--black females had a rate approximately two times higher than white females. Black women aged 75 years and older had the highest rate, with almost one in four having diabetes. We could not estimate incidence rates for blacks and other minorities because the sample sizes were too small to provide precise estimates. Overall, the South had the highest diabetes prevalence rate and the highest rate among women. Black males had the highest rate in the West and in the Northeast. Because prevalence is influenced by both disease incidence and duration (i.e., mortality rates), we have noted only small changes in the prevalence rate. Our results suggest an increase in diabetes incidence in the early 1980s with a leveling off after 1983. Mortality rates among persons with diabetes decreased slightly during 1980-1987 (Chapter 3). Relying on self-report for estimating incidence and prevalence of diabetes has two potential drawbacks: 1) inaccurate reporting of disease status; and 2) incomplete disease ascertainment. Recent research indicates excellent agreement between self-report and medical records concerning a person's diabetes status (Bush et al., 1989). Thus, self-report adequately estimates the incidence and prevalence of diagnosed diabetes. A substantial number of persons with diabetes, however, are not diagnosed. According to the second National Health and Nutrition Examination Survey (NHANES II), about half of the persons with diabetes have not been diagnosed (Harris et al., 1987). Thus, the NHIS undoubtedly underestimates the true prevalence of diabetes. For surveillance of temporal trends, diabetes cases not diagnosed would not be an impediment if the degree of underascertainment were constant over time and similar among different population groups. From NHANES II, the proportion of persons with undiagnosed diabetes was similar among males and females and among blacks and whites (Harris et al., 1987). Thus, differences among race and sex groups we have noted probably do not result from differences in disease ascertainment. We do not suspect that diabetes ascertainment changed from 1980 to 1987, but we cannot be certain until NHANES III, currently being conducted, is completed. Unstandardized diagnostic techniques and criteria also can cause the rate of diabetes to fluctuate (West, 1978). Because diagnostic criteria for diabetes have been standardized since 1979 (National Diabetes Data Group, 1979), we believe that changing diagnostic criteria have had very little impact on diabetes trends during 1980-1987. Random variation may have influenced our results, but we have tried to minimize the impact by presenting results that have less than 30% relative standard errors. Thus, we restricted race-specific incidence results to whites and used wide age groupings for all age-specific results. Data from NHIS indicate that the number of persons with diabetes is increasing, that blacks have higher prevalence rates than whites, and that the incidence rate is highest among women older than 64 years and is increasing in this group. As the population ages, we can expect that the number of persons with diabetes will continue to grow unless effective strategies are identified to prevent its occurrence. Update This section updates data presented in previous sections in light of two additional years of prevalence and incidence data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. Prevalence In 1989, about 6.7 million persons in the United States (2.7% of the population) reported that they had diabetes (Table 2.1). Although the prevalence of diabetes has increased since 1959, the overall rate of increase has slowed and leveled off. Diabetes prevalence as estimated from National Health Interview Survey (NHIS) data has increased as follows: 1) 67% increase from 1959 to 1966; 2) 41% increase from 1966 to 1973; 3) 21% increase from 1973 to 1980; and 4) 4% increase from 1980 to 1989. During the 1980s, diabetes prevalence was higher among blacks than whites (Figure 1.2, Tables 2.2-2.5). Black females aged 65 years and older had the highest rates. Black males were the only race-sex group to show a marked increase in prevalence during the 1980s, increasing 28% between 1980 and 1989. Incidence In 1989, there were 677,000 new cases of diabetes (Table 2.11). The rate of new diabetes cases (i.e., diabetes incidence) increased in the early 1980s and then leveled off (Figure 1.3). The lowest age-specific incidence rates occurred among persons younger than age 45. Throughout the 1980s, white females had higher incidence rates than white males (Tables 2.14-2.15). Incidence rates for black males and black females could not be examined because of small sample sizes. Detailed Tables 1.1-1.7 Resident Population by Age and Year, U.S., 80-89 1.1 Age and Year Table 1.1 Resident Population (a), by Age and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-4 16457 16931 17297 17651 17830 18004 5-9 16608 16094 16022 16149 16467 16826 10-14 18236 18314 18172 17913 17511 17101 15-19 21104 20503 19889 19277 18789 18555 20-24 21379 21614 21587 21487 21325 20993 25-29 19697 20202 20756 21205 21540 21764 30-34 17753 18787 18809 19213 19698 20271 35-39 14080 14379 15597 16161 16929 17706 40-44 11725 12019 12449 13134 13614 14057 45-49 11048 10991 11026 11228 11461 11646 50-54 11698 11614 11452 11207 11026 10936 55-59 11615 11577 11508 11524 11439 11336 60-64 10145 10372 10596 10695 10859 10980 65-69 8812 8917 9038 9181 9285 9432 70-74 6840 6996 7157 7310 7449 7573 75-79 4827 4951 5085 5223 5360 5499 80-84 2953 3017 3091 3166 3244 3330 85+ 2269 2353 2449 2538 2623 2694 Total 227247 229630 231981 234260 236448 238703 (a) In thousands. Table 1.1 Resident Population (a), by Age and Year, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-4 18157 18279 18459 18754 5-9 17300 17667 18034 18212 10-14 16567 16487 16630 16951 15-19 18616 18465 18222 17813 20-24 20407 19785 19178 18702 25-29 22013 21986 21886 21699 30-34 20778 21337 21804 22136 35-39 18723 18737 19142 19622 40-44 14351 15572 16129 16883 45-49 11927 12351 13030 13522 50-54 10882 10920 11131 11374 55-59 11267 11120 10892 10725 60-64 10947 10881 10918 10865 65-69 9661 9885 9992 10170 70-74 7670 7776 7901 8011 75-79 5635 5772 5898 6031 80-84 3418 3517 3615 3727 85+ 2776 2863 2947 3041 Total 241096 243400 245807 248239 (a) In thousands. 1.2 Age and Year, White Males Table 1.2 Resident Population (a) of White Males, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 6923 7104 7238 7370 7434 7496 5-9 6987 6742 6699 6747 6863 6990 10-14 7725 7740 7649 7504 7305 7099 15-19 8971 8663 8364 8081 7849 7746 20-24 9127 9204 9157 9084 8991 8807 25-29 8441 8646 8863 9046 9175 9253 30-34 7650 8077 8044 8199 8399 8639 35-39 6065 6191 6744 6970 7285 7607 40-44 5016 5137 5318 5628 5836 6025 45-49 4736 4702 4708 4788 4882 4948 50-54 5011 4972 4895 4775 4686 4634 55-59 4923 4886 4840 4848 4811 4771 60-64 4247 4349 4446 4474 4536 4576 65-69 3531 3578 3634 3704 3753 3823 70-74 2595 2658 2723 2789 2849 2904 75-79 1680 1724 1771 1822 1874 1927 80-84 937 956 978 1000 1023 1049 85+ 626 638 654 668 682 692 Total 95191 95966 96725 97498 98231 98986 (a) In thousands. Table 1.2 Resident Population (a) of White Males, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 7541 7573 7634 7716 5-9 7173 7308 7443 7504 10-14 6849 6804 6857 6973 15-19 7757 7664 7527 7327 20-24 8523 8228 7944 7731 25-29 9349 9314 9239 9142 30-34 8850 9074 9261 9385 35-39 8029 7993 8146 8342 40-44 6147 6699 6920 7229 45-49 5062 5241 5546 5758 50-54 4600 4610 4695 4791 55-59 4740 4673 4561 4480 60-64 4540 4499 4517 4498 65-69 3928 4026 4058 4130 70-74 2949 3001 3064 3120 75-79 1980 2036 2088 2147 80-84 1077 1112 1147 1189 85+ 706 722 739 761 Total 99802 100579 101387 102224 (a) In thousands. 1.3 Age and Year, White Females Table 1.3 Resident Population (a) of White Females, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 6571 6744 6876 7000 7061 7119 5-9 6635 6403 6355 6397 6508 6633 10-14 7360 7366 7271 7130 6932 6727 15-19 8634 8345 8063 7779 7558 7445 20-24 8985 9056 9026 8956 8860 8694 25-29 8357 8536 8734 8892 9003 9074 30-34 7663 8063 8008 8140 8313 8526 35-39 6153 6275 6814 7032 7332 7634 40-44 5140 5258 5441 5748 5958 6145 45-49 4913 4866 4864 4942 5033 5098 50-54 5332 5269 5168 5031 4926 4871 55-59 5464 5433 5383 5369 5301 5218 60-64 4882 4974 5065 5096 5162 5209 65-69 4387 4425 4473 4529 4564 4616 70-74 3595 3667 3738 3805 3865 3916 75-79 2700 2766 2837 2908 2977 3044 80-84 1784 1822 1864 1908 1954 2003 85+ 1461 1524 1594 1657 1717 1768 Total 100017 100792 101572 102317 103023 103741 (a) In thousands. Table 1.3 Resident Population (a) of White Females, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 7164 7194 7252 7335 5-9 6807 6938 7067 7124 10-14 6491 6442 6489 6601 15-19 7448 7349 7214 7015 20-24 8410 8125 7849 7628 25-29 9155 9127 9064 8960 30-34 8706 8907 9074 9182 35-39 8031 7975 8111 8283 40-44 6267 6811 7026 7321 45-49 5211 5391 5697 5915 50-54 4824 4823 4903 4998 55-59 5159 5062 4930 4830 60-64 5180 5129 5122 5071 65-69 4706 4796 4830 4899 70-74 3949 3990 4036 4074 75-79 3109 3171 3225 3282 80-84 2054 2109 2161 2220 85+ 1825 1884 1940 2000 Total 104497 105224 105990 106737 (a) In thousands. 1.4 Age and Year, Black Males Table 1.4 Resident Population (a) of Black Males, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 1248 1287 1313 1342 1351 1362 5-9 1263 1234 1235 1245 1277 1314 10-14 1350 1362 1367 1367 1356 1347 15-19 1503 1491 1467 1439 1412 1392 20-24 1317 1340 1350 1363 1370 1371 25-29 1106 1149 1201 1242 1277 1302 30-34 891 963 999 1036 1076 1119 35-39 671 682 721 757 809 861 40-44 572 585 604 623 638 653 45-49 519 522 527 538 550 563 50-54 508 510 511 512 513 514 55-59 470 478 486 491 496 500 60-64 389 398 408 420 430 439 65-69 334 338 342 347 353 361 70-74 236 241 246 251 255 259 75-79 154 158 162 165 169 172 80-84 76 77 79 80 82 83 85+ 54 56 58 61 63 65 Total 12659 12870 13074 13279 13475 13678 (a) In thousands. Table 1.4 Resident Population (a) of Black Males, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 1380 1400 1423 1469 5-9 1354 1383 1412 1423 10-14 1314 1315 1327 1362 15-19 1403 1408 1408 1394 20-24 1360 1335 1306 1279 25-29 1326 1334 1342 1342 30-34 1162 1213 1254 1289 35-39 930 961 999 1035 40-44 662 699 735 782 45-49 575 594 612 626 50-54 517 523 533 544 55-59 503 505 506 508 60-64 448 455 463 467 65-69 369 380 391 402 70-74 263 266 269 274 75-79 176 180 183 187 80-84 86 88 89 91 85+ 66 68 70 72 Total 13894 14106 14320 14545 (a) In thousands. 1.5 Age and Year, Black Females Table 1.5 Resident Population (a) of Black Females, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 1228 1263 1289 1312 1319 1326 5-9 1242 1213 1210 1218 1247 1284 10-14 1334 1341 1343 1338 1322 1310 15-19 1506 1489 1462 1434 1406 1381 20-24 1440 1463 1470 1480 1479 1476 25-29 1259 1301 1351 1392 1426 1449 30-34 1038 1120 1160 1201 1242 1287 35-39 806 819 866 910 970 1028 40-44 692 708 730 752 769 790 45-49 631 636 643 658 675 692 50-54 629 631 633 633 632 634 55-59 575 583 590 595 598 601 60-64 490 499 510 522 533 543 65-69 448 453 457 461 465 472 70-74 332 342 351 360 367 372 75-79 237 243 250 256 263 270 80-84 126 131 136 141 145 149 85+ 108 113 120 126 133 138 Total 14123 14347 14570 14787 14991 15202 (a) In thousands. Table 1.5 Resident Population (a) of Black Females, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 1340 1357 1380 1421 5-9 1320 1346 1371 1378 10-14 1278 1275 1286 1318 15-19 1386 1387 1384 1365 20-24 1458 1431 1402 1372 25-29 1471 1478 1487 1485 30-34 1329 1378 1420 1455 35-39 1107 1145 1186 1225 40-44 802 847 889 945 45-49 707 729 751 769 50-54 640 646 661 679 55-59 605 607 608 608 60-64 551 557 562 567 65-69 480 491 503 515 70-74 378 381 383 386 75-79 278 285 293 299 80-84 153 157 161 165 85+ 145 152 158 165 Total 15427 15648 15882 16115 (a) In thousands. 1.6 Age and Year, Other Males Table 1.6 Resident Population (a) of Other Males, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 247 270 294 316 336 353 5-9 245 256 266 274 288 305 10-14 238 259 279 294 305 316 15-19 253 268 278 285 295 308 20-24 256 279 297 310 321 332 25-29 254 274 294 307 321 336 30-34 239 265 284 303 321 339 35-39 184 197 215 232 251 270 40-44 149 162 174 185 198 212 45-49 116 125 136 146 157 169 50-54 99 105 111 116 123 130 55-59 86 91 95 99 103 108 60-64 64 70 77 83 91 96 65-69 54 57 61 64 68 72 70-74 41 44 48 50 53 56 75-79 27 29 31 34 36 40 80-84 12 14 15 16 17 19 85+ 8 8 9 10 11 12 Total 2573 2771 2962 3124 3296 3473 (a) In thousands. Table 1.6 Resident Population (a) of Other Males, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 370 381 391 414 5-9 326 349 374 394 10-14 325 332 342 355 15-19 325 343 360 371 20-24 339 344 349 357 25-29 350 362 372 381 30-34 355 373 389 404 35-39 295 315 333 354 40-44 225 244 262 283 45-49 181 192 204 217 50-54 140 150 161 174 55-59 113 119 125 133 60-64 102 106 110 113 65-69 79 86 94 100 70-74 59 62 66 69 75-79 42 45 49 51 80-84 20 21 24 26 85+ 14 15 16 17 Total 3661 3836 4022 4212 (a) In thousands. 1.7 Age and Year, Other Females Table 1.7 Resident Population (a) of Other Females, by Age and Year, United States, 1980-85 Year 1980 1981 1982 1983 1984 1985 Age 0-4 241 265 288 311 330 348 5-9 237 247 258 268 282 299 10-14 228 246 263 280 291 302 15-19 237 247 255 260 269 282 20-24 254 272 287 295 304 312 25-29 280 296 314 326 338 350 30-34 272 299 316 333 347 361 35-39 199 215 238 259 282 305 40-44 156 169 183 198 215 233 45-49 133 140 148 156 165 177 50-54 119 127 134 140 146 153 55-59 97 106 114 122 130 138 60-64 74 82 90 99 108 116 65-69 59 66 72 77 83 89 70-74 40 45 51 56 60 66 75-79 29 32 34 38 42 46 80-84 17 18 20 21 23 26 85+ 13 14 15 17 17 19 Total 2685 2884 3077 3255 3431 3623 (a) In thousands. Table 1.7 Resident Population (a) of Other Females, by Age and Year, United States, 1986-89 Year 1986 1987 1988 1989 Age 0-4 362 373 380 399 5-9 321 344 368 389 10-14 310 318 329 342 15-19 297 314 329 341 20-24 317 322 328 335 25-29 362 372 383 389 30-34 376 393 406 420 35-39 332 348 366 382 40-44 249 273 296 322 45-49 191 204 220 237 50-54 160 168 178 189 55-59 146 154 161 167 60-64 125 135 144 150 65-69 98 106 116 125 70-74 72 77 83 89 75-79 50 55 60 66 80-84 28 30 33 37 85+ 20 22 25 27 Total 3816 4007 4205 4406 (a) In thousands. 2.1-2.5 Prevalence of Diabetes, Age & Year, U.S., 80-89 2.1 Age and Year Table 2.1 Prevalence of Diabetes, by Age and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (a) 1010 952 984 1002 994 1038 Rate (b) 6.4 6.0 6.1 6.2 6.1 6.3 45-64 Number 2389 2544 2567 2599 2359 2330 Rate 53.7 57.1 57.6 58.2 52.7 51.9 65-74 Number 1522 1365 1525 1305 1757 1851 Rate 97.3 85.8 94.2 79.1 105.0 108.9 75+ Number 861 948 810 874 1090 1101 Rate 85.7 91.8 76.3 80.0 97.1 95.5 Total Number 5782 5809 5886 5781 6200 6320 Rate 25.4 25.1 25.2 24.5 25.9 26.2 Age-adjusted Rate 25.4 25.3 25.4 24.7 26.0 26.2 (a) In thousands. (b) Per 1,000 people. Table 2.1 Prevalence of Diabetes, by Age and Year, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (a) 1047 1364 1092 1224 Rate (b) 6.3 8.1 6.4 7.2 45-64 Number 2847 2552 2460 2707 Rate 63.2 56.4 53.5 58.2 65-74 Number 1593 1703 1704 1632 Rate 91.9 96.4 95.2 89.8 75+ Number 1284 1193 1094 1096 Rate 108.6 98.2 87.8 85.7 Total Number 6772 6812 6350 6659 Rate 27.8 27.7 25.6 26.6 Age-adjusted Rate 27.9 27.6 25.4 26.3 (a) In thousands. (b) Per 1,000 people. 2.2 Age and Year, White Males Table 2.2 Prevalence of Diabetes, by Age and Year, White Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (a) 311 369 384 408 354 392 Rate (b) 4.7 5.5 5.6 5.9 5.1 5.6 45-64 Number 917 1017 977 920 813 873 Rate 48.5 53.8 51.7 48.7 43.0 46.1 65-74 Number 595 553 430 417 592 679 Rate 97.1 88.7 67.6 64.2 89.6 101.0 75+ Number 256 228 301 328 324 350 Rate 78.8 68.8 88.4 94.0 90.5 95.5 Total Number 2079 2168 2092 2073 2083 2295 Rate 22.0 22.7 21.6 21.2 21.2 23.2 Age-adjusted Rate 22.9 23.5 22.6 22.2 22.1 24.1 (a) In thousands. (b) Per 1,000 people. Table 2.2 Prevalence of Diabetes, by Age and Year, White Males, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (a) 301 578 484 415 Rate (b) 4.3 8.2 6.8 5.8 45-64 Number 1237 1052 936 1080 Rate 65.3 55.3 48.5 55.3 65-74 Number 625 705 558 535 Rate 90.9 100.3 78.3 73.8 75+ Number 405 420 386 257 Rate 107.6 108.5 97.1 62.8 Total Number 2568 2756 2363 2288 Rate 25.7 27.4 23.3 22.4 Age-adjusted Rate 26.8 28.2 23.9 22.7 (a) In thousands. (b) Per 1,000 people. 2.3 Age and Year, White Females Table 2.3 Prevalence of Diabetes, by Age and Year, White Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (a) 476 420 475 404 439 500 Rate (b) 7.3 6.4 7.1 6.0 6.5 7.4 45-64 Number 980 998 986 1081 1045 913 Rate 47.6 48.6 48.1 52.9 51.2 44.8 65-74 Number 749 617 785 630 802 885 Rate 93.9 76.2 95.6 75.5 95.2 103.8 75+ Number 519 595 425 458 593 594 Rate 87.2 97.4 67.5 70.8 89.2 87.1 Total Number 2723 2630 2670 2572 2879 2893 Rate 26.7 25.6 25.9 24.7 27.4 27.4 Age-adjusted Rate 24.7 23.5 23.9 22.8 25.0 24.9 (a) In thousands. (b) Per 1,000 people. Table 2.3 Prevalence of Diabetes, by Age and Year, White Females, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (a) 591 511 356 547 Rate (b) 8.6 7.4 5.1 7.9 45-64 Number 1071 955 923 1045 Rate 52.6 46.8 44.7 50.2 65-74 Number 677 745 827 801 Rate 78.2 84.7 93.3 89.3 75+ Number 681 535 512 644 Rate 97.4 74.7 69.9 85.9 Total Number 3019 2746 2618 3037 Rate 28.2 25.6 24.2 27.9 Age-adjusted Rate 25.9 23.4 21.8 25.2 (a) In thousands. (b) Per 1,000 people. 2.4 Age and Year, Black Males Table 2.4 Prevalence of Diabetes, By Age and Year, Black Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (a) 73 64 62 37 55 63 Rate (b) 7.4 6.4 6.0 3.5 5.2 5.9 45-64 Number 186 185 180 204 215 222 Rate 98.7 97.2 93.2 104.2 108.3 110.1 65-74 Number 62 68 71 85 88 99 Rate 108.1 116.8 120.1 142.7 145.0 159.2 75+ Number 29 23 25 24 35 34 Rate 103.6 79.3 83.7 79.8 111.6 107.3 Total Number 350 340 337 351 394 418 Rate 28.2 26.9 25.8 26.2 29.1 30.7 Age-adjusted Rate 35.6 37.2 32.4 33.7 42.5 43.1 (a) In thousands. (b) Per 1,000 people. Table 2.4 Prevalence of Diabetes, by Age and Year, Black Males, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (a) 83 91 81 82 Rate (b) 7.6 8.2 7.2 7.3 45-64 Number 204 210 247 276 Rate 99.8 100.9 116.8 128.7 65-74 Number 91 104 85 87 Rate 143.3 160.5 128.6 128.2 75+ Number 39 35 51 54 Rate 119.5 104.4 150.9 155.2 Total Number 417 439 464 499 Rate 30.4 31.6 32.9 34.8 Age-adjusted Rate 38.7 38.2 46.3 45.5 (a) In thousands. (b) Per 1,000 people. 2.5 Age and Year, Black Females Table 2.5 Prevalence of Diabetes, By Age and Year, Black Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (a) 112 97 86 116 109 91 Rate (b) 10.6 9.0 7.9 10.5 9.7 8.1 45-64 Number 251 284 322 301 281 259 Rate 108.2 120.8 135.6 124.9 115.4 104.8 65-74 Number 103 137 160 200 186 183 Rate 132.5 172.3 197.9 243.6 224.0 216.6 75+ Number 71 70 68 84 92 118 Rate 151.2 144.9 134.1 160.1 170.6 211.6 Total Number 538 588 636 700 669 651 Rate 37.7 40.6 43.2 46.8 44.1 42.3 Age-adjusted Rate 43.7 45.0 55.8 53.9 56.9 46.2 (a) In thousands. (b) Per 1,000 people. Table 2.5 Prevalence of Diabetes, by Age and Year, Black Females, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (a) 87 109 135 131 Rate (b) 7.6 9.4 11.4 11.0 45-64 Number 280 280 243 226 Rate 112.0 110.2 94.2 86.2 65-74 Number 144 142 155 176 Rate 167.8 163.5 174.6 195.6 75+ Number 126 147 141 135 Rate 219.7 247.1 230.1 214.7 Total Number 638 678 674 669 Rate 40.9 42.7 41.8 40.9 Age-adjusted Rate 48.2 50.9 51.6 43.4 (a) In thousands. (b) Per 1,000 people. 2.6-2.10 Prevalence Rate of Diabetes per 1,000 Pop., U.S., 80-89 2.6 Region and Year Table 2.6 Prevalence (a) of Diabetes, by Region and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Region Rate Northeast Crude 26.0 25.1 25.3 25.2 26.8 29.5 Age-Adjusted 24.8 23.9 23.9 23.8 25.4 28.1 North Central Crude 24.6 24.8 24.5 25.0 25.6 26.4 Age-Adjusted 24.8 25.1 25.4 25.8 25.9 25.7 South Crude 27.8 27.9 27.8 27.9 27.4 27.5 Age-Adjusted 28.1 28.2 28.1 28.3 27.7 28.1 West Crude 20.8 21.3 20.1 21.0 21.1 22.3 Age-Adjusted 21.9 22.4 21.1 21.4 22.1 23.7 (a) Per 1,000 People Table 2.6 Prevalence (a) of Diabetes, by Region and Year, United States, 1986-1989 Year 1986 1987 1988 1989 Region Rate Northeast Crude 30.4 29.8 26.9 25.9 Age-Adjusted 28.4 27.7 24.9 23.9 North Central Crude 25.7 25.5 26.0 26.8 Age-Adjusted 25.0 25.1 25.8 26.4 South Crude 28.6 28.7 29.2 28.0 Age-Adjusted 29.1 29.1 29.2 28.0 West Crude 23.4 23.1 22.9 22.3 Age-Adjusted 25.5 24.5 24.1 23.4 (a) Per 1,000 People 2.7 Age and Region, White Males Table 2.7 Prevalence Rate of Diabetes per 1,000 Population, by Age and Region, White Males, United States, 1980-1989 Age 0-44 45-64 65-74 75+ Total Age-adjusted Region Northeast 5.6 53.4 97.5 99.2 25.7 25.4 North Central 5.7 53.7 78.8 83.0 22.5 23.6 South 6.2 52.7 92.9 82.5 23.9 24.6 West 4.9 44.6 72.2 85.6 19.2 20.9 2.8 Age and Region, White Females Table 2.8 Prevalence Rate of Diabetes per 1,000 Population, by Age and Region, White Females, United States, 1980-1989 Age 0-44 45-64 65-74 75+ Total Age-adjusted Region Northeast 5.4 47.9 93.4 89.7 27.7 23.5 North Central 7.1 48.7 94.3 79.9 26.5 24.5 South 8.4 52.0 83.0 85.3 27.6 25.5 West 6.1 44.1 80.5 80.0 22.5 21.9 2.9 Age and Region, Black Males Table 2.9 Prevalence Rate of Diabetes per 1,000 Population, by Age and Region, Black Males, United States, 1980-1989 Age 0-44 45-64 65-74 75+ Total Age-adjusted Region Northeast 4.8 111.2 150.9 176.0 30.1 43.3 North Central 3.8 112.8 93.9 106.8 26.8 35.9 South 7.6 87.3 126.8 106.8 27.9 35.8 West 8.2 180.0 214.1 78.2 43.7 59.2 2.10 Age and Region, Black Females Table 2.10 Prevalence Rate of Diabetes per 1,000 Population, by Age and Region, Black Females, United States, 1980-1989 Age 0-44 45-64 65-74 75+ Total Age-adjusted Region Northeast 4.3 93.9 152.4 113.4 30.2 36.9 North Central 11.0 132.6 102.3 150.8 40.2 47.3 South 10.8 115.4 221.2 203.1 47.0 54.3 West 13.8 59.4 93.5 273.2 33.1 39.7 2.11-15 Incidence Rate of Diabetes per 1,000 Pop., U.S., 80-89 2.11 Age and Year Table 2.11 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (b) 179 149 218 159 169 151 Rate 1.07 1.18 1.11 1.14 0.99 1.10 45-64 Number 191 243 367 363 319 294 Rate 4.94 6.07 7.34 7.91 7.34 6.54 65+ Number 172 103 128 168 145 235 Rate 5.65 5.44 5.25 5.68 6.91 6.73 Total Number 541 495 713 690 633 679 Rate 2.34 2.61 2.79 2.96 2.88 2.79 Age-adjusted Rate 2.35 2.62 2.80 2.98 2.90 2.80 (a) Three-year moving average (b) In thousands Table 2.11 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (b) 218 226 265 256 Rate 1.21 1.43 1.50 1.56 45-64 Number 260 215 256 335 Rate 5.73 5.41 5.90 6.45 65+ Number 165 290 156 86 Rate 8.34 7.25 6.18 4.18 Total Number 644 731 678 677 Rate 2.90 2.87 2.89 2.80 Age-adjusted Rate 2.90 2.87 2.89 2.81 (a) Three-year moving average (b) In thousands 2.12 Age and Year, Males Table 2.12 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (b) 45 84 110 14 26 56 Rate 0.85 1.04 0.89 0.63 0.40 0.69 45-64 Number 108 134 208 164 112 115 Rate 5.81 7.19 8.05 7.70 6.18 5.26 65+ Number 61 33 10 77 50 93 Rate 4.67 3.40 3.84 4.31 6.78 4.83 Total Number 215 251 328 255 189 263 Rate 2.18 2.45 2.53 2.32 2.11 1.95 Age-adjusted Rate 2.26 2.51 2.62 2.43 2.25 2.05 (a) Three-year moving average (b) In thousands Table 2.12 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, Males, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (b) 85 83 131 51 Rate 0.92 1.21 1.06 1.09 45-64 Number 107 112 133 188 Rate 5.22 5.46 6.63 7.31 65+ Number 17 91 54 43 Rate 5.91 4.66 5.28 4.06 Total Number 210 286 318 282 Rate 2.22 2.35 2.53 2.56 Age-adjusted Rate 2.32 2.43 2.63 2.64 (a) Three-year moving average (b) In thousands 2.13 Age and Year, Females Table 2.13 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (b) 134 65 108 145 143 95 Rate 1.29 1.31 1.34 1.65 1.58 1.51 45-64 Number 82 108 159 199 207 179 Rate 4.15 5.05 6.69 8.10 8.38 7.70 65+ Number 111 71 119 91 95 142 Rate 6.33 6.86 6.24 6.63 6.99 8.05 Total Number 327 245 385 435 444 416 Rate 2.49 2.76 3.02 3.55 3.61 3.57 Age-adjusted Rate 2.42 2.67 2.94 3.47 3.52 3.46 (a) Three-year moving average (b) In thousands Table 2.13 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, Females, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (b) 133 143 135 206 Rate 1.50 1.65 1.92 2.02 45-64 Number 153 102 124 147 Rate 6.19 5.36 5.23 5.67 65+ Number 148 199 102 42 Rate 10.05 9.07 6.81 4.26 Total Number 434 445 360 395 Rate 3.54 3.35 3.22 3.02 Age-adjusted Rate 3.39 3.22 3.13 2.99 (a) Three-year moving average (b) In thousands 2.14 Age and Year, White Males Table 2.14 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, White Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (b) 45 74 79 14 26 56 Rate 0.93 1.02 0.85 0.60 0.47 0.76 45-64 Number 96 109 177 94 53 103 Rate 5.52 6.85 6.80 5.78 4.44 4.65 65+ Number 61 22 10 65 50 93 Rate 4.59 3.38 3.45 4.35 7.10 5.33 Total Number 203 206 266 174 129 251 Rate 2.22 2.42 2.28 1.99 1.92 1.99 Age-adjusted Rate 2.25 2.43 2.31 2.04 2.00 2.04 (a) Three-year moving average (b) In thousands Table 2.14 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, White Males, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (b) 73 71 93 51 Rate 0.97 1.14 1.03 1.04 45-64 Number 107 47 112 149 Rate 4.53 4.66 5.35 6.78 65+ Number 17 74 50 43 Rate 5.98 4.47 5.20 4.31 Total Number 198 192 254 243 Rate 2.18 2.17 2.32 2.50 Age-adjusted Rate 2.23 2.21 2.35 2.53 (a) Three-year moving average (b) In thousands 2.15 Age and Year, White Females Table 2.15 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, White Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 Number (b) 96 60 108 102 125 86 Rate 1.21 1.35 1.37 1.68 1.56 1.69 45-64 Number 82 94 121 159 170 126 Rate 4.36 4.90 6.14 7.37 7.44 7.14 65+ Number 101 61 97 80 73 125 Rate 6.23 6.52 5.83 5.99 6.57 8.03 Total Number 279 216 325 342 368 338 Rate 2.53 2.77 2.94 3.42 3.43 3.66 Age-adjusted Rate 2.39 2.63 2.80 3.28 3.28 3.48 (a) Three-year moving average (b) In thousands Table 2.15 Incidence Rate (a) of Diabetes per 1,000 Population, by Age and Year, White Females, United States, 1986-1989 Year 1986 1987 1988 1989 Age 0-44 Number (b) 133 105 99 173 Rate 1.58 1.64 1.83 1.97 45-64 Number 141 67 98 113 Rate 5.47 4.99 4.52 5.11 65+ Number 148 92 102 36 Rate 8.32 7.65 5.06 4.53 Total Number 422 264 299 323 Rate 3.30 3.15 2.82 2.96 Age-adjusted Rate 3.11 2.97 2.72 2.88 (a) Three-year moving average (b) In thousands MORTALITY Introduction In 1986, diabetes mellitus was the seventh leading cause of death in the United States (National Center for Health Statistics, 1988) and the 13th leading cause of years of potential life lost before age 65 (Centers for Disease Control, 1988). Because these statistics are based on underlying cause of death, however, they understate diabetes' overall impact on mortality. Previous studies have shown that diabetes is selected as the underlying cause on approximately one quarter of the death certificates on which it appears in any field, and diabetes is recorded on only half of the certificates for persons who have the disease at the time of death (Harris and Entmacher, 1985). Thus, diabetes contributes to a much larger number of deaths than it directly causes. We describe the number of deaths resulting from diabetes, and the associated mortality rates, for 1980 through 1986. We examine diabetes both as an underlying cause and as any listed (either underlying or contributory) cause of death. We evaluate the number and rates of deaths from diabetes by age, race, sex, calendar year, and state. We determine mortality rates for the general US population, as well as rates among persons with diabetes. Other mortality rates of interest are presented somewhere else. These include mortality rates for cardiovascular disease among persons with diabetes (Chapter 5) and mortality rates associated with diabetic ketoacidosis (Chapter 7). Methods To enumerate deaths from diabetes during 1980 through 1986, we used mortality data provided by the National Center for Health Statistics (NCHS). The NCHS creates national mortality data tapes by abstracting and coding medical information, including underlying and contributing causes of death, recorded on vital records from each state. The underlying cause of death is selected according to standard criteria (including order) that determine which cause or contributing factor listed on the death certificate presides over others that may be listed. For each record on the mortality tape, a single underlying cause and a maximum of 20 contributory causes of death may be coded. We identified deaths attributable to diabetes (as either the underlying or contributing cause) by using rubric 250 of the 9th Version of the International Classification of Diseases. We used 1980 census estimates, and intercensal estimates for subsequent years, for calculating diabetes mortality rates in the general population. To determine diabetic persons' risks of dying from their disease, we calculated mortality rates for the U.S. population known to have diabetes. We estimated the number of persons with diabetes using information from annual Health Interview Surveys (Chapter 2) and used this estimate as the denominator in calculating mortality rates for persons known to have diabetes. Because the Health Interview Survey provides national or regional estimates, rather than state-specific estimates, of the diabetic population in the United States, we restricted our analysis of state diabetes mortality to general population rates. Mortality rates were standardized according to the direct method (Fleiss, 1981). We used the 1980 resident population of the United States to standardize rates in the general population and the estimated 1980 diabetic population to standardize diabetes-specific mortality rates. Results Diabetes Mortality in the General Population The annual number of deaths attributed to diabetes as an underlying cause steadily increased from 1980 to 1986, reaching 37,184 in 1986 (Figure 3.1). Between 1980 and 1986, the age-standardized mortality rates for diabetes as the underlying cause of death among U.S. residents declined 4.6%--from 15.3 to 14.6 per 100,000 population (Figure 3.2, Table 3.1). Most of the secular decline in mortality rates occurred among persons 65 years and older; rates in other age groups stayed about the same (Table 3.1). In each year, mortality rates increased with age, particularly after age 55. During these 7 years, age-adjusted mortality rates decreased for white males and females, while the corresponding rates for black males and females were unchanged (Tables 3.2-3.5). Diabetes-related mortality includes those deaths for which diabetes was listed as either an underlying or contributing cause on the vital record. In each year, the number of diabetes-related deaths was about four times the number of deaths in which diabetes was the underlying cause. The number of diabetes-related deaths increased each year and reached 150,000 in 1986 (Table 3.6). Age-adjusted mortality rates, however, for diabetes-related deaths declined 1.8% between 1980 and 1986 (Figure 3.2). As with mortality rates for diabetes as an underlying cause, most of the decline in rates during these years was seen among persons 65 years and older. Temporal trends in mortality rates for diabetes as any listed cause varied by race and sex (Figure 3.3). The age-standardized rates for white males and white females generally reflect the temporal trends seen in the total population. Between 1980 and 1986, the rates for white males and females declined 1.6% and 4.5%, respectively (Tables 3.7-3.8). The corresponding mortality rates for black males and females, however, increased 11% and 5.5%, respectively (Tables 3.9-3.10). Black females, the group with the highest mortality rates, had annual mortality rates that were two-fold higher than those for white females. Mortality rates for black males were 20%-40% higher than those for white males. We present annual unadjusted state-specific mortality rates for diabetes-related deaths (Table 3.11). The large variability in state-specific mortality rates reflects, in part, demographic differences among state populations. After adjustment for age and race, this variability diminishes, with average annual mortality rates (per 100,000) ranging from 37.3 in Arkansas to 76.7 in Rhode Island (Table 3.12). These state-specific rates are grouped by quartile (Figure 3.4). States with rates in the highest quartile appear to be located primarily in the Northeast and in the region surrounding the Great Lakes. Mortality Rates of Persons with Diabetes Among the diabetic population, the age-adjusted mortality rate for diabetes as the underlying cause of death declined 14.5% between 1980 and 1986 (Figure 3.5). This temporal trend, however, was somewhat erratic, with small rate increases noted during the periods 1981-1983 and 1984-1985. During these seven years, trends in age-specific mortality rates varied (Table 3.13). Rates clearly fell for persons aged 75 years and older. Mortality declines were also seen for persons aged 45 to 74, but these trends are less striking because of year-to-year variability. In contrast, for persons less than 45 years, mortality rates increased between 1980 and 1986. Mortality rates for diabetes as the underlying cause of death declined in each race and sex category. Between 1980 and 1986, the age-adjusted rate fell 18.6% for white males and black females, 12.0% for black males, and 7.9% for white females (Tables 3.14-3.17). Of the four groups, black males each year consistently had the highest rates. The age-adjusted rate for diabetes-related deaths decreased from 2,350 per 100,000 persons with diabetes in 1980 to 2,066 per 100,000 in 1986, a 12.1% decline (Figure 3.5, Table 3.18). As with age-specific mortality rates for diabetes as the underlying cause of death, diabetes-related mortality rates declined during this period in those 75 years and older; meanwhile, mortality rates in those persons less than 45 years old appeared to increase. Age-standardized mortality rates for diabetes-related deaths decreased in each race-sex category (Figure 3.6, Tables 3.19-3.22). Compared with rates in 1980, diabetes-related mortality rates in 1986 declined 16.6% for white males, 14.0% for black females, 4.9% for white females, and 3.6% for black males. In contrast to the results for mortality rates among the general population (Figure 3.3), the highest rates of diabetes-related mortality in the diabetic population were among white males (Figure 3.6). Moreover, whereas black females have the highest diabetes-related mortality rates in the general population, they have the lowest rates in the diabetic population. Discussion National death certificate data for 1980 to 1986 indicate that, although the number of deaths attributable to diabetes has increased, age-adjusted mortality rates for diabetes have declined. Compared with the rate in 1980, the mortality rate in the general population for diabetes as an underlying cause of death declined 4.6% to 14.6 per 100,000 by 1986. For diabetes-related mortality (diabetes as any listed cause), the age-adjusted mortality rate declined 1.8% to 58.7 per 100,000 by 1986. When we calculated mortality rates using the population of people with diabetes as the denominator, the declines were more substantial--12% for diabetes-related mortality. We found that diabetes-related mortality rates in the general population varied by race and sex. Rates for black females were highest and were double those for white females. Black males had the second highest mortality rates. Temporal trends also varied by race. Whereas diabetes-related mortality rates declined among whites during 1980-1986, the corresponding mortality rates increased among blacks. These rate increases probably reflect the higher prevalence of diabetes among blacks. In support of this explanation, mortality rates for the diabetic population, which are not influenced by the prevalence of diabetes, declined for both races. Moreover, in contrast to general population rates, rates of diabetes-related mortality among persons with diabetes were highest among white males. Death certificate data are useful for examining secular trends and relative differences within subgroups categorized by age, race, and sex. There are, however, several well known limitations associated with using death certificate data for monitoring cause-specific mortality. Foremost are the misclassification and underreporting of diabetes as a cause of death on vital records. Several studies have shown that diabetes is recorded on the death certificate of only about 40% of the people who are known to have diabetes (Brousseau, 1987; Ochi et al., 1985; Palumbo et al., 1976). This proportion has been fairly constant from studies conducted from the mid-1970s to the mid-1980s. The proportion has also been similar for different race and sex groups. Therefore, the mortality rates reported herein probably represent conservative estimates of the actual U.S. rates. Nonetheless, the temporal trends and relative differences between race and sex groups are probably valid. In each year, the number of deaths from diabetes as any listed cause were about four times greater than the number of deaths from diabetes as an underlying cause. Similarly, rates based on underlying cause of death, the usual measure of diabetes mortality, reflect only about one-quarter of the deaths to which diabetes may have contributed. Total diabetes-related deaths, and the corresponding mortality rates, more accurately reflect the considerable disease burden that diabetes imposes upon society. These results suggest that gradual declines in mortality from diabetes are occurring, but that diabetes continues to be a leading cause of mortality in the United States. During 1980 through 1986, there was a substantial decrease in the age-adjusted mortality rate of people with diabetes. Despite this improvement, the annual number of deaths related to diabetes increased. These findings indicate that, even with improved care for patients with diabetes, decreasing the disease burden from diabetes will be difficult because of the increasingly older population age structure and the concomitant increasing prevalence of diabetes. Update This section updates data presented in previous sections in light of two additional years of mortality data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. Diabetes Mortality in the General Population The annual number of deaths with diabetes as the underlying cause of death increased from 1980 (34,851) to 1988 (40,368) (Table 3.1). Between 1982 and 1988, the age-standardized mortality rates for both black males and females increased (23% and 11%, respectively) (Tables 3.4-3.5). The rates for white males and white females remained relatively constant (Tables 3.2-3.3). The annual number of deaths with diabetes listed as any cause of death (diabetes-related deaths) increased from 135,931 in 1980 to 157,265 in 1988 (Table 3.6). Between 1982 and 1988, age-standardized diabetes-related mortality rates increased 21% for black males and 15% for black females (Figure 1.4, Tables 3.9-3.10). The rates remained relatively constant for white males and white females (Figure 1.4, Tables 3.7-3.8). Between 1980 and 1988, both mortality rates for diabetes as an underlying cause of death and diabetes-related mortality rates increased with age, with the highest rates occurring among those aged 85 and older (Tables 3.1-3.6). Diabetes Mortality in the Diabetic Population When age-standardized mortality rates were calculated using as the denominator people known to have diabetes, race-sex trends in age-standardized mortality rates were less clear. Age-standardized rates for diabetes as underlying cause of death were lower in 1988 than in 1980 for white males, black males, and black females (Figure 1.5, Tables 3.14, 3.16, and 3.17). White females were the only group whose rates were higher in 1988 than in 1980 (Figure 1.5, Table 3.15). Of the four race-sex groups examined, black males had the highest age-standardized rates. Race-sex trends for diabetes-related mortality rates were similar to those seen for diabetes as underlying cause of death, except that white males had the highest age-standardized rates. Detailed Tables 3.1-3.5 Deaths with Diabetes as Underlying Cause & Mort. Rate 3.1 100,000 Pop., by Age and Year, U.S., 80-88 Table 3.1 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-14 Number 53 46 63 51 36 44 Rate 0.1 0.1 0.1 0.1 0.1 0.1 15-24 Number 128 149 134 129 119 121 Rate 0.3 0.4 0.3 0.3 0.3 0.3 25-34 Number 572 554 533 584 578 537 Rate 1.5 1.4 1.3 1.4 1.4 1.3 35-44 Number 900 916 922 1064 1072 1165 Rate 3.5 3.5 3.3 3.6 3.5 3.7 45-54 Number 2188 2167 2060 2078 2005 1991 Rate 9.6 9.6 9.2 9.3 8.9 8.8 55-64 Number 5789 5620 5643 5900 5495 5819 Rate 26.6 25.6 25.5 26.6 24.6 26.1 65-74 Number 10111 9841 9711 10185 9934 10159 Rate 64.6 61.8 60.0 61.8 59.4 59.7 75-84 Number 10134 10221 10339 10923 10857 11308 Rate 130.3 128.3 126.5 130.2 126.2 128.1 85+ Number 4971 5120 5170 5328 5690 5817 Rate 219.0 217.6 211.1 209.9 217.0 216.0 Total Number 34851 34642 34583 36246 35787 36969 Rate 15.3 15.1 14.9 15.5 15.1 15.5 Age-Adjusted Rate 15.3 15.0 14.6 15.0 14.5 14.7 Table 3.1 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1986-1988 Year 1986 1987 1988 Age 0-14 Number 36 41 40 Rate 0.1 0.1 0.1 15-24 Number 140 119 119 Rate 0.4 0.3 0.3 25-34 Number 634 618 656 Rate 1.5 1.4 1.5 35-44 Number 1174 1203 1395 Rate 3.5 3.5 4.0 45-54 Number 2158 2258 2502 Rate 9.5 9.7 10.4 55-64 Number 5780 5914 6109 Rate 26.0 26.9 28.0 65-74 Number 10269 10789 11092 Rate 59.3 61.1 62.0 75-84 Number 11048 11470 11907 Rate 122.0 123.5 125.2 85+ Number 5939 6118 6548 Rate 213.9 213.7 222.2 Total Number 37184 38532 40368 Rate 15.4 15.8 16.4 Age-Adjusted Rate 14.6 14.8 15.3 3.2 100,000 Pop., by Age and Year, U.S., 80-88, White Males Table 3.2 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, White Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-14 Number 19 20 19 15 9 11 Rate 0.1 0.1 0.1 0.1 0.0 0.1 15-24 Number 46 47 59 44 50 34 Rate 0.3 0.3 0.3 0.3 0.3 0.2 25-34 Number 260 247 221 239 243 253 Rate 1.6 1.5 1.3 1.4 1.4 1.4 35-44 Number 373 391 422 474 486 544 Rate 3.4 3.5 3.5 3.8 3.7 4.0 45-54 Number 853 898 841 812 837 793 Rate 8.8 9.3 8.8 8.5 8.7 8.3 55-64 Number 2217 2238 2203 2202 2067 2216 Rate 24.2 24.2 23.7 23.6 22.1 23.7 65-74 Number 3682 3572 3686 3749 3638 3802 Rate 60.1 57.3 58.0 57.7 55.1 56.5 75-84 Number 3314 3289 3380 3449 3650 3673 Rate 126.6 122.7 123.0 122.2 126.0 123.4 85+ Number 1361 1362 1261 1353 1470 1432 Rate 217.4 213.5 192.8 202.6 215.7 207.1 Total Number 12125 12066 12092 12337 12450 12758 Rate 12.7 12.6 12.5 12.7 12.7 12.9 Age-Adjusted Rate 14.6 14.2 14.0 14.0 14.0 14.0 Table 3.2 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, White Males, United States, 1986-1988 Year 1986 1987 1988 Age 0-14 Number 13 13 14 Rate 0.1 0.1 0.1 15-24 Number 55 50 50 Rate 0.3 0.3 0.3 25-34 Number 290 288 303 Rate 1.6 1.6 1.6 35-44 Number 504 583 622 Rate 3.6 4.0 4.1 45-54 Number 843 890 1002 Rate 8.7 9.0 9.8 55-64 Number 2201 2307 2293 Rate 23.7 25.2 25.3 65-74 Number 3835 4130 4091 Rate 55.8 58.8 57.4 75-84 Number 3580 3789 3941 Rate 117.1 120.3 121.8 85+ Number 1466 1503 1692 Rate 207.6 208.1 229.1 Total Number 12788 13553 14008 Rate 12.8 13.5 13.8 Age-Adjusted Rate 13.8 14.3 14.6 3.3 100,000 Pop., by Age and Year, U.S., 80-88, White Females Table 3.3 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, White Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-14 Number 18 15 26 22 19 22 Rate 0.1 0.1 0.1 0.1 0.1 0.1 15-24 Number 50 59 43 54 43 44 Rate 0.3 0.3 0.3 0.3 0.3 0.3 25-34 Number 192 189 194 216 198 171 Rate 1.2 1.1 1.2 1.3 1.1 1.0 35-44 Number 283 289 297 331 307 350 Rate 2.5 2.5 2.4 2.6 2.3 2.5 45-54 Number 741 687 664 685 604 596 Rate 7.2 6.8 6.6 6.9 6.1 6.0 55-64 Number 2231 2109 2151 2267 2093 2213 Rate 21.6 20.3 20.6 21.7 20.0 21.2 65-74 Number 4583 4454 4375 4637 4361 4415 Rate 57.4 55.0 53.3 55.6 51.7 51.7 75-84 Number 5507 5607 5632 5963 5716 5941 Rate 122.8 122.2 119.8 123.8 115.9 117.7 85+ Number 3137 3273 3431 3474 3675 3791 Rate 214.7 214.8 215.3 209.7 214.0 214.4 Total Number 16743 16684 16818 17650 17016 17547 Rate 16.7 16.6 16.6 17.3 16.5 16.9 Age-Adjusted Rate 13.6 13.3 13.1 13.5 12.7 12.9 Table 3.3 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, White Females, United States, 1986-1988 Year 1986 1987 1988 Age 0-14 Number 18 15 19 Rate 0.1 0.1 0.1 15-24 Number 56 45 37 Rate 0.4 0.3 0.2 25-34 Number 226 186 196 Rate 1.3 1.0 1.1 35-44 Number 354 352 395 Rate 2.5 2.4 2.6 45-54 Number 671 712 777 Rate 6.7 7.0 7.3 55-64 Number 2124 2130 2279 Rate 20.5 20.9 22.7 65-74 Number 4471 4561 4782 Rate 51.7 51.9 53.9 75-84 Number 5822 5905 6117 Rate 112.8 111.8 113.6 85+ Number 3752 3936 4082 Rate 205.6 208.9 210.4 Total Number 17496 17842 18684 Rate 16.7 17.0 17.6 Age-Adjusted Rate 12.7 12.7 13.1 3.4 100,000 Pop., by Age and Year, U.S., 80-88, Black Males Table 3.4 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-14 Number 10 4 6 3 6 7 Rate 0.3 0.1 0.2 0.1 0.2 0.2 15-24 Number 16 22 13 14 9 21 Rate 0.6 0.8 0.5 0.5 0.3 0.8 25-34 Number 55 63 65 69 73 59 Rate 2.8 3.0 3.0 3.0 3.1 2.4 35-44 Number 120 117 108 130 142 146 Rate 9.6 9.2 8.2 9.4 9.8 9.6 45-54 Number 216 244 223 257 264 259 Rate 21.0 23.6 21.5 24.5 24.8 24.1 55-64 Number 489 424 435 540 485 485 Rate 56.9 48.4 48.7 59.3 52.3 51.6 65-74 Number 577 560 525 569 621 615 Rate 101.3 96.7 89.3 95.2 102.1 99.1 75-84 Number 415 380 390 432 443 504 Rate 180.9 162.0 162.1 176.2 176.3 197.5 85+ Number 111 110 113 107 117 132 Rate 206.9 197.1 195.0 176.2 186.3 203.8 Total Number 2010 1925 1878 2123 2160 2230 Rate 15.9 15.0 14.4 16.0 16.0 16.3 Age-Adjusted Rate 24.5 22.9 22.0 24.2 24.2 24.7 Table 3.4 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Males, United States, 1986-1988 Year 1986 1987 1988 Age 0-14 Number 2 5 1 Rate 0.0 0.1 0.0 15-24 Number 17 9 16 Rate 0.6 0.3 0.6 25-34 Number 63 71 83 Rate 2.5 2.8 3.2 35-44 Number 166 139 210 Rate 10.4 8.4 12.1 45-54 Number 264 310 315 Rate 24.2 27.8 27.5 55-64 Number 526 550 585 Rate 55.3 57.3 60.4 65-74 Number 638 693 727 Rate 100.8 107.3 110.1 75-84 Number 467 469 540 Rate 178.6 175.5 199.1 85+ Number 150 141 163 Rate 228.4 208.4 234.1 Total Number 2295 2388 2640 Rate 16.5 16.9 18.4 Age-Adjusted Rate 24.8 25.2 27.3 3.5 100,000 Pop., by Age and Year, U.S., 80-88, Black Females Table 3.5 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-14 Number 5 6 11 10 1 3 Rate 0.1 0.2 0.3 0.3 0.0 0.1 15-24 Number 15 21 15 17 15 21 Rate 0.5 0.7 0.5 0.6 0.5 0.7 25-34 Number 58 48 48 56 58 49 Rate 2.5 2.0 1.9 2.2 2.2 1.8 35-44 Number 107 105 84 110 127 108 Rate 7.1 6.9 5.3 6.6 7.3 5.9 45-54 Number 328 292 285 293 256 294 Rate 26.0 23.0 22.3 22.7 19.6 22.2 55-64 Number 739 753 761 785 735 768 Rate 69.4 69.6 69.1 70.3 65.0 67.1 65-74 Number 1143 1125 1005 1088 1159 1163 Rate 146.5 141.5 124.4 132.6 139.3 137.8 75-84 Number 806 845 815 957 934 1065 Rate 221.9 226.2 211.2 241.4 229.2 254.4 85+ Number 330 338 322 351 364 401 Rate 306.1 299.8 269.2 279.3 274.4 291.0 Total Number 3534 3536 3349 3667 3650 3874 Rate 25.0 24.6 23.0 24.8 24.3 25.5 Age-Adjusted Rate 31.3 30.7 28.4 30.5 29.7 30.9 Table 3.5 Number of Deaths with Diabetes as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Females, United States, 1986-1988 Year 1986 1987 1988 Age 0-14 Number 3 7 6 Rate 0.1 0.2 0.1 15-24 Number 12 14 12 Rate 0.4 0.5 0.4 25-34 Number 48 63 68 Rate 1.7 2.2 2.3 35-44 Number 129 111 149 Rate 6.8 5.6 7.2 45-54 Number 330 298 336 Rate 24.5 21.7 23.8 55-64 Number 800 787 813 Rate 69.2 67.6 69.5 65-74 Number 1158 1210 1285 Rate 135.0 138.9 145.1 75-84 Number 1014 1151 1133 Rate 235.4 260.7 249.9 85+ Number 509 467 530 Rate 351.7 308.0 336.1 Total Number 4004 4109 4332 Rate 26.0 26.3 27.3 Age-Adjusted Rate 31.1 31.3 32.3 3.6-3.10 No. Deaths w/Diabetes as Any Listed Cause & Mort. Rate 3.6 100,000 Pop., by Age and Year, U.S., 80-88 Table 3.6 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 AGE 0-14 Number 69 75 93 92 61 Rate 0.1 0.1 0.2 0.2 0.1 15-24 Number 209 231 180 208 201 Rate 0.5 0.5 0.4 0.5 0.5 25-34 Number 918 910 968 953 991 Rate 2.5 2.3 2.4 2.4 2.4 35-44 Number 2038 2046 2042 2282 2426 Rate 7.9 7.8 7.3 7.8 7.9 45-54 Number 6956 6979 6729 6809 6648 Rate 30.6 30.9 29.9 30.4 29.6 55-64 Number 21873 21926 21759 22513 22383 Rate 100.5 99.9 98.4 101.3 100.4 65-74 Number 41000 40875 40898 42370 43036 Rate 262.0 256.9 252.5 256.9 257.2 75-84 Number 42938 42661 43340 45539 46462 Rate 551.9 535.4 530.1 542.9 540.0 85+ Number 19919 20223 20724 21787 22332 Rate 877.7 859.6 846.1 858.5 851.6 Total Number 135931 135939 136764 142570 144548 Rate 59.8 59.2 59.0 60.9 61.1 Age-adjusted Rate 59.8 58.7 57.8 59.0 58.7 Table 3.6 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 AGE 0-14 Number 59 57 53 60 Rate 0.1 0.1 0.1 0.1 15-24 Number 206 217 209 195 Rate 0.5 0.6 0.5 0.5 25-34 Number 960 1094 1117 1135 Rate 2.3 2.6 2.6 2.6 35-44 Number 2525 2652 2738 2903 Rate 7.9 8.0 8.0 8.2 45-54 Number 6736 6890 7231 7516 Rate 29.8 30.2 31.1 31.1 55-64 Number 22803 22809 22647 22646 Rate 102.2 102.7 102.9 103.8 65-74 Number 44058 44218 45735 46195 Rate 259.1 255.1 259.0 258.2 75-84 Number 47607 48220 48830 50549 Rate 539.2 532.6 525.7 531.4 85+ Number 23309 23945 24700 26057 Rate 865.4 862.6 862.8 884.1 Total Number 148284 150120 153271 157265 Rate 62.1 62.3 63.0 64.0 Age-adjusted Rate 59.1 58.7 58.9 59.3 3.7 100,000 Pop., by Age and Year, U.S., 80-88, White Males Table 3.7 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-14 Number 21 32 26 31 19 Rate 0.1 0.1 0.1 0.1 0.1 15-24 Number 70 78 77 69 80 Rate 0.4 0.4 0.4 0.4 0.5 25-34 Number 407 402 409 406 428 Rate 2.5 2.4 2.4 2.4 2.4 35-44 Number 854 872 852 1024 1078 Rate 7.7 7.7 7.1 8.1 8.2 45-54 Number 2997 3013 2943 2862 2883 Rate 30.7 31.1 30.6 29.9 30.1 55-64 Number 9702 9819 9705 9776 9655 Rate 105.8 106.3 104.5 104.9 103.3 65-74 Number 17064 17083 17498 17763 18081 Rate 278.6 273.9 275.3 273.6 273.9 75-84 Number 15244 15397 15604 16366 17048 Rate 582.3 574.5 567.7 579.9 588.5 85+ Number 5806 5610 5619 5946 6122 Rate 927.5 879.2 859.3 890.2 898.1 Total Number 52166 52310 52738 54247 55396 Rate 54.8 54.5 54.5 55.6 56.4 Age-adjusted Rate 63.0 62.0 61.4 62.0 62.3 Table 3.7 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 AGE 0-14 Number 16 17 19 20 Rate 0.1 0.1 0.1 0.1 15-24 Number 73 90 86 75 Rate 0.4 0.6 0.5 0.5 25-34 Number 412 487 512 495 Rate 2.3 2.7 2.8 2.7 35-44 Number 1111 1129 1261 1302 Rate 8.2 8.0 8.6 8.6 45-54 Number 2887 2857 3017 3115 Rate 30.1 29.6 30.6 30.4 55-64 Number 9906 9812 9810 9583 Rate 106.0 105.7 107.0 105.6 65-74 Number 18688 18746 19364 19688 Rate 277.8 272.6 275.6 276.4 75-84 Number 17271 17607 17952 18942 Rate 580.4 575.8 570.2 585.4 85+ Number 6284 6325 6591 7095 Rate 908.7 895.5 912.4 960.7 Total Number 56652 57075 58614 60317 Rate 57.2 57.2 58.3 59.5 Age-adjusted Rate 62.6 62.0 62.5 63.4 3.8 100,000 Pop., by Age and Year, U.S., 80-88, White Females Table 3.8 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-14 Number 30 30 37 37 32 Rate 0.1 0.1 0.2 0.2 0.2 15-24 Number 87 92 60 94 77 Rate 0.5 0.5 0.4 0.6 0.5 25-34 Number 304 310 326 335 328 Rate 1.9 1.9 1.9 2.0 1.9 35-44 Number 614 577 646 639 694 Rate 5.4 5.0 5.3 5.0 5.2 45-54 Number 2195 2154 2043 2154 2001 Rate 21.4 21.3 20.4 21.6 20.1 55-64 Number 8012 7997 7812 8157 8221 Rate 77.4 76.8 74.8 77.9 78.6 65-74 Number 18034 18039 17759 18468 18450 Rate 225.9 222.9 216.3 221.6 218.9 75-84 Number 23437 23065 23461 24247 24411 Rate 522.6 502.8 499.1 503.4 495.1 85+ Number 12686 13149 13596 14171 14470 Rate 868.1 862.8 853.0 855.4 842.5 Total Number 65401 65417 65755 68308 68685 Rate 65.4 64.9 64.7 66.8 66.7 Age-adjusted Rate 52.7 51.7 50.7 51.7 51.0 Table 3.8 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 AGE 0-14 Number 30 27 19 29 Rate 0.1 0.1 0.1 0.1 15-24 Number 77 88 83 65 Rate 0.5 0.6 0.5 0.4 25-34 Number 318 367 331 360 Rate 1.8 2.1 1.8 2.0 35-44 Number 749 778 764 778 Rate 5.4 5.4 5.2 5.1 45-54 Number 2006 2102 2171 2242 Rate 20.1 20.9 21.3 21.2 55-64 Number 8238 8164 7989 8050 Rate 79.0 79.0 78.4 80.1 65-74 Number 18621 18425 19198 18975 Rate 218.2 212.9 218.5 214.0 75-84 Number 24907 24949 25078 25295 Rate 493.4 483.2 475.0 469.6 85+ Number 15099 15443 15934 16547 Rate 853.8 846.0 845.6 852.8 Total Number 70055 70349 71572 72344 Rate 67.5 67.3 68.0 68.3 Age-adjusted Rate 51.1 50.4 50.4 50.1 3.9 100,000 Pop., by Age and Year, U.S., 80-88, Black Males Table 3.9 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-14 Number 11 8 11 5 8 Rate 0.3 0.2 0.3 0.1 0.2 15-24 Number 28 26 14 19 15 Rate 1.0 0.9 0.5 0.7 0.5 25-34 Number 100 103 106 112 123 Rate 5.0 4.9 4.8 4.9 5.2 35-44 Number 290 286 268 307 330 Rate 23.3 22.6 20.2 22.2 22.8 45-54 Number 704 781 712 808 796 Rate 68.6 75.7 68.6 77.0 74.9 55-64 Number 1590 1555 1561 1787 1768 Rate 185.1 177.6 174.6 196.1 190.8 65-74 Number 1946 1996 1889 2125 2208 Rate 341.6 344.7 321.2 355.4 363.1 75-84 Number 1309 1227 1304 1452 1483 Rate 570.4 523.0 542.1 592.3 590.2 85+ Number 346 357 373 403 406 Rate 645.0 639.8 643.8 663.5 646.4 Total Number 6326 6341 6239 7021 7138 Rate 50.0 49.3 47.7 52.9 53.0 Age-adjusted Rate 77.8 76.2 73.9 81.4 81.0 Table 3.9 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 AGE 0-14 Number 8 5 6 2 Rate 0.2 0.1 0.1 0.0 15-24 Number 26 22 14 28 Rate 0.9 0.8 0.5 1.0 25-34 Number 122 119 145 140 Rate 5.0 4.8 5.7 5.4 35-44 Number 326 381 354 446 Rate 21.5 23.9 21.3 25.7 45-54 Number 791 784 930 953 Rate 73.5 71.8 83.3 83.3 55-64 Number 1819 1879 1889 1894 Rate 193.6 197.6 196.7 195.5 65-74 Number 2340 2439 2550 2618 Rate 377.1 385.5 394.7 396.5 75-84 Number 1585 1725 1720 1869 Rate 621.0 659.6 643.7 689.2 85+ Number 446 494 501 518 Rate 688.6 752.3 740.5 743.9 Total Number 7466 7851 8110 8469 Rate 54.6 56.5 57.5 59.1 Age-adjusted Rate 83.5 86.4 87.3 89.4 3.10 100,000 Pop., by Age and Year, U.S., 80-88, Black Females Table 3.10 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-14 Number 6 4 18 16 1 Rate 0.2 0.1 0.5 0.4 0.0 15-24 Number 22 35 24 25 25 Rate 0.7 1.2 0.8 0.9 0.9 25-34 Number 96 83 115 93 100 Rate 4.2 3.4 4.6 3.6 3.7 35-44 Number 246 277 246 264 289 Rate 16.4 18.1 15.4 15.9 16.6 45-54 Number 935 905 901 866 821 Rate 74.2 71.4 70.6 67.1 62.8 55-64 Number 2289 2298 2380 2446 2392 Rate 215.0 212.3 216.2 218.9 211.4 65-74 Number 3543 3385 3281 3524 3746 Rate 454.0 425.9 406.1 429.5 450.2 75-84 Number 2544 2602 2524 2993 3020 Rate 700.4 696.4 654.2 755.1 741.2 85+ Number 930 958 978 1083 1103 Rate 862.7 849.6 817.6 861.7 831.6 Total Number 10617 10550 10477 11313 11501 Rate 75.2 73.5 71.9 76.5 76.7 Age-adjusted Rate 94.6 92.0 89.1 94.4 93.9 Table 3.10 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 AGE 0-14 Number 4 5 7 9 Rate 0.1 0.1 0.2 0.2 15-24 Number 28 17 22 21 Rate 1.0 0.6 0.8 0.8 25-34 Number 97 103 111 128 Rate 3.5 3.7 3.9 4.4 35-44 Number 286 307 304 334 Rate 15.7 16.1 15.3 16.1 45-54 Number 901 972 925 993 Rate 67.9 72.1 67.3 70.3 55-64 Number 2435 2556 2522 2640 Rate 212.8 221.0 216.6 225.6 65-74 Number 3789 4018 3953 4160 Rate 448.8 468.4 453.6 469.8 75-84 Number 3303 3314 3458 3721 Rate 789.0 769.2 783.2 820.8 85+ Number 1248 1450 1409 1607 Rate 905.5 1001.8 929.2 1019.0 Total Number 12095 12746 12714 13616 Rate 79.6 82.6 81.3 85.7 Age-adjusted Rate 96.7 99.6 97.4 102.0 3.11 No. Deaths with Diabetes as Any Listed Cause, State & Year Table 3.11 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by State and Year, United States, 1980-1982 Year 1980 1981 1982 Number Rate Number Rate Number Rate State Alabama 1829 46.9 1856 47.3 1937 49.1 Alaska 38 9.4 54 13.0 52 11.7 Arizona 1004 36.7 1079 38.4 1033 35.9 Arkansas 1050 45.9 1059 46.0 998 43.2 California 11922 50.1 12183 50.2 12812 51.7 Colorado 1003 34.5 993 33.3 1053 34.3 Connecticut 2189 70.4 2244 71.9 2381 76.1 Delaware 386 64.9 357 59.8 403 67.2 Dist of Columbia 469 73.4 418 66.0 428 68.3 Florida 6548 66.1 6740 66.1 6624 63.3 Georgia 2563 46.7 2558 45.9 2530 44.7 Hawaii 406 41.5 419 42.7 492 49.3 Idaho 341 36.0 356 36.9 345 35.3 Illinois 7612 66.6 7453 65.0 7750 67.5 Indiana 3393 61.8 3469 63.2 3357 61.2 Iowa 1759 60.4 1761 60.3 1786 61.4 Kansas 1296 54.7 1314 55.0 1388 57.6 Kentucky 2057 56.2 2115 57.5 2011 54.4 Louisiana 2151 50.9 2308 53.7 2326 53.1 Maine 781 69.4 724 63.8 809 71.0 Maryland 2315 54.8 2325 54.6 2315 54.2 Massachusetts 4074 71.0 3888 67.6 3913 68.1 Michigan 6089 65.8 6050 65.7 6104 66.9 Minnesota 2337 57.2 2297 55.9 2442 59.1 Mississippi 1499 59.3 1441 56.6 1401 54.6 Missouri 2971 60.4 2999 60.7 3025 61.2 Montana 322 40.8 369 46.4 360 44.7 Nebraska 875 55.7 923 58.3 918 57.7 Nevada 252 31.1 263 31.1 285 32.5 New Hampshire 560 60.6 595 63.5 617 65.1 New Jersey 5958 80.8 5752 77.7 5662 76.2 New Mexico 434 33.1 374 28.0 476 34.8 New York 13403 76.3 12923 73.6 12452 70.9 North Carolina 3601 61.1 3619 60.7 3672 61.0 North Dakota 400 61.1 374 56.6 420 62.5 Ohio 8262 76.5 8241 76.3 7999 74.2 Oklahoma 1565 51.4 1670 53.7 1623 50.2 Oregon 1218 46.1 1273 47.7 1232 46.2 Pennsylvania 10464 88.2 10307 86.8 10280 86.5 Rhode Island 858 90.5 822 86.3 840 88.1 South Carolina 1589 50.7 1614 50.7 1629 50.6 South Dakota 389 56.3 396 57.2 472 68.0 Tennessee 2075 45.1 2188 47.2 2148 46.0 Texas 5677 39.6 5853 39.6 5830 37.9 Utah 530 36.0 502 33.1 556 35.7 Vermont 326 63.7 319 61.8 340 65.4 Virginia 2649 49.4 2617 48.1 2649 48.3 Washington 1863 44.8 1820 43.0 1955 45.7 West Virginia 1361 69.8 1410 71.9 1318 67.2 Wisconsin 3093 65.7 3110 65.7 3164 66.7 Wyoming 125 26.4 145 29.4 152 29.8 Table 3.11 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by State and Year, United States, 1983-1985 Year 1983 1984 1985 Number Rate Number Rate Number Rate State Alabama 1901 48.0 2019 50.6 2002 49.8 Alaska 65 13.5 58 11.5 68 13.0 Arizona 1255 42.5 1252 41.1 1263 40.0 Arkansas 1065 45.8 1075 45.8 1118 47.4 California 12943 51.1 13718 53.2 14379 54.6 Colorado 1094 34.7 1162 36.4 1190 36.8 Connecticut 2414 76.9 2566 81.4 2492 78.6 Delaware 365 60.2 336 54.7 416 66.9 Dist of Columbia 447 71.6 397 63.6 452 72.5 Florida 7037 65.4 7002 63.4 7486 65.9 Georgia 2765 48.2 2842 48.6 2920 48.9 Hawaii 517 50.8 560 54.1 562 53.4 Idaho 380 38.5 440 44.0 423 42.1 Illinois 7942 69.1 7699 66.8 7960 69.0 Indiana 3712 67.8 3707 67.5 3789 68.9 Iowa 1845 63.5 1873 64.5 1921 66.7 Kansas 1354 55.8 1402 57.4 1372 56.0 Kentucky 2175 58.5 2047 55.0 2171 58.2 Louisiana 2455 55.3 2464 55.2 2532 56.4 Maine 851 74.2 855 73.9 917 78.7 Maryland 2438 56.7 2437 56.0 2526 57.5 Massachusetts 4021 69.8 4303 74.3 4262 73.2 Michigan 6101 67.4 6379 70.4 6361 70.0 Minnesota 2543 61.3 2599 62.4 2676 63.8 Mississippi 1549 60.0 1515 58.3 1623 62.1 Missouri 3083 62.1 3098 61.9 3100 61.6 Montana 336 41.2 333 40.4 352 42.6 Nebraska 947 59.3 944 58.8 912 56.8 Nevada 310 34.6 348 38.0 363 38.8 New Hampshire 675 70.4 641 65.5 670 67.1 New Jersey 6000 80.4 6031 80.3 6278 83.0 New Mexico 488 34.8 521 36.5 540 37.2 New York 12607 71.4 12345 69.7 12507 70.5 North Carolina 3766 61.9 3968 64.3 4130 66.0 North Dakota 380 55.8 380 55.3 435 63.5 Ohio 8514 79.3 8444 78.6 8762 81.5 Oklahoma 1747 52.7 1739 52.5 1755 53.1 Oregon 1378 51.8 1443 53.9 1438 53.5 Pennsylvania 10560 88.8 10750 90.4 10845 91.4 Rhode Island 893 93.5 888 92.5 857 88.6 South Carolina 1703 52.3 1807 54.8 1814 54.4 South Dakota 422 60.4 431 61.1 443 62.5 Tennessee 2423 51.7 2518 53.2 2515 52.8 Texas 6411 40.5 6393 39.8 6619 40.4 Utah 560 35.1 613 37.8 618 37.6 Vermont 334 63.6 344 64.9 388 72.5 Virginia 2825 50.8 2872 51.0 2875 50.4 Washington 2079 48.3 2132 49.0 2278 51.7 West Virginia 1541 78.5 1421 72.8 1387 71.6 Wisconsin 3194 67.3 3264 68.5 3360 70.4 Wyoming 160 31.0 173 33.7 162 31.8 Table 3.11 Number of Deaths with Diabetes as Any Listed Cause and Mortality Rate per 100,000 Population, by State and Year, United States, 1986-1988 Year 1986 1987 1988 Number Rate Number Rate Number Rate State Alabama 2111 52.1 2045 50.1 2199 53.4 Alaska 85 16.0 91 17.3 109 20.1 Arizona 1393 42.5 1404 41.5 1536 43.6 Arkansas 1088 45.9 1126 47.1 1224 50.9 California 14929 55.3 15876 57.4 16624 58.9 Colorado 1228 37.6 1230 37.3 1293 38.7 Connecticut 2553 80.0 2475 77.1 2448 75.7 Delaware 447 70.6 421 65.4 425 65.2 Dist of Columbia 505 80.8 510 82.0 480 77.5 Florida 7458 63.8 8063 67.1 7866 64.0 Georgia 2875 47.1 3151 50.6 3158 49.6 Hawaii 588 55.2 644 59.5 598 54.3 Idaho 423 42.2 441 44.2 464 46.2 Illinois 8089 70.0 8218 71.0 8297 71.5 Indiana 3714 67.5 3664 66.2 3831 69.1 Iowa 1775 62.3 1861 65.7 1779 63.3 Kansas 1369 55.7 1382 55.8 1464 58.9 Kentucky 2097 56.3 2111 56.6 2435 65.2 Louisiana 2586 57.5 2497 56.0 2771 61.8 Maine 879 75.0 890 75.0 930 77.7 Maryland 2563 57.4 2716 59.9 2725 59.2 Massachusetts 4446 76.2 4301 73.5 4361 74.2 Michigan 6443 70.5 6392 69.5 6731 72.8 Minnesota 2755 65.4 2769 65.2 2806 65.6 Mississippi 1639 62.5 1604 61.1 1753 66.2 Missouri 3176 62.7 3141 61.6 3137 61.0 Montana 357 43.7 365 45.1 435 53.8 Nebraska 950 59.5 996 62.5 975 61.2 Nevada 371 38.4 469 46.6 424 41.1 New Hampshire 744 72.4 691 65.4 735 67.7 New Jersey 6108 80.1 6268 81.7 6258 80.8 New Mexico 561 37.9 546 36.4 608 39.4 New York 12374 69.5 12056 67.6 12495 70.1 North Carolina 4300 67.9 4744 74.0 4895 75.3 North Dakota 347 51.1 398 59.2 406 60.7 Ohio 8811 82.0 8723 80.9 8747 81.0 Oklahoma 1843 55.7 1844 56.4 1974 60.2 Oregon 1401 51.8 1618 59.4 1712 62.5 Pennsylvania 10802 90.8 10953 91.8 10957 91.9 Rhode Island 784 80.4 828 84.0 892 90.4 South Carolina 1955 57.8 2000 58.4 2084 60.1 South Dakota 432 61.1 433 61.1 439 61.8 Tennessee 2669 55.6 2688 55.4 2822 57.6 Texas 6619 39.7 7049 42.0 7212 42.2 Utah 634 38.1 600 35.7 683 39.9 Vermont 374 69.1 395 72.1 383 69.2 Virginia 3073 53.0 3108 52.6 3158 52.7 Washington 2311 51.8 2233 49.2 2328 50.7 West Virginia 1526 79.6 1620 85.4 1521 80.7 Wisconsin 3413 71.4 3461 72.0 3481 72.3 Wyoming 147 29.0 162 33.0 197 39.8 3.12 Avg. Mort. Rate for Diabetes as Listed Cause, State & Rank Table 3.12 Average Mortality Rate for Diabetes as Any Listed Cause per 100,000 Population, By State and Rank, United States, 1980-1988 Adjusted Rate Rate Rank (a) Rank State Alabama 49.7 38 43.9 47 Alaska 14.2 51 51.9 33 Arizona 40.4 44 41.2 50 Arkansas 46.5 41 37.5 51 California 53.8 33 59.6 19 Colorado 36.0 48 46.3 44 Connecticut 76.5 5 69.9 6 Delaware 63.9 19 63.7 13 Dist of Columbia 72.9 8 42.1 49 Florida 65.0 18 45.9 45 Georgia 47.9 40 50.6 36 Hawaii 51.4 36 51.6 34 Idaho 40.7 43 57.4 21 Illinois 68.5 13 65.8 10 Indiana 65.9 17 65.4 12 Iowa 63.1 20 55.2 26 Kansas 56.3 29 50.6 37 Kentucky 57.6 27 56.7 23 Louisiana 55.6 30 57.2 22 Maine 73.2 7 61.9 17 Maryland 56.8 28 59.0 20 Massachusetts 72.0 9 63.1 15 Michigan 68.8 12 70.4 5 Minnesota 61.8 21 60.7 18 Mississippi 60.1 24 53.5 29 Missouri 61.5 22 52.0 32 Montana 44.3 42 43.0 48 Nebraska 58.9 25 52.7 31 Nevada 37.2 46 46.9 42 New Hampshire 66.5 15 66.2 9 New Jersey 80.1 3 73.2 4 New Mexico 35.5 49 44.7 46 New York 71.1 10 63.0 16 North Carolina 66.0 16 63.4 14 North Dakota 58.4 26 47.9 41 Ohio 78.9 4 75.7 2 Oklahoma 54.0 32 51.0 35 Oregon 52.6 34 54.6 27 Pennsylvania 89.6 1 74.5 3 Rhode Island 88.3 2 75.7 1 South Carolina 54.5 31 55.3 25 South Dakota 61.1 23 50.5 38 Tennessee 51.7 35 48.1 40 Texas 40.2 45 46.3 43 Utah 36.6 47 55.4 24 Vermont 67.0 14 69.5 8 Virginia 50.8 37 53.0 30 Washington 48.3 39 54.1 28 West Virginia 75.2 6 69.8 7 Wisconsin 68.9 11 65.5 11 Wyoming 31.6 50 48.1 39 (a) Ajusted for age and race. 3.13-3.17 Mort. Rate for Diabetes as Underlying Cause,U.S.,80-88 3.13 100,000 Diabetic Pop., Age and Year Table 3.13 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 163.7 174.9 167.9 182.4 181.5 179.8 45-64 333.8 306.1 300.1 306.9 318.0 335.2 65-74 664.2 721.1 636.6 780.4 565.5 548.8 75+ 1753.9 1619.0 1913.6 1859.0 1517.7 1555.8 Total 602.7 596.4 587.5 627.0 577.2 585.0 Age-Adjusted 602.6 588.0 605.9 641.0 538.0 546.1 Table 3.13 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, United States, 1986-1988 Year 1986 1987 1988 Age 0-44 189.5 145.2 202.4 45-64 278.8 320.3 350.0 65-74 644.6 633.6 650.9 75+ 1322.8 1473.7 1686.9 Total 549.1 565.7 635.7 Age-Adjusted 515.0 544.0 602.6 3.14 100,000 Diabetic Pop., Age and Year, White Males Table 3.14 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 224.3 191.0 187.6 189.2 222.8 214.8 45-64 334.6 308.3 311.5 327.5 357.0 344.5 65-74 619.0 645.8 857.8 900.0 614.9 559.8 75+ 1828.4 2038.2 1542.7 1463.1 1580.4 1457.0 Total 583.2 556.7 578.0 595.1 597.8 556.0 Age-Adjusted 612.7 634.3 617.1 623.2 583.7 544.3 Table 3.14 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1986-1988 Year 1986 1987 1988 Age 0-44 286.3 161.5 204.4 45-64 246.1 303.8 351.9 65-74 613.6 585.8 733.8 75+ 1245.8 1260.1 1460.1 Total 498.0 491.8 592.7 Age-Adjusted 498.8 495.6 591.7 3.15 100,000 Diabetic Pop., Age and Year, White Females Table 3.15 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 114.1 131.4 117.9 154.4 129.3 117.3 45-64 303.3 280.3 285.6 273.1 258.1 307.6 65-74 611.7 722.0 557.6 736.5 543.5 498.7 75+ 1667.0 1491.7 2131.9 2060.3 1584.6 1639.3 Total 614.8 634.5 629.8 686.2 591.1 606.6 Age-Adjusted 554.6 551.0 602.9 640.5 508.3 523.0 Table 3.15 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1986-1988 Year 1986 1987 1988 Age 0-44 110.7 117.0 181.9 45-64 261.0 297.5 331.1 65-74 660.8 612.6 578.1 75+ 1406.1 1838.1 1992.2 Total 579.5 649.7 713.8 Age-Adjusted 510.6 578.4 617.5 3.16 100,000 Diabetic Pop., Age and Year, Black Males Table 3.16 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 275.4 320.0 311.2 588.5 416.6 370.9 45-64 378.8 360.2 365.5 390.2 347.8 335.0 65-74 937.3 828.1 743.3 667.0 704.1 622.5 75+ 1793.6 2127.3 2013.9 2207.2 1597.2 1851.8 Total 574.3 565.4 556.7 605.4 548.4 533.5 Age-Adjusted 718.5 739.5 701.0 768.3 639.7 642.9 Table 3.16 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1986-1988 Year 1986 1987 1988 Age 0-44 298.9 246.6 385.1 45-64 387.6 410.3 364.6 65-74 703.8 668.1 856.0 75+ 1577.9 1744.4 1367.2 Total 551.0 543.8 569.4 Age-Adjusted 632.6 648.3 646.9 3.17 100,000 Diabetic Pop., Age and Year, Black Females Table 3.17 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1985 Year 1980 1981 1982 1983 1984 1985 Age 0-44 165.0 186.1 184.2 166.3 184.5 198.2 45-64 424.3 368.3 324.5 358.2 352.1 410.4 65-74 1105.1 821.5 628.5 544.3 622.0 636.0 75+ 1595.3 1678.9 1677.1 1564.8 1408.5 1245.3 Total 656.6 601.5 526.7 523.5 545.7 595.3 Age-Adjusted 732.7 651.0 581.5 553.4 551.2 557.1 Table 3.17 Mortality Rate for Diabetes as Underlying Cause per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1986-1988 Year 1986 1987 1988 Age 0-44 220.3 179.0 174.0 45-64 403.0 387.9 472.3 65-74 804.8 849.2 831.3 75+ 1204.5 1103.7 1182.8 Total 627.7 606.3 643.2 Age-Adjusted 596.2 579.5 620.5 3.18-3.22 Mort. Rate for Diabetes as Any Listed Cause,U.S.,80-88 3.18 100,000 Diabetic Pop., Age & Year Tables 3.18 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 320.4 342.6 333.7 352.7 370.0 45-64 1206.5 1136.1 1110.0 1128.1 1230.8 65-74 2693.4 2995.1 2681.1 3246.6 2449.8 75+ 7298.6 6636.2 7904.7 7701.7 6309.9 Total 2350.7 2340.3 2323.4 2466.3 2331.4 Age-adjusted 2350.5 2306.1 2400.0 2529.5 2157.9 Table 3.18 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 361.2 384.0 301.9 393.1 45-64 1267.8 1043.0 1171.0 1226.0 65-74 2380.1 2775.5 2686.0 2710.9 75+ 6442.8 5619.7 6161.0 7002.4 Total 2346.3 2216.9 2250.1 2476.5 Age-adjusted 2173.1 2065.7 2161.3 2331.8 3.19 100,000 Diabetic Pop., Age & Year, White Males Table 3.19 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 434.5 375.0 354.9 375.0 453.8 45-64 1384.2 1261.5 1294.5 1373.4 1541.3 65-74 2868.6 3088.3 4071.9 4264.1 3056.0 75+ 8232.5 9205.7 7054.7 6798.3 7152.0 Total 2509.0 2413.3 2520.9 2616.9 2659.7 Age-adjusted 2629.1 2770.8 2719.5 2768.1 2585.8 Table 3.19 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 411.3 572.2 324.7 391.0 45-64 1464.9 1024.4 1218.7 1356.2 65-74 2751.7 2999.4 2746.6 3531.4 75+ 6722.7 5908.6 5844.1 6749.0 Total 2468.7 2222.7 2126.8 2552.1 Age-adjusted 2402.8 2192.8 2153.7 2563.5 3.20 100,000 Diabetic Pop., Age & Year, White Females Table 3.20 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 217.5 240.3 225.0 273.8 257.8 45-64 1041.7 1017.6 999.8 953.9 978.3 65-74 2407.0 2924.2 2263.4 2933.4 2299.2 75+ 6966.3 6083.4 8717.1 8387.4 6560.5 Total 2401.4 2487.7 2462.3 2655.7 2386.0 Age-adjusted 2139.6 2138.3 2346.6 2463.4 2031.6 Table 3.20 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 234.6 213.3 234.2 346.4 45-64 1121.7 958.6 1063.7 1115.2 65-74 2103.3 2723.1 2578.5 2294.0 75+ 6738.7 5932.3 7660.4 8173.0 Total 2421.7 2330.1 2606.3 2763.7 Age-adjusted 2061.8 2033.8 2300.2 2342.5 3.21 100,000 Diabetic Pop., Age & Year, Black Males Table 3.21 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 587.7 657.2 646.7 1206.9 862.3 45-64 1232.7 1259.5 1262.7 1270.4 1190.5 65-74 3161.2 2951.5 2674.4 2491.2 2503.4 75+ 5643.4 6876.8 6714.3 7596.2 5387.6 Total 1807.6 1862.3 1849.6 2002.1 1812.4 Age-adjusted 2284.7 2436.4 2338.7 2522.8 2103.9 Table 3.21 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 767.3 635.1 571.4 765.1 45-64 1175.3 1306.6 1344.9 1153.5 65-74 2368.5 2690.5 2458.5 3082.7 75+ 5913.5 5674.9 6351.2 4642.3 Total 1786.0 1884.8 1846.8 1826.5 Age-adjusted 2123.9 2204.3 2248.6 2113.1 3.22 100,000 Diabetic Pop., Age & Year, Black Females Table 3.22 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 330.1 412.5 469.7 343.0 381.0 45-64 1282.1 1128.9 1017.9 1100.6 1141.6 65-74 3425.5 2471.8 2051.9 1763.1 2010.4 75+ 4878.6 5052.4 5165.6 4876.3 4474.0 Total 1972.7 1794.6 1647.8 1615.2 1719.5 Age-adjusted 2215.8 1941.7 1812.2 1705.1 1733.8 Table 3.22 Mortality Rate for Diabetes as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 454.3 495.7 407.6 364.3 45-64 1289.0 1258.1 1232.4 1493.3 65-74 2072.1 2792.3 2774.4 2691.1 75+ 3865.9 3767.6 3320.0 3789.4 Total 1858.7 1998.1 1876.1 2021.6 Age-adjusted 1733.2 1902.7 1805.3 1953.5 HOSPITALIZATIONS Introduction Hospitalization related to diabetes mellitus is one indicator of the morbidity and health care burden associated with this disease. In this chapter, we examine trends in hospitalizations related to diabetes in the United States during 1980-1987. We evaluate the numbers and rates of hospitalizations by calendar year, age, sex, race, and geographic region of the country. We present rates based on denominators for both the general population and the population with diabetes. We examine hospitalizations related to diabetes both as a primary diagnosis and as any listed hospital discharge diagnosis. We will emphasize results based on any listed diagnosis because they more accurately represent the disease burden associated with diabetes. We present overall hospitalization data in this chapter. In subsequent chapters, we evaluate hospital discharges related specifically to cardiovascular disease (Chapter 5), lower extremity amputations (Chapter 6), and diabetic ketoacidosis (Chapter 7). Methods We used data from the National Hospital Discharge Survey (NHDS) to estimate the number of diabetes-related hospitalizations in U.S. noninstitutional, nonfederal hospitals (National Center for Health Statistics, 1988b). Conducted by the National Center for Health Statistics, NHDS provides a continuous sample of hospital discharge records. The survey collects information on the characteristics of patients, on their diagnoses and surgical procedures, and on the characteristics of the hospitals from which they are discharged. Sampling of hospital discharges is based on a two-stage, stratified design. At the first stage, sample hospitals are chosen from strata based on geographic region and number of beds. At the second stage, sample discharges are selected from each hospital in the survey. The overall sampling fraction for all discharges is 1 in 100. We used SAS (SAS Institute Inc., 1985) to compute the weighted number of discharges and hospital discharge rates. To account for the multistage survey design, we used SESUDAAN (Shah, 1981) to compute associated standard errors. To determine numbers and rates of diabetes-related discharges, we selected all discharges for which any of the up to seven listed discharge diagnoses were coded to the International Classification of Diseases, Ninth Revision rubric 250. We used estimates of the total population of the United States (Irwin, 1989) as the denominators in calculating general population rates. We used estimates of the prevalence of diabetes from the National Health Interview Survey (Chapter 2) to estimate numbers of people with diabetes and used these numbers in calculating rates of hospital discharges among people with diabetes. We standardized rates according to the direct method (Fleiss, 1981). We used the 1980 U.S resident population to standardize rates based on the total resident population. We used the 1980 U.S. population of persons with diabetes to standardize rates based on the diabetic population. Results General Information In 1987, the last year for which data are available, an estimated 2.8 million hospital discharges listed diabetes as one of the discharge diagnoses. Among these discharges, the most common primary discharge diagnosis was for diseases of the circulatory system (33.7%), followed by diabetes-specific conditions (17.2%) (Table 4.1). General Population Rates In 1987, diabetes was the primary diagnosis for 474,000 hospital discharges (Table 4.2). From 1980 through 1983, the number and rate of hospital discharges with diabetes as the primary discharge diagnosis were relatively stable, but both figures declined from 1984 through 1987. Trends similar to those noted in the total population were also seen among white males and white females (Tables 4.3-4.4). Among black males, however, temporal trends were not as clear as among whites (Table 4.5). Among black females, the rates decreased steadily from 1981 through 1987 (Table 4.6). Many more hospital discharges had diabetes as any listed diagnosis than as the primary diagnosis. Both the numbers and rates of hospitalizations with diabetes as any listed diagnosis increased from 1980 through 1984, decreased in 1985, and then increased again in subsequent years (Figures 4.1-4.2). In all years, the rate of hospitalization increased with increasing age (Table 4.7). In 1987, the rate of hospitalization for which diabetes was any listed diagnosis increased from 8.7 per 10,000 among those 19 years old or younger to 580.7 per 10,000 among those 75 years old or older. In all years, black women had the highest age-adjusted rate of hospitalizations related to diabetes (Figure 4.3, Tables 4.8-4.11). In 1987, the age-adjusted rate of 183 hospitalizations per 10,000 black women was 36% higher than for black men (135 per 10,000), 95% higher than for white women (94/10,000), and 108% higher than for white men (88 per 10,000). Diabetes Population Rates When rates of hospitalization were calculated by using people known to have diabetes as the denominator, the rates of hospital discharges with diabetes as a primary diagnosis showed a small increase from 1980 to 1983, but then steadily decreased after 1983 (Table 4.12). The temporal trends varied among the four race-sex groups (Tables 4.13-4.16). Among people known to have diabetes, the rates of hospital discharges with diabetes as any listed diagnosis showed a similar temporal trend to that seen for diabetes as a primary diagnosis. The rates increased from 1980 to 1983 and decreased after 1983 (Figure 4.4). The 1987 rate of 402 hospital discharges per 1,000 persons with diabetes was 14% lower than the peak rate in 1983 of 469 per 1,000 persons. In all years, the age-specific rates were highest in the oldest age group, decreased with decreasing age, and leveled off or increased slightly in the youngest age group (Table 4.17). In 1987, the rates ranged from 287 hospital discharges per 1,000 people with diabetes among those younger than age 45 to 591 per 1,000 people with diabetes among those 75 years old or older. Among people known to have diabetes, differences in hospitalization rates for diabetes as any listed diagnosis were not consistent between the four race-sex groups (Figure 4.5, Tables 4.8-4.21). In all except two years, white women had the highest hospital discharge rates. The relative rankings of the other three race-sex groups varied from year to year. In 1987, the rates of hospital discharges with diabetes as any listed diagnosis per 1,000 people with diabetes were 409 for white women, 311 for white men, 365 for black men, and 382 for black women. Rates by Region The rates of hospital discharges with diabetes as a primary diagnosis were highest in the South and lowest in the West (Table 4.22). The West also had the lowest rates of hospital discharges with diabetes as any listed diagnosis (Table 4.23). When the rates were age- and race-adjusted, the rankings between Northeast, Midwest, and South tended to vary from year to year. In all years, the hospitalization rates in the West were at least 25% lower than for the other three regions. Discussion In 1987, diabetes was listed as one of the discharge diagnoses for 2.8 million hospital discharges. In general, during 1980-1987, hospital discharges with diabetes as any listed diagnosis tended to increase; they reached a peak in 1984 and have slightly decreased and leveled off subsequently. Rates of diabetes-related hospitalizations based on general population denominators are influenced by the prevalence of diabetes in the population, the severity of the disease, and the availability and use of health care. Except for a dip in 1985, the rates of diabetes-related hospital discharges in the general population increased during 1980-1987, similar to the trends in numbers of diabetes-related hospital discharges. The rates per 10,000 general population increased with increasing age, reflecting both the increasing prevalence of diabetes and the more frequent occurrence of complications as people age. Rates of diabetes hospitalizations calculated by using the population of people known to have diabetes as the denominator are not affected by prevalence of diabetes, but rather are dependent on disease severity and health care utilization. In 1987, there were 400 hospital discharges related to diabetes for every 1,000 people known to have diabetes. During the years covered in this report, the rates of hospitalization per 1,000 people with diabetes increased during 1980-1983 and decreased thereafter. Among people with diabetes, the age-specific rates of hospitalization were highest in the oldest age group (75 years or older) and decreased with decreasing age until leveling off, or increasing slightly, for the age group younger than age 45. The general tendency of hospitalization rates to increase with increasing age reflects the higher prevalence of complications among older people with diabetes. The tendency for the age group below age 45 to have rates similar to or higher than the 45 to 64 group may reflect the higher proportion, in the younger age group, of people with insulin-dependent diabetes relative to noninsulin-dependent diabetes. We noted some differences in race- and sex-specific rates for diabetes-related hospitalizations. When calculated by using general population denominators, the hospital discharge rate for diabetes as any listed diagnosis was higher among blacks than among whites, with black women having the highest rates and white men having the lowest. Black men tended to have rates about 50% higher than white men, and black women tended to have rates nearly twice as high as white women. When hospital discharge rates were calculated for the population of persons known to have diabetes, however, white women tended to have the highest rates; no consistent differences emerged between the other three race-sex groups. These results suggest that the higher rates of diabetes-related hospitalizations seen among blacks in the general population are at least partly due to the higher prevalence of diabetes among blacks. The most striking regional variation in the hospital discharge rates occurred in the West, where rates of diabetes-related hospital discharges were lowest among the four regions. The age- and race-adjusted rates of hospital discharges for diabetes as any listed diagnosis were 25% to 32% lower in the West than in the other regions. We have emphasized the results based on discharges with diabetes as any listed diagnosis rather than those based on primary diagnosis because the former better indicate the diabetes-related disease burden. Also, listing of primary diagnosis may be more subject to changes in coding practices. For example, in 1983 Medicare instituted the prospective payment system and diagnosis-related groups. After 1983, there was a 30% decrease in hospital discharges with diabetes listed as the primary diagnosis (from 675,000 in 1983 to 474,000 in 1987). The number of discharges with diabetes as any listed diagnosis, on the other hand, slightly decreased (7% decrease) in 1985, but increased thereafter. As a consequence of these different trends, the proportion of diabetes-related hospital discharges for which diabetes was listed as the primary diagnosis decreased from 25% in 1983 to 17% in 1987. The NHDS data also suggest that hospitalization practices for patients with diabetes changed after 1983. As noted, the rate of hospital discharges per 1,000 people with diabetes decreased after 1983. The age-adjusted rate decreased 14% from 1983 to 1987 (from 469 to 402 per 1,000 people with diabetes). The increasing number of diabetes-related hospitalizations, despite decreasing rates of hospitalization among people with diabetes, is due to the disease's increasing prevalence. The methods we used have some limitations when interpreting the results in this chapter. First, the NHDS is limited to the civilian population of the United States and thus probably underestimates diabetes-related hospital discharge rates. This limitation, however, should not affect the temporal patterns nor the relative differences between different population groups. Second, the rates calculated for the population of people with diabetes were computed from estimates derived from the NHIS and thus represent people with diagnosed diabetes. About half of the people with diabetes, however, do not know they have the disease (Harris et al., 1987). Third, the NHDS sample represents hospital discharges and not individual persons. Thus, some people who were hospitalized on more than one occasion for the same condition may have been counted more than once. This is not a serious problem for public health purposes, however, since we are primarily concerned with the impact of diabetes on overall health care utilization-and multiple hospitalizations certainly are a part of health care use. Although not a perfect surveillance mechanism, the NHDS provides useful indicators of the morbidity and public health burden related to diabetes in the United States. Update This section updates data presented in previous sections in light of one additional year of hospitalization data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. In 1988, diabetes was the primary diagnosis for 454,000 hospital discharges and occurred as any one of seven listed diagnoses for 2.8 million hospital discharges (Tables 4.2 and 4.7). Hospital discharge rates with diabetes as primary diagnosis among people known to have diabetes showed a small increase from 1980 to 1983, but then decreased and leveled off (Table 4.12). This temporal trend varied somewhat among the four race-sex groups (Tables 4.13-4.16). Regardless of race and sex, hospital discharge rates for diabetes as primary diagnosis among people known to have diabetes were highest among persons younger than 45 years of age. The next highest rates were found among persons aged 75 or older, and only small differences were seen among those aged 45-64 and those aged 65-74. In general, rates of hospital discharges with diabetes as any listed diagnosis among people known to have diabetes (Figure 1.6) showed a similar temporal trend as those with diabetes as a primary diagnosis (Tables 4.17- 4.21). However, among black females, these rates have tended to increase since 1983. The 1988 rate of 411 hospital discharges per 1,000 black females with diabetes was 27% higher than the corresponding 1983 rate of 324 per 1,000 (Table 4.21). Among white males and white females with diabetes, hospital discharge rates for diabetes as any listed diagnosis tended to increase with age. For black males and black females with diabetes, the rates were higher among the youngest (under 45 years of age) and oldest age groups (75 years and older) than among the middle two age groups (45-64 and 65-74 years of age). Detailed Tables 4.1 Dist. among Hospital Discharges with Diabetes as Diagnosis Table 4.1 Distribution of Primary Diagnosis among all Hospital Discharges with Diabetes as Any Listed Diagnosis, United States, 1988 Primary Diagnosis (ICD-9-CM Codes) Percent Circulatory System (390-459) 33.9 Diabetes (250) 16.3 Digestive System (520-579) 8.4 Respiratory System (460-519) 8.3 Genitourinary System (580-629) 5.2 Injury and Poisoning (800-999) 5.1 Neoplasms (140-239) 4.7 Musculoskeletal System and Connective Tissue 3.3 (710-739) Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279, not 250) 2.8 Skin and Subcutaneous Tissue (680-709) 2.7 Nervous System and Sense Organs (320-389) 2.5 Mental Disorders (290-319) 1.9 Infectious and Parasitic Disease (001-139) 1.9 Other 3.0 4.2-4.6 Hosp. Discharges & Rates w/Diabetes as Primary Diagnosis 4.2 10,000 Pop., by Age and Year, U.S., 80-88 Table 4.2 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 44 44 41 48 45 Rate 6.1 6.1 5.7 6.8 6.4 20-44 Number 114 123 139 135 121 Rate 13.5 14.1 15.6 14.8 13.0 45-64 Number 245 239 241 237 199 Rate 55.0 53.6 54.1 53.0 44.4 65-74 Number 138 144 145 146 130 Rate 87.9 90.4 89.3 88.6 77.5 75+ Number 105 106 95 109 98 Rate 104.0 102.4 89.8 99.8 87.0 Total Number 645 655 661 675 593 Rate 28.4 28.5 28.5 28.8 25.1 Age-adjusted Rate 28.4 28.5 28.3 28.6 24.8 (a) In thousands Table 4.2 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 39 40 49 41 Rate 5.6 5.7 6.9 5.8 20-44 Number 110 113 109 112 Rate 11.6 11.7 11.2 11.4 45-64 Number 160 159 150 134 Rate 35.5 35.4 33.2 29.2 65-74 Number 96 107 92 91 Rate 56.3 61.9 52.1 50.7 75+ Number 75 72 74 76 Rate 65.1 61.0 60.8 60.7 Total Number 480 491 474 454 Rate 20.1 20.4 19.5 18.5 Age-adjusted Rate 19.8 20.0 19.1 18.0 (a) In thousands 4.3 10,000 Pop., by Age and Year, U.S., 80-88, White Males Table 4.3 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 13 16 12 16 13 Rate 4.2 5.2 3.9 5.3 4.3 20-44 Number 36 42 53 42 41 Rate 10.0 11.2 13.8 10.7 10.4 45-64 Number 63 78 71 67 54 Rate 33.1 41.0 37.4 35.6 28.7 65-74 Number 32 45 38 39 32 Rate 52.5 72.8 59.7 59.9 48.7 75+ Number 24 28 25 25 25 Rate 72.8 84.7 74.2 72.4 70.2 Total Number 167 209 198 189 166 Rate 17.6 21.8 20.5 19.4 16.9 Age-adjusted Rate 18.4 22.6 21.1 20.0 17.3 (a) In thousands Table 4.3 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 11 15 16 12 Rate 3.6 5.1 5.5 4.0 20-44 Number 34 29 33 36 Rate 8.4 7.1 7.9 8.6 45-64 Number 47 42 40 43 Rate 24.8 22.1 20.9 22.4 65-74 Number 23 28 26 28 Rate 34.1 40.1 36.5 39.7 75+ Number 19 20 16 22 Rate 51.6 53.9 40.9 54.7 Total Number 133 133 130 141 Rate 13.4 13.4 12.9 13.9 Age-adjusted Rate 13.7 13.7 13.1 14.0 (a) In thousands 4.4 10,000 Pop., by Age and Year, U.S., 80-88, White Females Table 4.4 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 18 18 19 20 22 Rate 6.0 6.2 6.6 7.2 7.8 20-44 Number 40 53 48 53 36 Rate 10.9 14.3 12.7 13.5 9.2 45-64 Number 97 96 102 100 72 Rate 47.0 46.9 49.9 48.9 35.2 65-74 Number 66 74 66 74 59 Rate 82.9 91.9 80.8 88.5 70.3 75+ Number 55 64 53 61 53 Rate 92.0 104.4 84.9 93.8 79.1 Total Number 275 305 289 307 242 Rate 27.5 30.3 28.5 30.0 23.5 Age-adjusted Rate 25.0 27.4 25.9 27.2 21.1 (a) In thousands Table 4.4 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 19 16 18 16 Rate 6.9 5.6 6.4 5.8 20-44 Number 41 38 38 36 Rate 10.3 9.4 9.2 8.8 45-64 Number 57 60 52 42 Rate 28.1 29.4 25.5 20.5 65-74 Number 41 46 41 38 Rate 48.0 53.0 47.2 42.6 75+ Number 35 33 37 35 Rate 51.8 47.0 51.8 47.9 Total Number 194 192 186 167 Rate 18.7 18.4 17.7 15.8 Age-adjusted Rate 17.1 16.8 16.0 14.2 (a) In thousands 4.5 10,000 Pop., by Age and Year, U.S., 80-88, Black Males Table 4.5 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 2 2 2 3 2 Rate 3.5 3.7 4.4 5.1 3.8 20-44 Number 12 13 10 13 13 Rate 25.4 26.6 20.8 25.5 25.6 45-64 Number 21 20 17 16 15 Rate 113.2 103.5 86.4 81.5 73.7 65-74 Number 5 6 7 5 6 Rate 82.8 107.0 113.3 89.9 93.6 75+ Number 3 4 2 3 3 Rate 113.5 151.2 65.9 103.1 88.0 Total Number 43 45 38 40 38 Rate 33.8 34.9 28.9 30.2 28.5 Age-adjusted Rate 43.5 45.4 36.8 37.8 35.5 (a) In thousands Table 4.5 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 3 3 4 4 Rate 4.7 5.5 7.3 6.9 20-44 Number 10 14 12 16 Rate 19.5 26.0 21.5 28.1 45-64 Number 14 16 12 14 Rate 70.8 77.3 56.9 63.9 65-74 Number 4 6 6 4 Rate 58.8 100.9 88.3 53.4 75+ Number 3 3 3 4 Rate 106.5 82.3 102.9 108.5 Total Number 34 42 37 40 Rate 25.0 30.2 26.2 28.2 Age-adjusted Rate 31.4 37.2 32.1 33.7 (a) In thousands 4.6 10,000 Pop., by Age and Year, U.S., 80-88, Black Females Table 4.6 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 5 6 2 3 3 Rate 9.4 11.9 3.8 5.9 5.8 20-44 Number 13 13 16 10 11 Rate 24.5 24.5 28.1 18.1 18.3 45-64 Number 36 38 29 27 29 Rate 154.4 159.8 122.9 111.1 117.5 65-74 Number 14 15 18 16 17 Rate 180.2 194.3 226.1 201.0 200.8 75+ Number 9 8 5 10 9 Rate 193.9 156.2 92.1 186.3 158.6 Total Number 77 80 70 66 68 Rate 54.5 55.9 47.9 45.0 45.2 Age-adjusted Rate 63.4 64.5 55.4 52.5 52.5 (a) In thousands Table 4.6 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 4 4 2 5 Rate 7.7 7.0 4.1 8.6 20-44 Number 11 14 8 12 Rate 18.9 22.1 13.5 18.4 45-64 Number 19 21 24 16 Rate 76.8 83.7 94.7 61.7 65-74 Number 15 13 8 13 Rate 181.7 147.1 91.4 145.0 75+ Number 8 7 6 8 Rate 149.4 121.5 106.2 125.3 Total Number 58 58 49 53 Rate 38.3 37.5 31.3 33.3 Age-adjusted Rate 43.7 42.4 35.9 37.2 (a) In thousands 4.7-4.11 Hosp. Discharge/Rate w/Diabetes as Any Listed Diagnosis 4.7 10,000 Pop., by Age and Year, U.S., 80-88 Table 4.7 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 61 58 52 69 63 Rate 8.5 8.1 7.3 9.7 9.0 20-44 Number 255 278 311 320 326 Rate 30.1 32.0 34.9 35.1 35.0 45-64 Number 798 791 850 873 897 Rate 179.3 177.5 190.7 195.5 200.3 65-74 Number 605 647 687 738 800 Rate 386.8 406.6 424.3 447.5 477.9 75+ Number 507 549 583 669 720 Rate 504.9 532.0 549.1 611.9 641.4 Total Number 2227 2324 2484 2669 2806 Rate 98.0 101.2 107.1 113.9 118.7 Age-adjusted Rate 98.0 100.8 106.2 112.3 116.4 (a) In thousands Table 4.7 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 54 55 62 56 Rate 7.7 7.7 8.7 7.8 20-44 Number 315 316 330 314 Rate 33.2 32.8 33.9 32.0 45-64 Number 834 845 863 858 Rate 185.9 187.6 190.6 186.6 65-74 Number 738 799 800 807 Rate 434.1 461.1 453.2 451.1 75+ Number 663 701 707 743 Rate 575.7 593.0 581.4 596.6 Total Number 2605 2716 2762 2778 Rate 109.1 112.7 113.5 113.0 Age-adjusted Rate 106.6 109.4 109.6 108.4 (a) In thousands 4.8 10,000 Pop., by Age and Year, U.S., 80-88, White Males Table 4.8 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 18 22 16 23 19 Rate 5.9 7.2 5.4 7.9 6.3 20-44 Number 70 82 96 85 92 Rate 19.4 22.0 25.2 21.8 23.2 45-64 Number 248 274 282 289 293 Rate 131.1 145.0 149.2 152.9 155.1 65-74 Number 186 232 224 234 245 Rate 303.8 372.7 351.6 360.5 371.5 75+ Number 129 161 171 203 202 Rate 398.4 484.6 501.7 580.5 564.5 Total Number 652 771 788 834 851 Rate 68.5 80.3 81.5 85.5 86.7 Age-adjusted Rate 73.3 86.0 86.7 91.1 91.6 (a) In thousands Table 4.8 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 16 19 21 17 Rate 5.4 6.4 7.0 5.7 20-44 Number 83 76 81 87 Rate 20.6 18.7 19.7 21.0 45-64 Number 286 270 276 306 Rate 151.3 142.7 145.1 158.5 65-74 Number 245 274 269 289 Rate 364.9 397.9 382.3 405.6 75+ Number 185 205 203 223 Rate 503.8 545.5 524.3 560.5 Total Number 815 845 850 922 Rate 82.4 84.6 84.5 90.9 Age-adjusted Rate 86.4 88.5 87.5 93.4 (a) In thousands 4.9 10,000 Pop., by Age and Year, U.S., 80-88, White Females Table 4.9 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 28 24 24 29 30 Rate 9.4 8.2 8.4 10.3 10.8 20-44 Number 101 123 120 135 126 Rate 27.7 33.2 31.5 34.9 31.9 45-64 Number 319 327 337 357 346 Rate 154.9 159.4 164.8 174.5 169.5 65-74 Number 274 320 323 353 370 Rate 343.1 395.7 393.1 423.1 438.7 75+ Number 272 335 307 356 397 Rate 456.7 548.0 488.1 550.2 597.6 Total Number 993 1130 1111 1230 1269 Rate 99.2 112.1 109.4 120.2 123.2 Age-adjusted Rate 87.5 97.7 95.3 103.9 105.1 (a) In thousands Table 4.9 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 27 22 23 22 Rate 9.5 7.9 8.1 7.9 20-44 Number 124 120 133 118 Rate 30.9 29.6 32.5 28.6 45-64 Number 316 309 316 297 Rate 154.9 151.9 155.1 143.8 65-74 Number 319 335 342 323 Rate 374.3 386.8 389.3 364.0 75+ Number 338 350 353 383 Rate 495.4 500.1 493.2 522.7 Total Number 1123 1136 1168 1143 Rate 108.3 108.7 111.0 107.8 Age-adjusted Rate 92.6 92.1 93.7 89.5 (a) In thousands 4.10 10,000 Pop., by Age and Year, U.S., 80-88, Black Males Table 4.10 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 2 2 3 3 2 Rate 3.5 4.2 5.0 5.1 3.8 20-44 Number 21 23 19 26 23 Rate 45.4 48.4 39.4 50.8 45.3 45-64 Number 51 53 45 53 60 Rate 272.5 276.3 230.7 271.8 300.8 65-74 Number 20 22 23 26 29 Rate 356.9 385.0 399.4 431.3 483.9 75+ Number 12 14 13 12 16 Rate 428.5 494.8 436.3 382.6 520.2 Total Number 106 114 103 119 131 Rate 84.1 88.9 78.7 89.7 97.3 Age-adjusted Rate 114.9 121.9 108.2 120.4 133.3 (a) In thousands Table 4.10 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 3 4 5 5 Rate 5.4 6.5 9.3 9.4 20-44 Number 24 28 26 31 Rate 44.6 52.3 47.7 54.3 45-64 Number 62 59 52 61 Rate 307.2 290.4 249.7 289.6 65-74 Number 29 31 32 37 Rate 461.8 490.0 500.9 559.4 75+ Number 22 24 24 25 Rate 684.7 745.2 705.8 732.8 Total Number 139 147 139 159 Rate 101.7 105.6 98.8 111.0 Age-adjusted Rate 140.6 145.1 135.3 150.9 (a) In thousands 4.11 10,000 Pop., by Age and Year, U.S., 80-88, Black Females Table 4.11 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 6 9 3 7 5 Rate 11.6 16.5 5.5 12.3 9.1 20-44 Number 32 40 41 36 36 Rate 61.8 73.6 73.7 62.5 60.4 45-64 Number 88 106 99 88 100 Rate 377.6 450.9 418.5 364.7 410.6 65-74 Number 42 57 46 58 73 Rate 536.9 712.0 570.6 710.7 879.3 75+ Number 27 29 31 35 41 Rate 563.0 602.9 623.0 675.7 765.5 Total Number 195 240 221 224 255 Rate 137.9 167.6 151.8 151.3 170.1 Age-adjusted Rate 162.6 196.7 178.0 177.4 200.2 (a) In thousands Table 4.11 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 5 6 4 6 Rate 9.6 11.2 6.6 10.7 20-44 Number 42 46 39 38 Rate 69.0 75.0 62.2 60.1 45-64 Number 78 96 103 98 Rate 315.4 382.9 403.8 380.1 65-74 Number 65 71 62 82 Rate 765.5 827.7 712.8 931.2 75+ Number 42 45 40 45 Rate 745.8 787.5 672.6 729.3 Total Number 231 264 247 269 Rate 151.8 171.4 157.9 169.6 Age-adjusted Rate 176.2 198.3 183.2 196.6 (a) In thousands 4.12-4.16 Hosp. Discharge Rate for Diabetes as Primary Diagnosis 4.12 1,000 Diabetic Pop., by Age and Year, U.S., 80-88 Table 4.12 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 156.7 175.1 183.0 182.4 167.3 45-64 102.5 93.9 93.9 91.1 84.3 65-74 90.3 105.5 94.8 111.9 73.8 75+ 121.4 111.6 117.7 124.8 89.6 Total 111.6 112.8 112.3 116.7 95.6 Age-adjusted 111.6 113.7 113.3 117.5 96.8 Table 4.12 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 144.0 145.7 115.7 140.1 45-64 68.5 55.9 58.9 54.6 65-74 51.7 67.4 54.1 53.2 75+ 68.2 56.2 61.9 69.2 Total 75.9 72.5 69.6 71.5 Age-adjusted 77.2 74.6 68.0 71.3 4.13 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, White Male Table 4.13 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 157.7 156.5 167.5 140.7 152.8 45-64 68.2 76.2 72.4 73.1 66.7 65-74 54.1 82.1 88.3 93.4 54.3 75+ 92.4 123.1 83.9 77.0 77.6 Total 80.5 96.3 94.8 91.1 79.5 Age-adjusted 83.7 98.8 94.9 90.8 80.1 Table 4.13 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 112.9 145.6 84.6 97.9 45-64 53.7 33.8 37.9 46.3 65-74 33.8 44.1 36.4 50.8 75+ 54.0 50.0 37.7 56.4 Total 58.0 52.0 47.3 59.6 Age-adjusted 58.9 58.4 45.6 58.0 4.14 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, White Female Table 4.14 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 120.0 168.5 141.4 180.7 132.8 45-64 98.8 96.6 103.6 92.4 68.7 65-74 88.3 120.5 84.6 117.2 73.9 75+ 105.5 107.2 125.7 132.6 88.8 Total 100.9 116.1 108.3 119.5 84.0 Age-adjusted 100.7 117.0 108.5 120.3 84.2 Table 4.14 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 120.4 91.2 108.8 146.9 45-64 62.8 55.9 54.6 45.9 65-74 46.3 67.8 55.6 45.6 75+ 59.4 48.2 69.4 68.6 Total 67.0 63.7 67.8 64.0 Age-adjusted 68.0 64.0 66.5 66.8 4.15 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, Black Male Table 4.15 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 184.3 226.4 202.0 422.9 277.2 45-64 114.7 106.5 92.8 78.3 68.0 65-74 76.6 91.6 94.4 63.0 64.5 75+ 109.6 190.6 78.7 129.2 78.9 Total 122.1 131.9 112.0 114.2 97.5 Age-adjusted 116.1 136.0 110.2 142.0 105.2 Table 4.15 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 204.9 206.5 175.4 244.5 45-64 64.3 77.5 56.4 54.7 65-74 36.9 70.4 55.0 41.5 75+ 99.3 68.8 98.6 71.9 Total 81.8 100.8 84.1 87.1 Age-adjusted 86.9 96.9 83.1 86.9 4.16 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, Black Female Table 4.16 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 159.1 202.7 206.3 116.5 127.6 45-64 142.7 132.3 90.6 88.9 101.8 65-74 136.0 112.8 114.2 82.5 89.7 75+ 128.2 107.8 68.6 116.4 93.0 Total 142.9 136.4 109.8 94.9 101.4 Age-adjusted 141.7 135.8 113.7 96.1 101.8 Table 4.16 Hospital Discharge Rate for Diabetes as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 169.9 199.1 98.0 121.5 45-64 73.4 74.8 86.0 65.5 65-74 83.9 87.7 55.9 83.0 75+ 70.6 55.3 43.0 54.5 Total 89.4 90.8 72.3 78.4 Age-adjusted 92.6 97.0 73.8 78.2 4.17-4.21 Discharge Rate for Diabetes as Any Listed Diagnosis 4.17 1,000 Diabetic Pop., by Age & Year, U.S., 80-88 Table 4.17 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 313.4 353.7 369.3 388.4 391.3 45-64 334.0 310.8 331.3 335.8 380.3 65-74 397.7 474.2 450.5 565.4 455.2 75+ 589.2 579.4 719.9 764.8 660.5 Total 385.2 400.0 422.0 461.6 452.6 Age-adjusted 385.2 401.3 427.2 469.3 443.7 Table 4.17 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 355.5 354.3 287.3 338.5 45-64 358.2 296.7 338.1 348.7 65-74 398.8 501.6 470.1 473.6 75+ 602.7 546.3 592.0 679.6 Total 412.2 401.1 405.4 437.5 Age-adjusted 404.8 397.9 401.8 429.1 4.18 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, White Male Table 4.18 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 284.5 280.7 291.4 265.7 313.0 45-64 270.4 269.5 288.4 313.8 360.6 65-74 312.8 420.2 520.1 561.9 414.5 75+ 505.4 704.7 567.5 617.3 623.5 Total 313.5 355.7 376.7 402.2 408.7 Age-adjusted 319.0 376.0 391.5 415.9 405.6 Table 4.18 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 252.2 316.3 176.3 214.7 45-64 328.0 218.6 262.3 327.0 65-74 361.4 437.8 381.1 518.2 75+ 527.3 507.0 483.3 577.4 Total 355.4 328.9 308.3 390.0 Age-adjusted 353.2 336.3 311.5 395.0 4.19 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, White Female Table 4.19 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 269.3 350.3 302.5 407.1 355.9 45-64 325.6 328.3 342.4 329.9 331.2 65-74 365.5 519.0 411.4 560.0 460.8 75+ 523.7 562.5 722.8 777.5 670.3 Total 364.5 429.6 416.1 478.0 440.9 Age-adjusted 355.8 417.2 410.2 470.6 420.1 Table 4.19 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 300.3 240.8 304.9 393.3 45-64 346.0 289.0 331.3 321.9 65-74 360.7 494.8 459.4 390.1 75+ 568.7 513.3 660.0 748.0 Total 388.3 376.3 425.2 436.5 Age-adjusted 375.0 368.2 409.4 415.8 4.20 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, Black Male Table 4.20 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 309.2 389.8 354.3 770.3 461.8 45-64 276.1 284.2 247.7 260.9 277.8 65-74 330.3 329.6 332.6 302.3 333.6 75+ 413.7 623.8 521.4 479.2 466.0 Total 304.1 336.1 305.2 339.5 332.8 Age-adjusted 316.6 365.1 329.4 393.2 352.6 Table 4.20 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 423.6 385.6 347.3 445.1 45-64 278.9 291.1 247.4 248.0 65-74 290.1 341.9 312.0 434.9 75+ 637.9 623.6 675.9 485.8 Total 332.8 352.2 317.5 342.8 Age-adjusted 360.6 370.5 345.7 367.0 4.21 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, Black Female Table 4.21 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 343.8 502.1 513.6 365.0 370.8 45-64 349.1 373.4 308.6 291.9 355.7 65-74 405.1 413.2 288.3 291.7 392.6 75+ 372.4 416.2 464.5 422.0 448.6 Total 361.8 409.0 347.8 319.5 381.3 Age-adjusted 366.4 412.7 362.3 324.0 381.9 Table 4.21 Hospital Discharge Rate for Diabetes as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 511.2 598.6 391.2 327.1 45-64 301.1 342.0 366.6 403.4 65-74 353.4 493.4 435.9 533.4 75+ 352.5 358.4 272.2 316.9 Total 354.6 414.4 364.7 399.9 Age-adjusted 359.2 429.1 375.1 411.4 4.22 Hosp. Discharges & Rates with Diabetes as Primary Diagnosis Table 4.22 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number (a) 152 143 150 144 137 Rate 31.0 29.1 30.4 29.0 27.7 Adjusted Rate (b) 26.8 28.2 26.4 24.9 21.9 North Number 185 179 180 185 152 Central Rate 31.4 30.3 30.6 31.3 25.7 Adjusted Rate 27.8 31.1 28.6 28.7 23.8 South Number 232 254 245 255 219 Rate 30.7 32.9 31.3 32.0 27.1 Adjusted Rate 28.0 31.7 29.1 30.4 23.8 West Number 76 79 86 91 84 Rate 17.4 17.9 18.9 19.8 17.9 Adjusted Rate 16.2 19.0 18.0 16.9 16.0 (a) In thousands (b) Adjusted for age and race Table 4.22 Number of Discharges with Diabetes as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number (a) 119 94 99 96 Rate 24.0 18.8 19.7 19.0 Adjusted Rate (b) 21.8 16.9 17.4 17.4 North Number 115 128 126 120 Central Rate 19.5 21.7 21.1 20.1 Adjusted Rate 18.0 18.9 18.8 18.2 South Number 172 191 167 172 Rate 21.1 23.0 20.0 20.2 Adjusted Rate 17.8 19.5 16.9 18.0 West Number 73 78 82 66 Rate 15.2 15.9 16.4 13.0 Adjusted Rate 13.3 15.0 14.1 9.7 (a) In thousands (b) Adjusted for age and race 4.23 Hosp. Discharges/Rates w/ Diabetes as Any Listed Diagnosis Table 4.23 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number (a) 571 558 594 618 649 Rate 116.1 113.2 120.5 124.9 130.7 Ajusted Rate (b) 99.9 107.2 105.2 108.8 111.0 North Number 641 661 699 719 741 Central Rate 108.8 111.9 118.6 121.9 125.3 Ajusted Rate 96.1 113.1 108.6 109.8 113.9 South Number 732 802 860 950 1029 Rate 96.6 104.0 109.6 119.1 127.3 Ajusted Rate 88.5 102.7 104.1 113.6 117.0 West Number 284 304 330 382 387 Rate 65.3 68.5 73.1 82.9 82.6 Ajusted Rate 60.7 72.6 66.1 73.3 76.2 (a) In thousands (b) Adjusted for age and race Table 4.23 Number of Discharges with Diabetes as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number (a) 672 635 648 680 Rate 134.8 126.9 128.9 134.8 Ajusted Rate (b) 118.0 111.0 111.9 117.2 North Number 664 707 736 723 Central Rate 112.2 119.3 123.5 121.1 Ajusted Rate 103.6 105.7 108.0 108.3 South Number 864 954 918 1011 Rate 105.5 114.9 109.4 118.8 Ajusted Rate 92.8 100.3 96.1 108.0 West Number 405 421 460 364 Rate 84.8 86.3 92.6 72.0 Ajusted Rate 74.7 75.5 79.6 54.3 (a) In thousands (b) Adjusted for age and race CARDIOVASCULAR DISEASE Introduction Cardiovascular disease is the leading cause of mortality among persons with diabetes. The last analysis of national mortality data that examined the toll of cardiovascular disease mortality among the diabetic population was from 1978 (Harris & Entmacher, 1985). We examine the latest national data concerning mortality and hospitalizations from cardiovascular disease among people with diabetes. Using national vital statistics data from 1980 to 1986, we determined the nu age-specific mortality rates and crude and age-adjusted mortality rates by calendar year, age, and race-sex groups. Using the National Hospital Discharge Survey (NHDS) data from 1980 through 1987, we calculated the number of persons with diabetes who were hospitalized for major CVD, IHD, and stroke and we calculated age-specific hospital discharge rates and crude and age-adjusted hospital discharge rates by calendar year, age, and race-sex groups. Methods For the years 1980-1986, the number of deaths from major CVD (ICD-9 390-448), IHD (ICD-9 410-414), and stroke (ICD-9 430-434, 436-438) coded as the underlying cause of death and diabetes (ICD-9 250) as a contributing cause of death were determined. For the years 1980-1987, we determined, using data from the NHDS, the number of hospital discharges with major CVD (ICD-9-CM 390-448), IHD (ICD-9-CM 410-414), and stroke (ICD-9-CM 430-434, 436-438) listed as the primary diagnosis and diabetes (ICD-9-CM 250) listed as a secondary diagnosis. Rates of mortality and hospitalization were calculated using the estimated number of persons with diabetes determined from the 1980-1987 National Health Interview Surveys (Chapter 2). Crude, age-adjusted, and age-specific rates were calculated. Age-standardization was done using the direct method with the 1980 diabetic population of the United States as the standard. Results Major CVD Mortality The total number of deaths coded with major CVD as the underlying cause and diabetes as a contributing cause increased during the 7-year period with 75,594 such deaths reported in 1980 compared with 80,129 in 1986 (Table 5.1, Figure 5.1). Despite this increase in the absolute number of major CVD deaths among persons with diabetes, the age-adjusted mortality rate declined, in general, during the 7-year period, although the rates increased in 1982 and 1983 (Figure 5.2). The rate in 1986 was about 16% lower than the rate in 1980. Although the age-specific mortality rates vary greatly, the decrease occurred primarily among persons with diabetes who were 75 years or older, for whom the mortality rate in 1986 was 27% lower than that in 1980 (Table 5.1). A 28% increase in mortality rates occurred in persons aged 44 years or younger. Furthermore, all four race-sex groups had lower CVD mortality rates in 1986 than in 1980 (Tables 5.2-5.5). The mortality rate from major CVD increased sharply with age, with persons with diabetes aged 75 years or older experiencing mortality rates from CVD that were about 30 to 50 times higher than those of persons with diabetes who were aged 44 years or younger. During the 7-year period, the age-adjusted mortality rate was highest for white males and was followed by that of white females, black males, and black females in order of decreasing rank (Figure 5.3). The age-specific rates for white males were higher than those for black males at every age group except for those 0-44 years old. The age-specific rates for the two oldest age groups of white females exceeded those of black females. When the mortality rates are calculated based on the number of deaths with diabetes and major CVD listed anywhere on the death certificate, the trends are the same. The magnitude of the age-adjusted rate, however, is about 60% higher in this situation (data not shown). IHD Mortality Because IHD constitutes the bulk of CVD among persons with diabetes, the patterns described for major CVD previously also hold for IHD (Tables 5.6-5.10, Figures 5.1-5.2). Stroke Mortality The number of deaths with stroke as the underlying cause of death and diabetes as a contributing cause of death decreased from 12,735 in 1980 to 11,705 in 1986 (Table 5.11, Figure 5.1). The age-adjusted mortality rate declined from 220 deaths per 100,000 diabetic population in 1980 to 156 deaths per 100,000 diabetic population in 1986, a 29% decline (Figure 5.2). The age-specific rates suggest that this decrease occurred primarily in persons aged 45 years and older with the steepest decline (38%) occurring in persons with diabetes who were 75 years or older. Stroke mortality rates remained essentially unchanged in the 0- to 44-year-old age group. With advancing age, the age-specific stroke mortality rates increased sharply. The decreases in stroke mortality occurred in all four race-sex groups (Tables 5.12-5.15). Furthermore, during the 7-year period, the mortality rates for stroke were similar for the four race-sex groups. The mortality rates calculated based on the number of deaths with diabetes and stroke listed anywhere on the death certificate were from 2.15 to 2.41 times higher than those based on stroke as the underlying cause of death and diabetes as a contributing cause. The trends, however, are the same (data not shown). Major CVD Hospitalizations The number of hospital discharges with major CVD as the primary diagnosis and diabetes as a co-diagnosis increased in every year from 1980 through 1987 except in 1985. In 1987, an estimated 902,000 such hospitalizations were recorded (Table 5.16, Figure 5.4). From 1980 to 1987, the overall age-adjusted hospital discharge rate increased (Table 5.16, Figure 5.5). In 1987, the overall age-adjusted hospital discharge rate was 34% higher than in 1980. In every year from 1980 to 1987, rates of hospital discharge increased with age, with rates among persons 75 years or older 8 to 12.5 times higher than rates among persons less than 45 years. Increases occurred in all age groups (Table 5.16) and in each of the four race-sex groups (Table 5.17). Hospital discharge rates for white males and females exceeded those for black males and females in every year. IHD Hospitalizations In 1980, an estimated 245,000 hospitalizations with IHD as the primary diagnosis and diabetes as a co-diagnosis were recorded (Table 5.18, Figure 5.4). By 1987, this number had increased to 390,000. In general, the IHD hospitalization rate follows the same patterns as that for major CVD (Table 5.18, Figure 5.5). In 1987, the overall age-adjusted hospital discharge rate was 38% higher than in 1980. Hospitalization rates for IHD increased rapidly with increasing age and were greatest for white males, followed by those for white females (Table 5.19, Figure 5.6). Hospital discharge rates for black males and females were similar and were appoximately half those of white males and females. Among white males and females, hospital discharge rates peaked in 1984 and 1983, respectively, whereas among black males and females hospital discharge rates were stable before 1984 and increased thereafter. Stroke Hospitalizations The total number of hospitalizations for stroke as the primary diagnosis and diabetes as a co-diagnosis also increased between 1980 and 1987, with an estimated 77,000 such hospitalizations occurring in 1980 and 128,000 in 1987 (Table 5.20). The age-adjusted hospital discharge rate increased from 1980 through 1983 and subsequently leveled off (Table 5.20, Figure 5.5). In 1983, the overall age-adjusted hospital discharge rate was 38% higher than in 1980. In every age group, hospitalizations for strokes appear to have increased during the 8-year period. Hospital discharge rates increased with age, with hospital discharge rates among those older than 74 years of age exceeding the rates among those less than 45 years old by a factor ranging from 11 to 56. Hospital discharge rates among the four race-sex groups are similar (Table 5.21). Hospital discharge rates among white females, black males, and black females generally increased during the 8-year period, whereas hospital discharge rates for white males increased from 1980 to 1983 and then stabilized. Discussion The analysis of national mortality data suggests that mortality rates from major CVD, IHD, and stroke among persons with diabetes decreased between 1980 and 1986 and that this decline occurred among all four race-sex groups and all age groups except for those less than 45 years of age. Hospital discharge data, on the other hand, indicate that hospitalization rates for major CVD, IHD, and stroke among people with diabetes increased between 1980 and 1987. In general, these increases were observed among all four race-sex groups and all age groups. Interpreting the mortality data is complicated by several potential problems. Death certificate data are known to have limitations. For example, as many as 16% of IHD deaths and 40% of stroke deaths may not be identified as such on death certificates (Kuller et al., 1969; Matsumoto et al., 1973; Corwin et al., 1982; Fortmann et al., 1986; Folsom et al., 1987). Furthermore, in as many as half of all deaths among persons with diabetes, the death certificate fails to mention diabetes (Harris & Entmacher, 1985). The National Health Interview Survey results may underestimate the diabetic population by half further complicating the interpretation of the mortality data (Harris et al., 1987). Consequently, the absolute magnitude of the mortality rate remains only an approximation. If the sources of variation remained constant during the 7-year period, and we have no reason to believe that they did not, the temporal trends and relative differences between groups reported herein should be generally valid. As with the mortality data, sources of error affect the estimates of both the numerator and denominator of the hospital discharge rate. Changes in the type and frequency of diagnostic procedures and the introduction of new treatments may have affected the number of hospitalized patients who were diagnosed with coronary heart disease (Kuller, 1988). For example, increased utilization of coronary arteriography in patients with acute myocardial infarction has been reported (Gore et al., 1988). Data from the NHDS have also shown large increases in the number and rates of cardiac catheterization in the 1980s. In addition, how the increased use of CAT-scans has influenced the diagnosis of stroke is unknown. Changes in referral patterns might have contributed to changing trends, but no data are available to evaluate this possible influence. A major change, however, occurred when diagnosis related groups (DRGs) were introduced in 1983. DRGs have complicated the interpretation of trend data. Between 1980 and 1987, the co-diagnosis of diabetes increased from 12.4% to 17.4% of hospitalizations for CVD, from 13.7% to 18.0% of hospitalizations for IHD, and from 12.8% to 18.7% of hospitalizations for stroke. National data have demonstrated decreases in CVD mortality in the population of the United States (Sempos et al., 1988). From 1980 to 1986, the age-adjusted mortality rates for major CVD, IHD, and cerebrovascular disease decreased by about 15.3%, 20.7%, and 24.0%, respectively (NCHS, 1983, 1988a). Compared with 1980, mortality rates in 1986 among persons with diabetes were 16% lower for CVD, 17.5% lower for IHD, and 29% lower for stroke. Thus, persons with diabetes appear to have shared in the decline in CVD-related mortality in the general population. Whereas hospitalization rates for major CVD, IHD, and stroke among people with diabetes have increased, mortality rates have decreased for these same conditions during the same period. The same trends have been described for the total population (CDC, 1989). Although DRGs may explain some of the increase in hospitalization rates, other explanations include changes in hospital use and better survival from IHD and stroke with subsequent readmission for the same conditions. Unfortunately, the NHDS cannot separate repeat hospitalizations from incident hospitalizations. Mortality rates for major CVD and IHD were higher among diabetic men than diabetic women regardless of race. Hospitalization rates among persons with diabetes also were higher among white men than white women but were similar among black men and black women. This contrasts with the higher CVD and IHD mortality rates among men in the general population. Among diabetic persons of both races, the mortality rates and hospitalization rates for stroke were similar among men and women. White persons with diabetes have higher age-adjusted mortality rates for major CVD and IHD but a similar age-adjusted mortality rate for stroke. Similarly, whites are hospitalized at higher rates for major CVD and IHD than blacks and at the same rate for stroke. Reasons for the lower hospitalization rates among blacks could include fewer complications from diabetes among blacks, inaccessability to hospitals, or higher out-of- hospital mortality rates. During this decade, the mortality rates for major CVD, IHD, and stroke among persons with diabetes have decreased. The decreases in mortality have occurred in all age groups older than 44 years and have occurred among black males and females and white males and females. In contrast, the hospitalization rates for these conditions have increased during the same period among all four groups. Update This section updates data presented in previous sections in light of one additional year of hospitalization data and two additional years of mortality data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. Among persons with diabetes, age-standardized mortality rates attributed to major cardiovascular disease (CVD), ischemic heart disease, and stroke increase dramatically with age. Mortality rates from these diseases were lower in 1988 than in 1980, with most of the decline occurring between 1983 and 1984 (Figure 1.7, Tables 5.1, 5.6, and 5.11). The declines for these two years were apparent among persons with diabetes who were 65 years of age or older. Cardiovascular mortality among persons with diabetes younger than 45 years of age tended to increase rather than decrease. Of the four race-sex groups examined, white males had the highest age- standardized mortality rates for CVD (Figure 1.8, Tables 5.2-5.5). Rates for black males exceeded those for white males among persons younger than age 45. Although the age-standardized rates for white females were higher than those for black females, black females under the age of 65 had higher rates than white females. Detailed Tables 5.1-5.5 Deaths w/ Cardiovascular Disease as Underlying Cause 5.1 Mortality Rate per 100,000 Diabetic Pop., Age & Year, 80-88 Table 5.1 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 834 860 859 955 1057 Rate 82.6 90.3 87.3 95.3 106.3 45-64 Number 14931 15201 14875 15248 15246 Rate 624.9 597.5 579.6 586.6 646.4 65-74 Number 23024 22775 22905 23656 23880 Rate 1512.5 1668.8 1501.5 1812.6 1359.3 75+ Number 36802 36206 37002 38527 38812 Rate 4273.2 3820.9 4565.6 4407.3 3559.9 Total Number 75594 75044 75657 78397 78999 Rate 1307.3 1292.0 1285.3 1356.2 1274.2 Age-adjusted Rate 1307.2 1271.1 1330.0 1392.6 1173.7 Table 5.1 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 995 1110 1139 1120 Rate 95.8 106.0 83.5 102.6 45-64 Number 15317 15205 15100 14813 Rate 657.4 534.0 591.8 602.1 65-74 Number 24379 23910 24527 24221 Rate 1317.0 1500.8 1440.5 1421.4 75+ Number 39322 39895 39885 40716 Rate 3572.5 3106.7 3341.9 3721.7 Total Number 80023 80129 80658 80876 Rate 1266.2 1183.3 1184.1 1273.6 Age-adjusted Rate 1167.2 1097.0 1136.1 1195.2 5.2 Mortality Rate per 100,000 Diabetic Pop., White Males Table 5.2 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 386 386 371 481 503 Rate 124.1 104.6 96.5 117.9 142.2 45-64 Number 7150 7215 7104 7103 7090 Rate 779.4 709.3 727.1 771.9 871.6 65-74 Number 9794 9831 10052 10119 10328 Rate 1646.5 1777.3 2339.2 2429.1 1745.6 75+ Number 12088 11952 11959 12681 12864 Rate 4727.5 5237.6 3975.2 3863.8 3970.8 Total Number 29419 29384 29491 30387 30787 Rate 1415.0 1355.6 1409.7 1465.9 1478.2 Age-adjusted Rate 1481.2 1559.3 1525.1 1554.5 1435.9 Table 5.2 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 432 514 523 509 Rate 110.2 170.7 90.4 105.2 45-64 Number 7189 6942 6956 6638 Rate 823.2 561.3 660.9 709.0 65-74 Number 10640 10497 10586 10713 Rate 1566.7 1679.5 1501.5 1921.6 75+ Number 12846 12964 13142 13679 Rate 3666.3 3200.7 3129.3 3545.7 Total Number 31109 30921 31208 31541 Rate 1355.6 1204.2 1132.4 1334.6 Age-adjusted Rate 1317.9 1180.6 1150.2 1345.3 5.3 Mortality Rate per 100,000 Diabetic Pop., White Females Table 5.3 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 248 242 269 230 310 Rate 52.1 57.6 56.6 57.0 70.7 45-64 Number 5108 5136 4914 5128 5215 Rate 521.3 514.9 498.5 474.4 499.1 65-74 Number 10271 10144 10012 10422 10334 Rate 1370.9 1644.4 1276.1 1655.4 1287.8 75+ Number 21808 21440 22108 22549 22588 Rate 4205.7 3601.6 5200.6 4922.9 3811.3 Total Number 37436 36962 37309 38333 38448 Rate 1374.6 1405.6 1397.1 1490.3 1335.6 Age-adjusted Rate 1211.8 1192.1 1326.4 1375.0 1125.2 Table 5.3 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 302 332 306 311 Rate 60.3 56.2 59.9 87.4 45-64 Number 5027 5117 4936 4846 Rate 550.4 477.8 516.8 525.1 65-74 Number 10348 9872 10390 9914 Rate 1168.8 1459.0 1395.5 1198.5 75+ Number 22911 23123 22917 22897 Rate 3859.2 3396.0 4280.5 4472.5 Total Number 38594 38446 38553 37970 Rate 1334.2 1273.4 1403.9 1450.6 Age-adjusted Rate 1120.5 1097.1 1228.9 1213.9 5.4 Mort. Rate per 100,000 Diabetic Pop., Black Males Table 5.4 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 97 121 97 118 125 Rate 132.9 188.0 157.2 321.5 226.4 45-64 Number 1049 1154 1097 1243 1179 Rate 563.7 622.2 609.4 608.5 547.4 65-74 Number 949 967 928 1084 1077 Rate 1541.6 1429.9 1313.8 1270.8 1221.1 75+ Number 784 734 797 904 873 Rate 2673.4 3186.6 3191.0 3701.9 2489.9 Total Number 2879 2976 2920 3350 3254 Rate 822.7 874.0 865.7 955.3 826.2 Age-adjusted Rate 1060.1 1141.0 1100.4 1193.5 958.0 Table 5.4 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 118 134 159 157 Rate 187.9 161.5 175.1 195.0 45-64 Number 1297 1249 1319 1305 Rate 584.1 612.8 629.3 528.7 65-74 Number 1166 1197 1220 1230 Rate 1180.2 1320.5 1176.2 1448.3 75+ Number 891 1026 1028 1043 Rate 2594.3 2623.9 2939.7 2028.4 Total Number 3472 3607 3726 3736 Rate 830.6 865.9 848.5 805.7 Age-adjusted Rate 971.2 1019.8 1038.1 935.9 5.5 Mortality Rate per 100,000 Diabetic Pop., Black Females Table 5.5 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 91 98 106 113 101 Rate 81.2 101.3 123.6 97.4 92.7 45-64 Number 1469 1541 1569 1552 1546 Rate 584.2 543.1 486.8 515.8 549.3 65-74 Number 1799 1661 1652 1770 1871 Rate 1739.3 1212.9 1033.1 885.5 1004.1 75+ Number 1802 1794 1798 2045 2102 Rate 2530.6 2546.1 2652.1 2446.5 2280.9 Total Number 5162 5096 5129 5483 5621 Rate 959.1 866.9 806.7 782.8 840.4 Age-adjusted Rate 1090.4 940.6 889.7 827.6 847.2 Table 5.5 Number of Deaths with Major Cardiovascular Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1985 1986 1987 1988 Age 0-44 Number 117 111 126 127 Rate 128.1 127.4 115.7 94.0 45-64 Number 1552 1630 1593 1690 Rate 599.7 581.3 569.6 694.6 65-74 Number 1905 2039 1992 1991 Rate 1041.8 1417.0 1398.1 1288.0 75+ Number 2258 2343 2337 2590 Rate 1918.1 1853.0 1594.2 1842.1 Total Number 5834 6125 6050 6399 Rate 896.5 960.2 892.7 950.1 Age-adjusted Rate 830.1 911.4 861.0 916.9 5.6-5.10 Deaths w/ Ischemic Heart Disease as Underlying Cause 5.6 Mort. Rate per 100,000 Diabetic Pop., Age & Year, 80-88 Table 5.6 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 506 509 565 584 637 Rate 50.1 53.5 57.4 58.3 64.1 45-64 Number 10448 10511 10398 10530 10329 Rate 437.2 413.1 405.1 405.1 437.9 65-74 Number 15487 15178 15618 15755 15899 Rate 1017.4 1112.2 1023.8 1207.2 905.0 75+ Number 21725 21519 21951 23002 22867 Rate 2522.6 2270.9 2708.5 2631.3 2097.4 Total Number 48169 47719 48539 49876 49734 Rate 833.0 821.5 824.6 862.8 802.2 Age-adjusted Rate 833.0 811.1 850.4 887.3 742.8 Table 5.6 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 613 671 656 630 Rate 59.1 64.1 48.1 57.7 45-64 Number 10204 9975 9815 9485 Rate 438.0 350.3 384.7 385.5 65-74 Number 16084 15624 15925 15640 Rate 868.9 980.7 935.3 917.8 75+ Number 23170 23518 23166 23677 Rate 2105.0 1831.4 1941.1 2164.3 Total Number 50074 49793 49566 49433 Rate 792.3 735.3 727.7 778.4 Age-adjusted Rate 733.5 686.9 702.7 733.3 5.7 Mort. Rate per 100,000 Diabetic Pop., White Males Table 5.7 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 278 269 273 336 345 Rate 89.3 72.9 71.0 82.4 97.5 45-64 Number 5411 5455 5360 5316 5152 Rate 589.8 536.3 548.6 577.7 633.3 65-74 Number 6979 6936 7258 7170 7298 Rate 1173.2 1253.9 1689.0 1721.2 1233.5 75+ Number 7530 7586 7552 8044 8101 Rate 2944.9 3324.3 2510.3 2451.0 2500.6 Total Number 20199 20246 20446 20868 20898 Rate 971.5 934.0 977.3 1006.7 1003.4 Age-adjusted Rate 1006.8 1059.5 1057.6 1071.2 975.9 Table 5.7 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 300 345 330 322 Rate 76.5 114.6 57.0 66.6 45-64 Number 5192 4962 4887 4638 Rate 594.5 401.2 464.3 495.4 65-74 Number 7406 7280 7290 7358 Rate 1090.5 1164.8 1034.0 1319.8 75+ Number 8037 8174 8115 8472 Rate 2293.8 2018.1 1932.3 2196.0 Total Number 20936 20763 20623 20790 Rate 912.3 808.6 748.3 879.7 Age-adjusted Rate 887.7 793.0 761.8 890.8 5.8 Mort. Rate per 100,000 Diabetic Pop., White Females Table 5.8 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 144 151 178 138 183 Rate 30.3 36.0 37.5 34.2 41.7 45-64 Number 3645 3527 3488 3593 3632 Rate 372.0 353.6 353.9 332.4 347.6 65-74 Number 6984 6776 6876 6970 6954 Rate 932.2 1098.4 876.4 1107.1 866.6 75+ Number 12825 12522 13025 13312 13146 Rate 2473.3 2103.5 3063.9 2906.3 2218.1 Total Number 23599 22976 23569 24014 23915 Rate 866.5 873.7 882.6 933.6 830.8 Age-adjusted Rate 772.8 754.8 839.8 867.6 709.4 Table 5.8 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 193 208 194 184 Rate 38.6 35.2 38.0 51.7 45-64 Number 3441 3398 3300 3204 Rate 376.8 317.3 345.5 347.2 65-74 Number 6868 6513 6792 6463 Rate 775.8 962.6 912.2 781.3 75+ Number 13364 13493 13243 13275 Rate 2251.1 1981.7 2473.6 2593.0 Total Number 23867 23614 23532 23127 Rate 825.1 782.1 856.9 883.5 Age-adjusted Rate 701.9 685.8 758.0 744.4 5.9 Mort. Rate per 100,000 Diabetic Pop., Black Males Table 5.9 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 41 49 53 58 51 Rate 56.2 76.1 85.9 158.0 92.4 45-64 Number 545 653 575 682 627 Rate 292.9 352.1 319.4 333.9 291.1 65-74 Number 509 510 464 568 544 Rate 826.8 754.1 656.9 665.9 616.8 75+ Number 396 388 367 444 437 Rate 1350.3 1684.5 1469.4 1818.2 1246.4 Total Number 1491 1600 1459 1753 1659 Rate 426.0 469.9 432.5 499.9 421.2 Age-adjusted Rate 549.6 608.2 538.8 611.6 484.4 Table 5.9 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 53 65 59 67 Rate 84.4 78.3 65.0 83.2 45-64 Number 665 639 670 638 Rate 299.5 313.5 319.6 258.5 65-74 Number 622 622 651 601 Rate 629.6 686.1 627.6 707.7 75+ Number 449 496 487 468 Rate 1307.3 1268.5 1392.6 910.2 Total Number 1789 1822 1867 1774 Rate 428.0 437.4 425.2 382.6 Age-adjusted Rate 498.9 512.8 516.1 443.2 5.10 Mort. Rate per 100,000 Diabetic Pop., Black Females Table 5.10 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 38 35 53 45 46 Rate 33.9 36.2 61.8 38.8 42.2 45-64 Number 740 781 846 799 784 Rate 294.3 275.3 262.5 265.5 278.5 65-74 Number 884 849 855 891 931 Rate 854.7 620.0 534.7 445.8 499.6 75+ Number 810 874 821 1007 960 Rate 1137.5 1240.4 1211.0 1204.7 1041.7 Total Number 2473 2541 2577 2743 2721 Rate 459.5 432.2 405.3 391.6 406.8 Age-adjusted Rate 521.9 468.0 440.4 413.3 409.2 Table 5.10 Number of Deaths with Ischemic Heart Disease as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 56 41 55 51 Rate 61.3 47.0 50.5 37.8 45-64 Number 745 813 776 802 Rate 287.9 289.9 277.4 329.6 65-74 Number 975 1023 980 981 Rate 533.2 710.9 687.8 634.6 75+ Number 1090 1115 1070 1181 Rate 925.9 881.8 729.9 840.0 Total Number 2867 2993 2881 3015 Rate 440.6 469.2 425.1 447.7 Age-adjusted Rate 407.9 446.5 413.2 435.0 5.11-5.15 Deaths with Stroke as Underlying Cause 5.11 Mort. Rate per 100,000 Diabetic Pop., Age & Year, 80-88 Table 5.11 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 87 102 68 102 108 Rate 8.6 10.7 6.9 10.2 10.9 45-64 Number 1630 1584 1514 1469 1566 Rate 68.2 62.3 59.0 56.5 66.4 65-74 Number 3410 3397 3005 3264 3145 Rate 224.0 248.9 197.0 250.1 179.0 75+ Number 7608 7042 7145 7125 7265 Rate 883.4 743.2 881.6 815.1 666.4 Total Number 12735 12125 11734 11961 12085 Rate 220.2 208.7 199.3 206.9 194.9 Age-adjusted Rate 220.2 203.8 208.7 212.4 175.7 Table 5.11 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 103 93 98 101 Rate 9.9 8.9 7.2 9.2 45-64 Number 1480 1549 1468 1461 Rate 63.5 54.4 57.5 59.4 65-74 Number 3257 3112 3032 2982 Rate 175.9 195.3 178.1 175.0 75+ Number 7083 6949 7084 7107 Rate 643.5 541.1 593.6 649.6 Total Number 11925 11705 11683 11653 Rate 188.7 172.9 171.5 183.5 Age-adjusted Rate 170.1 156.0 160.3 169.0 5.12 Mort. Rate per 100,000 Diabetic Pop., White Males Table 5.12 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 28 28 23 40 44 Rate 9.0 7.6 6.0 9.8 12.4 45-64 Number 611 562 552 545 599 Rate 66.6 55.3 56.5 59.2 73.6 65-74 Number 1283 1296 1147 1233 1166 Rate 215.7 234.3 266.9 296.0 197.1 75+ Number 2306 2055 2101 2115 2152 Rate 901.9 900.5 698.4 644.4 664.3 Total Number 4228 3941 3823 3933 3961 Rate 203.4 181.8 182.7 189.7 190.2 Age-adjusted Rate 220.2 220.0 198.7 200.1 183.4 Table 5.12 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 34 44 39 43 Rate 8.7 14.6 6.7 8.9 45-64 Number 572 556 530 529 Rate 65.5 45.0 50.4 56.5 65-74 Number 1236 1183 1164 1105 Rate 182.0 189.3 165.1 198.2 75+ Number 2087 1980 2064 2157 Rate 595.6 488.8 491.5 559.1 Total Number 3930 3764 3797 3834 Rate 171.3 146.6 137.8 162.2 Age-adjusted Rate 165.2 143.8 138.6 160.3 5.13 Mort. Rate per 100,000 Diabetic Pop., White Females Table 5.13 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 34 35 24 30 31 Rate 7.1 8.3 5.1 7.4 7.1 45-64 Number 552 560 492 478 530 Rate 56.3 56.1 49.9 44.2 50.7 65-74 Number 1488 1529 1292 1423 1346 Rate 198.6 247.9 164.7 226.0 167.7 75+ Number 4558 4338 4313 4281 4363 Rate 879.0 728.7 1014.6 934.6 736.2 Total Number 6632 6462 6123 6213 6271 Rate 243.5 245.7 229.3 241.5 217.8 Age-adjusted Rate 207.7 198.4 216.0 218.3 176.0 Table 5.13 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 32 26 16 26 Rate 6.4 4.4 3.1 7.3 45-64 Number 479 539 493 472 Rate 52.4 50.3 51.6 51.1 65-74 Number 1437 1332 1298 1260 Rate 162.3 196.9 174.3 152.3 75+ Number 4206 4176 4209 4058 Rate 708.5 613.3 786.2 792.6 Total Number 6155 6073 6016 5817 Rate 212.8 201.1 219.1 222.2 Age-adjusted Rate 171.0 164.7 184.9 180.6 5.14 Mort. Rate per 100,000 Diabetic Pop., Black Males Table 5.14 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 12 15 11 12 17 Rate 16.4 23.3 17.8 32.7 30.8 45-64 Number 168 156 160 157 158 Rate 90.3 84.1 88.9 76.9 73.4 65-74 Number 189 184 190 209 206 Rate 307.0 272.1 269.0 245.0 233.6 75+ Number 175 163 197 180 176 Rate 596.7 707.7 788.7 737.1 502.0 Total Number 544 518 558 558 557 Rate 155.4 152.1 165.4 159.1 141.4 Age-adjusted Rate 209.9 215.8 228.1 211.8 171.9 Table 5.14 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 12 12 23 12 Rate 19.1 14.5 25.3 14.9 45-64 Number 159 159 163 177 Rate 71.6 78.0 77.8 71.7 65-74 Number 197 189 191 217 Rate 199.4 208.5 184.1 255.5 75+ Number 180 200 202 220 Rate 524.1 511.5 577.6 427.9 Total Number 548 560 579 626 Rate 131.1 134.4 131.9 135.0 Age-adjusted Rate 163.5 165.8 171.1 163.2 5.15 Mort. Rate per 100,000 Diabetic Pop., Black Female Table 5.15 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 11 19 10 19 15 Rate 9.8 19.6 11.7 16.4 13.8 45-64 Number 289 284 284 253 250 Rate 114.9 100.1 88.1 84.1 88.8 65-74 Number 415 355 334 359 380 Rate 401.2 259.2 208.9 179.6 203.9 75+ Number 479 405 448 463 486 Rate 672.7 574.8 660.8 553.9 527.4 Total Number 1194 1063 1076 1094 1131 Rate 221.9 180.8 169.2 156.2 169.1 Age-adjusted Rate 255.0 198.6 191.9 167.4 171.3 Table 5.15 Number of Deaths with Stroke as Underlying Cause and Mortality Rate per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 21 10 19 19 Rate 23.0 11.5 17.4 14.1 45-64 Number 245 257 250 249 Rate 94.7 91.6 89.4 102.3 65-74 Number 341 363 334 350 Rate 186.5 252.3 234.4 226.4 75+ Number 530 501 510 562 Rate 450.2 396.2 347.9 399.7 Total Number 1137 1132 1114 1181 Rate 174.7 177.5 164.4 175.3 Age-adjusted Rate 159.3 165.3 153.5 163.9 5.16-5.17 Discharges & Rates for Major Cardiovascular Disease 5.16 1,000 Diabetic Pop., by Age and Year, U.S., 80-88 Table 5.16 Number of Discharges for Major Cardiovascular Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number (a) 16 21 20 27 26 Rate 15.9 22.2 20.4 27.0 25.9 45-64 Number 198 195 226 232 255 Rate 83.1 76.5 88.1 89.3 108.1 65-74 Number 193 205 226 237 263 Rate 126.6 150.4 148.3 181.9 149.9 75+ Number 166 189 207 235 249 Rate 193.0 199.1 255.6 269.1 228.4 Total Number 573 610 680 732 793 Rate 99.2 104.9 115.5 126.6 127.9 Age-adjusted Rate 99.2 104.7 117.1 129.6 122.7 (a) In thousands Table 5.16 Number of Discharges for Major Cardiovascular Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number (a) 27 28 26 31 Rate 26.1 26.5 18.8 28.5 45-64 Number 246 268 296 288 Rate 105.6 94.2 116.0 117.2 65-74 Number 260 298 310 311 Rate 140.4 187.1 182.0 182.3 75+ Number 231 255 270 278 Rate 210.0 198.3 226.5 254.1 Total Number 764 849 902 908 Rate 120.9 125.3 132.4 143.0 Age-adjusted Rate 116.4 122.3 132.9 139.2 (a) In thousands 5.17 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88 Table 5.17 Number of Discharges for Major Cardiovascular Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number (a) 197 217 244 257 264 Rate 95.0 100.0 116.5 124.2 126.9 Adjusted Rate (b) 95.2 107.3 123.5 130.5 125.3 Female Number 245 305 293 333 362 Rate 89.8 116.1 109.7 129.6 125.7 Adjusted Rate 85.0 108.6 106.4 124.8 114.5 Black Male Number 21 20 21 26 34 Rate 59.0 58.1 61.6 74.7 86.0 Adjusted Rate 65.5 69.8 65.4 81.2 89.9 Female Number 36 53 51 53 60 Rate 67.4 90.5 79.9 75.6 89.2 Adjusted Rate 72.9 92.6 82.4 76.0 88.3 Total Total Number 573 610 680 732 793 Rate 99.2 104.9 115.5 126.6 127.9 Adjusted Rate 99.2 104.7 117.1 129.6 122.7 (a) In thousands (b) Adjusted for age Table 5.17 Number of Discharges for Major Cardiovascular Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number (a) 271 300 314 335 Rate 118.0 116.9 114.0 141.5 Adjusted Rate (b) 116.4 114.8 117.5 146.2 Female Number 323 359 374 372 Rate 111.5 118.8 136.4 142.3 Adjusted Rate 104.5 115.4 129.9 129.2 Black Male Number 35 38 39 38 Rate 82.7 91.9 89.3 81.3 Adjusted Rate 89.8 102.3 102.6 87.5 Female Number 58 65 68 78 Rate 89.8 101.3 100.0 115.9 Adjusted Rate 86.7 102.7 101.6 121.1 Total Total Number 764 849 902 908 Rate 120.9 125.3 132.4 143.0 Adjusted Rate 116.4 122.3 132.9 139.2 (a) In thousands (b) Adjusted for age 5.18-5.19 Hosp. Discharges & Rates for Ischemic Heart Disease 5.18 1,000 Diabetic Pop., by Age and Year, U.S., 80-88 Table 5.18 Number of Discharges for Ischemic Heart Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number (a) 9 8 10 9 11 Rate 9.1 7.9 10.2 8.9 11.5 45-64 Number 98 90 111 111 130 Rate 41.0 35.5 43.3 42.6 55.1 65-74 Number 76 73 91 94 113 Rate 49.9 53.8 59.8 72.0 64.4 75+ Number 62 65 78 89 86 Rate 71.5 68.6 96.4 101.5 79.3 Total Number 245 236 290 302 341 Rate 42.3 40.7 49.3 52.3 55.0 Age-adjusted Rate 42.3 40.4 49.8 53.2 53.5 (a) In thousands Table 5.18 Number of Discharges for Ischemic Heart Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number (a) 12 13 12 16 Rate 11.4 12.3 9.1 15.0 45-64 Number 117 137 156 144 Rate 50.3 48.0 61.0 58.7 65-74 Number 111 124 134 129 Rate 59.8 77.8 78.9 75.8 75+ Number 80 91 87 96 Rate 72.6 71.1 73.2 87.9 Total Number 320 365 390 386 Rate 50.6 53.9 57.2 60.8 Age-adjusted Rate 49.3 53.1 58.4 59.9 (a) In thousands 5.19 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88 Table 5.19 Number of Discharges for Ischemic Heart Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number (a) 96 98 116 122 133 Rate 46.0 45.0 55.5 59.1 63.6 Adjusted Rate (b) 45.8 46.9 57.9 61.5 63.4 Female Number 103 112 127 136 149 Rate 37.9 42.7 47.6 52.8 51.6 Adjusted Rate 36.5 40.2 46.7 51.0 48.0 Black Male Number 6 6 5 7 13 Rate 18.2 17.6 14.8 19.1 32.7 Adjusted Rate 20.0 19.7 15.8 18.7 31.9 Female Number 10 14 15 14 18 Rate 19.0 23.7 23.4 20.6 27.6 Adjusted Rate 21.4 23.8 24.3 20.8 27.2 Total Total Number 245 236 290 302 341 Rate 42.3 40.7 49.3 52.3 55.0 Adjusted Rate 42.3 40.4 49.8 53.2 53.5 (a) In thousands (b) Adjusted for age Table 5.19 Number of Discharges for Ischemic Heart Disease as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number (a) 125 141 153 160 Rate 54.3 55.1 55.7 67.9 Adjusted Rate (b) 54.0 53.9 57.8 70.5 Female Number 132 155 163 158 Rate 45.8 51.3 59.2 60.3 Adjusted Rate 44.3 51.3 58.3 56.7 Black Male Number 10 13 14 10 Rate 24.3 32.3 31.1 21.9 Adjusted Rate 25.0 35.7 34.3 22.0 Female Number 18 18 19 19 Rate 26.9 28.9 28.3 28.9 Adjusted Rate 25.6 29.3 30.2 30.2 Total Total Number 320 365 390 386 Rate 50.6 53.9 57.2 60.8 Adjusted Rate 49.3 53.1 58.4 59.9 (a) In thousands (b) Adjusted for age 5.20-5.21 Hosp. Discharges/Rates for Stroke as Primary Diagnosis 5.20 1,000 Diabetic Pop., by Age & Year, U.S., 80-88 Table 5.20 Number of Discharges for Stroke as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number (a) 1 1 1 3 1 Rate 1.2 1.0 1.1 3.3 0.8 45-64 Number 18 19 21 25 27 Rate 7.6 7.4 8.1 9.5 11.5 65-74 Number 30 36 31 36 39 Rate 19.8 26.3 20.3 28.0 22.2 75+ Number 28 31 40 41 49 Rate 32.4 32.6 49.1 46.5 44.9 Total Number 77 87 93 105 116 Rate 13.4 14.9 15.7 18.2 18.7 Age-adjusted Rate 13.4 15.0 16.2 18.8 17.4 (a) In thousands Table 5.20 Number of Discharges for Stroke as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number (a) 3 3 2 1 Rate 2.8 2.9 1.7 1.2 45-64 Number 28 27 32 32 Rate 12.2 9.5 12.4 13.1 65-74 Number 47 46 46 38 Rate 25.1 28.7 27.1 22.4 75+ Number 41 41 48 43 Rate 36.9 31.9 40.1 39.1 Total Number 118 117 128 114 Rate 18.7 17.2 18.8 18.0 Age-adjusted Rate 17.6 16.7 18.5 17.3 (a) In thousands 5.21 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88 Table 5.21 Number of Discharges for Stroke as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number (a) 26 27 33 38 32 Rate 12.5 12.2 15.9 18.3 15.2 Adjusted Rate (b) 12.8 13.2 17.1 19.8 14.8 Female Number 33 45 38 44 54 Rate 12.0 17.0 14.2 17.2 18.8 Adjusted Rate 11.0 15.7 13.5 16.4 16.1 Black Male Number 3 4 4 5 5 Rate 7.2 10.4 12.5 13.4 12.7 Adjusted Rate 9.6 13.5 13.9 15.5 13.7 Female Number 5 9 6 7 11 Rate 9.7 14.7 9.7 10.6 16.3 Adjusted Rate 10.8 16.1 10.1 10.9 16.3 Total Total Number 77 87 93 105 116 Rate 13.4 14.9 15.7 18.2 18.7 Adjusted Rate 13.4 15.0 16.2 18.8 17.4 (a) In thousands (b) Adjusted for age Table 5.21 Number of Discharges for Stroke as Primary Diagnosis and Hospital Discharge Rate per 1,000 Diabetic Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number (a) 37 40 36 36 Rate 16.2 15.4 13.0 15.3 Adjusted Rate (b) 15.8 15.5 13.3 15.7 Female Number 52 43 55 46 Rate 18.0 14.3 20.0 17.8 Adjusted Rate 15.9 13.2 18.3 15.2 Black Male Number 6 5 7 5 Rate 15.4 11.9 15.3 10.1 Adjusted Rate 16.9 13.2 17.1 11.8 Female Number 11 15 11 11 Rate 17.0 23.6 16.3 16.3 Adjusted Rate 16.4 24.4 16.6 17.6 Total Total Number 118 117 128 114 Rate 18.7 17.2 18.8 18.0 Adjusted Rate 17.6 16.7 18.5 17.3 (a) In thousands (b) Adjusted for age LOWER EXTREMITY AMPUTATIONS Introduction Diabetes is the leading cause of lower extremity amputation (LEA) in the United States. The relative risk for a LEA among persons with diabetes is about 15 times that of persons without diabetes. About half of all nontraumatic LEAs occur among persons with diabetes (Bild et al., 1989). We examine hospitalization trends for LEA among persons with diabetes in the United States during 1980-1987. When appropriate, we present LEA hospitalization rates categorized by age, race, sex, region, and calendar year. We determine LEA rates for the general United States population, as well as rates among persons with diabetes. Methods The methods have been described previously (Chapter 4). Data for amputations were obtained from the National Hospital Discharge Survey (NHDS), and the diabetic population was estimated using data from the National Health Interview Survey (Chapter 2). LEAs were identified using International Classification of Diseases-9th Revision (ICD-9) procedure code 84.1. Traumatic amputations of the toe, foot, or leg (ICD-9 disease codes 895, 896, and 897) were excluded from the analysis. Thus, for our purposes, the term LEA refers to nontraumatic amputations. Diabetes-related discharges were identified by selecting for ICD-9 disease code 250. Because of small sample sizes, when calculating race-specific rates, we combined results for males and females. Similarly, when calculating sex-specific rates, we combined results for all races. Results The number of LEAs performed among persons with diabetes was relatively stable from 1980 to 1982, increased about 50% in 1983, and then leveled off through 1987 (Figure 6.1). A similar pattern was seen for the LEA rates in the diabetic population (Figure 6.2) and within each age category (Table 6.1). Hospital discharge rates for LEA increased with age. In 1987, 68% of the discharges occurred among those persons older than 64 years of age and 95% were among those 45 years of age or older (Table 6.1). Rates among males and females exhibited the same temporal trends as noted in the total diabetic population (Figure 6.3, Table 6.2). Discharge rates for LEA among males with diabetes were from 10% to 64% higher than among females with diabetes. From 1980 to 1987, blacks accounted for 13% to 25% of all hospital discharges for LEAs related to diabetes (Table 6.3). The hospital discharge rates for blacks with diabetes were consistently higher than those for whites with diabetes, particularly from 1980 to 1981 and 1984 to 1987, when the rates were 1.5 to 2 times higher (Figure 6.4, Table 6.3). Using the general population as the denominator resulted in similar trends as seen using diabetic population denominators (Tables 6.4-6.6). Because stable diabetic population estimates were not available by region, we calculated region-specific rates using general population denominators only. Discharge rates for LEAs varied by geographic region (Table 6.7). Unadjusted rates and rates adjusted for age and race were consistently highest in the Northeast and, for the most part, lowest in the West. Discussion One of the most striking findings from this analysis was the dramatic increase in numbers and rates of LEAs among persons with diabetes that occurred in 1983. In 1983, Medicare instituted the prospective payment system with diagnosis-related groups for reimbursement. This reimbursement change may have influenced the listing of diabetes on hospital records as a contributing cause for LEA and may, in part, be responsible for the increases seen in hospital discharges for LEA related to diabetes in 1983. The hospital discharge rates for LEA among persons with diabetes were higher for males than for females and for blacks than for whites. These findings are consistent with the findings of previous research, which has shown that the risk of LEA in blacks (as well as certain groups of Native Americans) with diabetes is 2 to 4 times higher than the corresponding risk in whites, and that the risk among males is 1.5 to 3 times higher than among females (Bild et al., 1989). The rate of LEA related to diabetes also increased with age. The major pathogenetic mechanisms by which diabetes can lead to a LEA are peripheral vascular disease and peripheral neuropathy. Both of these conditions are more prevalent with increasing age and with longer duration of diabetes. Other factors that can lead to LEA among persons with diabetes are infection, hyperglycemia, improper foot care, extant foot lesions, and a history of a previous amputation (Most & Sinnock, 1983). LEA is a significant contributor to morbidity, mortality, disability, and costs among persons with diabetes. The direct cost of an amputation has been estimated to be 8,000 to 12,000 dollars. Therefore, the 56,000 LEAs that were performed among persons with diabetes in 1987 represent a direct cost of about 500 million dollars. Intensive glycemic and hypertension control, coupled with proper foot care, have been shown to be effective in reducing the frequency of amputations among persons with diabetes (Davidson et al., 1981). Applying these measures among patients with diabetes could result in substantial savings in morbidity and costs. Update This section updates data presented in previous sections in light of one additional year of hospitalization data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. Among persons with diabetes, the number and rate of hospital discharges coded with lower extremity amputation (LEA) were relatively stable from 1980 to 1982, increased dramatically in 1983 (see Chapter 6 for discussion), and then leveled off (Figure 1.9, Table 6.1). Hospital discharge rates for LEA increased with age and were higher for males than for females (Table 6.2) and for blacks than for whites (Table 6.3). Detailed Tables 6.1-6.7 Nontraumatic Lower Extremity Amputation 6.1 No./Rate of Discharges per 1,000 Diabetic Pop., Age & Year Table 6.1 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number (a) 2 2 2 3 2 Rate 1.6 1.6 1.6 2.8 2.4 45-64 Number 11 10 10 16 17 Rate 4.7 3.8 3.9 6.1 7.2 65-74 Number 12 9 9 17 14 Rate 7.6 6.4 6.0 13.1 8.0 75+ Number 12 10 10 12 14 Rate 13.5 10.5 12.6 13.2 12.9 Total Number 36 30 31 47 47 Rate 6.3 5.1 5.3 8.2 7.6 Age-adjusted Rate 6.3 5.1 5.4 8.4 7.4 (a) In thousands Table 6.1 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number (a) 4 2 3 3 Rate 4.2 2.3 2.1 2.5 45-64 Number 19 15 15 20 Rate 8.1 5.4 5.8 8.0 65-74 Number 16 17 20 13 Rate 8.6 10.5 12.0 7.5 75+ Number 14 13 18 20 Rate 12.4 10.2 14.8 18.0 Total Number 53 48 56 55 Rate 8.4 7.1 8.2 8.6 Age-adjusted Rate 8.2 6.9 8.1 8.4 (a) In thousands 6.2 No./Rate of Discharges per 1,000 Diabetic Pop., Sex & Year Table 6.2 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Sex and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 SEX Male Number (a) 19 15 15 23 22 Rate 7.9 5.7 6.1 9.5 8.8 Age-adjusted Rate 8.3 6.4 6.5 10.3 8.8 Female Number 17 15 16 24 25 Rate 5.1 4.7 4.7 7.2 6.8 Age-adjusted Rate 4.9 4.5 4.7 7.2 6.6 Total Number 36 30 31 47 47 Rate 6.3 5.1 5.3 8.2 7.6 Age-adjusted Rate 6.3 5.1 5.4 8.4 7.4 (a) In thousands Table 6.2 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Sex and Year, United States, 1985-1988 Year 1985 1986 1987 1988 SEX Male Number (a) 24 27 28 35 Rate 8.6 9.0 8.6 11.9 Age-adjusted Rate 8.7 9.0 8.8 12.2 Female Number 29 21 28 20 Rate 8.2 5.5 7.8 5.8 Age-adjusted Rate 7.7 5.5 7.4 5.3 Total Number 53 48 56 55 Rate 8.4 7.1 8.2 8.6 Age-adjusted Rate 8.2 6.9 8.1 8.4 (a) In thousands 6.3 No./Rate of Discharges per 1,000 Diabetic Pop., Race & Year Table 6.3 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Race and Year, United States 1980-1984 Year 1980 1981 1982 1983 1984 Race White Number (a) 23 24 24 36 32 Rate 4.7 4.9 5.0 7.7 6.5 Age-adjusted 4.6 4.8 5.0 7.9 6.3 Black Number 8 6 4 8 10 Rate 9.2 6.2 4.5 7.3 9.0 Age-adjusted 10.7 7.0 4.6 8.7 9.4 Total Number 36 30 31 47 47 Rate 6.3 5.1 5.3 8.2 7.6 Age-adjusted 6.3 5.1 5.4 8.4 7.4 (a) In thousands Table 6.3 Number of Discharges for Nontraumatic Lower Extremity Amputation and Hospital Discharge Rate per 1,000 Diabetic Population, by Race and Year, United States 1985-1988 Year 1985 1986 1987 1988 Race White Number (a) 32 29 35 38 Rate 6.3 5.1 6.4 7.6 Age-adjusted 6.2 5.1 6.3 7.3 Black Number 13 12 10 9 Rate 12.2 11.6 8.6 8.2 Age-adjusted 12.4 11.8 8.7 8.1 Total Number 53 48 56 55 Rate 8.4 7.1 8.2 8.6 Age-adjusted 8.2 6.9 8.1 8.4 (a) In thousands 6.4 Discharge Rate (Diabetes Listed Diagnosis), by Age & Year Table 6.4 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis per 10,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 0.1 0.1 0.1 0.2 0.1 45-64 2.5 2.1 2.3 3.5 3.8 65-74 7.4 5.5 5.6 10.4 8.4 75+ 11.6 9.7 9.6 10.6 12.5 Total 1.6 1.3 1.3 2.0 2.0 Age-adjusted Rate 1.6 1.3 1.3 2.0 2.0 Table 6.4 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis per 10,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 0.3 0.1 0.2 0.2 45-64 4.2 3.4 3.3 4.3 65-74 9.3 9.7 11.5 7.1 75+ 11.9 11.1 14.5 15.8 Total 2.2 2.0 2.3 2.2 Age-adjusted Rate 2.2 1.9 2.2 2.1 6.5 Discharge Rate (Diabetes Listed Diagnosis), by Sex & Year Table 6.5 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation with Diabetes as a Listed Diagnosis per 10,000 Population, by Sex and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 SEX Male Rate 1.8 1.3 1.3 2.0 1.9 Age-adjusted Rate 2.0 1.5 1.5 2.3 2.1 Female Rate 1.4 1.3 1.3 2.0 2.1 Age-adjusted Rate 1.3 1.2 1.2 1.8 1.9 Total Rate 1.6 1.3 1.3 2.0 2.0 Age-adjusted Rate 1.6 1.3 1.3 2.0 2.0 Table 6.5 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation with Diabetes as a Listed Diagnosis per 10,000 Population, by Sex and Year, United States, 1985-1988 Year 1985 1986 1987 1988 SEX Male Rate 2.1 2.3 2.4 2.9 Age-adjusted Rate 2.3 2.5 2.6 3.2 Female Rate 2.4 1.7 2.2 1.6 Age-adjusted Rate 2.1 1.5 1.9 1.3 Total Rate 2.2 2.0 2.3 2.2 Age-adjusted Rate 2.2 1.9 2.2 2.1 6.6 Discharge Rate (Diabetes Listed Diagnosis), by Race & Year Table 6.6 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis per 10,000 Population, by Race and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race White Rate 1.2 1.2 1.2 1.8 1.6 Age-adjusted 1.1 1.1 1.1 1.7 1.5 Black Rate 3.0 2.1 1.6 2.8 3.4 Age-adjusted 4.2 2.8 2.1 3.7 4.5 Total Rate 1.6 1.3 1.3 2.0 2.0 Age-adjusted 1.6 1.3 1.3 2.0 2.0 Table 6.6 Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis per 10,000 Population, by Race and Year, United States, 1980-1984 Year 1985 1986 1987 1988 Race White Rate 1.6 1.4 1.7 1.8 Age-adjusted 1.5 1.3 1.6 1.7 Black Rate 4.5 4.2 3.2 3.1 Age-adjusted 5.8 5.5 4.3 4.0 Total Rate 2.2 2.0 2.3 2.2 Age-adjusted 2.2 1.9 2.2 2.1 6.7 Discharge Rate/No. (Diabetes Listed Diagnosis),Region & Year Table 6.7 Number of Discharges for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number (a) 13 10 11 12 13 Rate 2.6 2.0 2.3 2.5 2.7 Adjusted Rate (b) 2.2 2.0 1.9 2.2 2.3 North Number 7 9 10 13 13 Central Rate 1.2 1.6 1.6 2.2 2.2 Adjusted Rate 1.0 1.6 1.4 2.1 1.9 South Number 11 7 7 16 16 Rate 1.4 0.8 0.9 2.0 2.0 Adjusted Rate 1.2 0.8 0.8 1.9 1.8 West Number 5 4 3 6 5 Rate 1.3 0.9 0.7 1.2 1.0 Adjusted Rate 1.1 1.1 0.6 1.2 1.0 (a) In thousands (b) Adjusted for age and race Table 6.7 Number of Discharges for Nontraumatic Lower Extremity Amputation With Diabetes as a Listed Diagnosis and Hospital Discharge Rate per 10,000 Population, by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number (a) 12 9 11 13 Rate 2.4 1.8 2.2 2.7 Adjusted Rate (b) 2.1 1.6 1.9 2.3 North Number 14 14 13 16 Central Rate 2.3 2.4 2.3 2.6 Adjusted Rate 2.1 2.4 2.0 2.1 South Number 18 14 20 20 Rate 2.2 1.7 2.4 2.3 Adjusted Rate 1.8 1.3 2.0 1.9 West Number 9 10 11 6 Rate 1.9 2.1 2.3 1.2 Adjusted Rate 1.3 2.2 1.5 0.7 (a) In thousands (b) Adjusted for age and race DIABETIC KETOACIDOSIS Introduction Diabetic ketoacidosis (DKA) is an acute, life-threatening disorder that can strike a person with diabetes at any age. Expert consensus regards DKA morbidity and mortality as largely preventable (Schlade and Eaton, 1979). Prevention strategies include improved compliance with glucose control regimens, early recognition of symptoms and signs of DKA, and prompt treatment of any precipitating medical conditions, such as infections (National Diabetes Advisory Board, 1983). We examine hospitalization and mortality trends for DKA in the United States during the years 1980-1987. Data on overall diabetic hospitalizations and mortality, and on the other complications of diabetes, are presented elsewhere. We present DKA hospitalization and mortality rates categorized by age, race, region, and calender year. We determine DKA rates for the general U.S. population, as well as rates among people with diabetes (diabetes-specific rates). Methods We used information from the National Hospital Discharge Survey (NHDS) to determine the annual number of hospitalizations for DKA (Chapter 4). Rubric 250.1 (diabetes with ketoacidosis) from the clinical modification of the 9th revision of the International Classification of Diseases (ICD9-CM) was used to identify discharges in which DKA was listed as either a primary or secondary diagnosis. To calculate denominators for annual rates in the general population, we used intercensal estimates based on 1980 census data. To calculate denominators for diabetes-specific rates, we estimated the U.S. diabetic population using information from National Health Interview Surveys (Chapter 2). ICD-9 rubric 250.1 was also used to identify deaths in which DKA was listed as either an underlying or a contributing cause on mortality records supplied by the National Center for Health Statistics. Methods (Chapter 3) for calculating general population and diabetes-specific mortality rates were similar to those used for hospitalization rates. For both hospital discharge and mortality analyses, general population rates were age- and race-adjusted using the direct method, with the 1980 U.S. resident population as the standard. To adjust diabetes-specific rates, we used the estimated 1980 U.S. population of persons with diabetes as the standard. Results Hospital Discharges for DKA in the General Population In 1987, the latest year for which data are available, there were about 110,000 hospitalizations in which DKA was listed as a discharge diagnosis (Figure 7.1). In 1980 there were about 70,000 hospital discharges with DKA as a listed diagnosis. The number and rate of hospital discharges with DKA as a primary diagnosis has steadily increased during 1980-1987 (Figure 7.2). The age-adjusted rate was 2.6 discharges per 10,000 population in 1980, whereas the corresponding rate in 1987 was 3.8 per 10,000, an average annual increase of 7% (Table 7.1). Age-specific data indicate that rising rates among persons less than 45 years old account for much of this overall increase. Discharge rates were relatively unchanged among those in older age groups (Table 7.1). Hospital discharge rates for DKA were consistently higher among blacks than among whites (Table 7.2). In 1987, the age-adjusted rate for black males, 7.8 discharges per 10,000, was 2.7-fold higher than the corresponding rate of 2.8 for white males. Similarly, the rate of discharges for black females, 5.6 per 10,000, was 1.8-fold higher than the rate of 3.2 per 10,000 for white females. Among white males and females, the temporal trends were comparable, with each group showing increases in rates of DKA as a primary hospital discharge diagnosis. Among blacks, the temporal trends were less evident because of sizable year-to-year variability resulting from smaller sample sizes. In each of four geographic regions, hospital discharge rates for DKA as a primary diagnosis exhibited similar trends--a gradual secular increase (Table 7.3). Rates were generally lower in the Northeast and higher in the South. In all regions and for each year, age- and race-adjusted discharge rates were lower than the corresponding unadjusted rates (Table 7.3). During the period 1980 through 1987, most (greater than 78%) hospital records that mention DKA as a discharge diagnosis list this condition as the primary diagnosis (Figure 7.2). Thus, although hospital discharge rates are roughly 20% higher for DKA as any listed diagnosis, the rate trends parallel those for hospital discharges in which DKA is the primary diagnosis. Age-specific rates for DKA as any listed diagnosis are presented in Table 7.4, race- and sex-specific rates in Table 7.5, and region-specific rates in Table 7.6. Hospital Discharges for DKA Among Persons With Diabetes During 1980-1987, the age-adjusted rate (per 1,000 persons with diabetes) of hospital discharges for DKA as a primary diagnosis has shown an overall gradual increase (Figure 7.3). The age-adjusted rate, which was 10.3 discharges per 1,000 persons in 1980, peaked at 14.6 discharges per 1,000 in 1984 and then declined slightly to 12.5 per 1,000 in 1987. The overall increase during this period resulted from rising rates within the 0- to 44-year age category (Table 7.7). Within this age group, rates increased yearly--from 36.6 discharges per 1,000 persons with diabetes in 1980--until 1985, when they peaked at 58.6 per 1,000 and then declined to 49.9 per 1,000 in 1987. In contrast, rates within older age categories were stable during this time. In each year, rates were highest in the youngest age category and decreased with age. During this period, black males consistently had the highest annual DKA hospital discharge rates whereas, with few exceptions, white males had the lowest rates (Table 7.8). In 1987, for example, the age-adjusted rate among black males, 24.7 per 1,000 persons with diabetes, was nearly threefold higher than the corresponding rate of 8.7 per 1,000 among white males. In contrast, rates among black females were only slightly higher than those among white females. Regarding temporal trends, the most striking rate increases were seen among black males, although there was considerable variability, particularly during 1983-1984, because of small sample sizes. Temporal trends were less discernible in other race-sex categories. In general, the trends in hospital discharge rates for DKA as any listed diagnoses were similar to those for which DKA was listed as the primary diagnosis. One exception, however, was that the discharge rate for DKA as any listed diagnosis increased during 1980-1987 in the 45- to 64-year age group, as well as in the 0- to 44-year age group (Table 7.9). Race- and sex-specific rates are also presented (Table 7.10). DKA Mortality in the General Population From 1980 to 1986, age-adjusted rates declined for DKA as an underlying cause of death (Figure 7.4) The mortality rate declined from 1.60 per 100,000 population in 1980 to 1.37 per 100,000 in 1986, an average annual decrease of 2%. During this period, however, the temporal trends varied by age group (Table 7.11). Mortality rates remained the same, about 0.2 per 100,000, in persons less than 45 years old<197>meanwhile, they decreased in all older age categories. Within each year, mortality rates increased with age. In 1987, for example, the mortality rate was 0.23 per 100,000 for those persons 0 to 44 years old, 0.88 for those 45 to 64 years old, 2.06 for those 65 to 74 years old, and 5.02 for those more than 74 years old. For mortality resulting from DKA as an underlying cause, each race and sex category showed similar temporal trends: gradual declines since 1980 (Table 7.12). In all years, black males and females had the highest rates, whereas white males had the lowest rates. Declining rates were seen in each geographic region (Table 7.13). In all years, the unadjusted mortality rate for DKA as an underlying cause was lowest in the West. After rates were standardized for age and race, regional differences in mortality were less pronounced (Table 7.13). Total DKA-related mortality reflects those deaths in which DKA is listed on the death certificate as either an underlying or contributing cause. In 1986, of the 2,969 total DKA-related deaths, there were 1,735 deaths (58%) for which DKA was the underlying cause (Tables 7.11 and 7.14). During 1980-1985, DKA as an underlying cause of death constituted a similar proportion of total DKA-related deaths. Temporal trends in total DKA-related mortality rates resemble those for which DKA is listed as the underlying cause of death (Figure 7.4, Tables 7.14-7.16). Overall, the age-adjusted mortality rate has slightly declined (Table 7.14). Although age-specific rates appear to have declined for older age groups, rate declines were less evident for persons less than 45 years old. From 1980 to 1986, rates declined in all race-sex categories (Table 7.15), as well as in all geographic regions (Table 7.16). DKA Mortality in Persons with Diabetes During 1980 through 1986, among persons with diabetes, mortality rates for DKA as either an underlying or contributing cause of death declined (Figure 7.5). For DKA as an underlying cause, the age-adjusted mortality rate of 30.6 per 100,000 persons with diabetes in 1980 fell to 25 per 100,000 by 1986--an annual average decrease of 3% (Table 7.17). Temporal trends in age-specific rates among persons with diabetes resembled rate trends among persons in the general population: there was little change in rates for persons aged 0 to 44 years, whereas rates declined among all older age categories. Among the 45- to 64-year age group, the rate dropped from 21.2 per 100,000 in 1980 to 13.9 per 100,000 in 1986, an average annual decline of 5.7%. In contrast to rates based on the general population, the lowest age-specific mortality rates for DKA among persons with diabetes were not in persons less than 45 years old (Table 7.17). Rather, average age-specific mortality rates were lowest among the 45- to 64-year age group, and only the rate among persons 75 years and older exceeded the rate among the youngest age group (Figure 7.6). Mortality rates for DKA as an underlying cause of death declined among all race-sex groups during 1980-1986 (Table 7.18). Within each year, the lowest rates were seen among white males and females (Figure 7.7). For black males and females, DKA mortality rates decreased, on average, 4.3% annually. The corresponding average annual rate decreases for white males and females were 3.4% and 1.7%, respectively. Total DKA-related mortality rates among persons with diabetes are shown for each age group and for each race-sex group (Tables 7.19-7.20). Because total DKA-related mortality includes those deaths in which DKA is listed on the death certificate as a contributing cause, rates are higher than those based solely on DKA as the underlying cause of death (Figure 7.5). Temporal trends for total DKA-related mortality were similar to those for underlying-cause mortality, with declining rates in persons older than 45 years old and in each race-sex category. Discussion We present hospital discharge and mortality rates for DKA during 1980 through 1987. Overall, mortality rates for DKA in the general population have declined during this period. At the same time, however, hospitalization rates for DKA have increased. One difficulty in interpreting these data is that the increasing prevalence of diabetes, as described in Chapter 2, may be influencing these findings. Because DKA, by definition, is a condition restricted to those with diabetes, examining diabetes-specific data provides more useful information about temporal patterns within the appropriate population-at-risk for this largely preventable condition. Thus, more emphasis should be placed on examining rates in the diabetic population. We found that mortality rates for DKA among persons with diabetes varied by race. Although mortality rates declined in each race and sex group during this period, blacks consistently had higher mortality rates than whites. For DKA as an underlying cause of death, the 1986 age-adjusted mortality rates among black males and females were 2.7 to 2.9 times higher than the corresponding rates in white males and females. Because these are diabetes-specific rates, these rate ratios are not influenced by the higher prevalence of diabetes among blacks. Thus, differences in patient and provider actions (Fishbein, 1985) or other elements related to health care use may account for the higher rates seen among blacks with diabetes. Among persons with diabetes, the age-adjusted rate of hospital discharges for DKA has gradually increased during 1980-1987. Whether DKA is listed as a primary or secondary diagnosis, similar patterns are seen. Hospital discharge rates for DKA were highest in 1984 and have declined slightly since then, but were still higher during 1985-1987 than they were during 1980-1983. This temporal increase can be attributed primarily to rising rates of hospitalization among persons less than 45 years old. In contrast, hospitalization rates were relatively unchanged in older age groups during these years. At the same time, overall age-adjusted mortality rates for DKA among persons with diabetes have been declining. Yet, as with hospital discharge trends, the secular mortality experience has varied by age. Among persons older than 45 years old, mortality rates from DKA as an underlying cause of death have clearly declined during this decade. The same is not true, however, for those younger. For persons less than 45 years old, mortality rates for DKA as an underlying cause of death have not changed. Similar age-specific patterns are seen when total DKA-related mortality is examined. Hospital discharge and mortality rates may vary over time for several reasons. Changes in reporting practices may influence the enumeration of episodes of DKA. Prospective payment mechanisms with diagnostic related groups (DRGs) were implemented in 1983. Such a reimbursement system might alter diagnostic coding practices for certain conditions, but probably has less impact on recording serious, life-threatening disorders, such as DKA. Further, if DRGs influenced DKA diagnoses, similar relative changes should occur within all age categories, which is not the case. Reporting artifacts unlikely influence the secular trends seen in DKA mortality rates, because reporting and coding practices for death certificates did not change during this time. Other factors that may influence trends in DKA morbidity and mortality include changes in medical care access and treatment. Medical care treatment changes include improved and more widespread use of self-care techniques designed to prevent ketoacidosis and avert hospitalization (National Diabetes Advisory Board, 1983), as well as technological advances, such as life support techniques for the critically ill. That hospital discharge rates for DKA in older persons stayed the same while the corresponding mortality rates declined would suggest that advances in hospital treatment, or perhaps improving access to them, is responsible for these trends. Unlike their older counterparts with diabetes, persons less than 45 years old have unchanging mortality rates but increasing hospitalization rates for DKA. Together, these findings suggest that, although certain advances may have occurred in preventing and treating DKA among certain groups, DKA remains a significant source of morbidity among younger persons with diabetes. Additional studies should be directed toward identifying any subgroups within this age group who are at increased risk for DKA. Identifying these subgroups would help to target resources to reduce morbidity, as well as mortality, from this largely preventable complication of diabetes. Update This section updates data presented in previous sections in light of one additional year of hospitalization data and two additional years of mortality data. For a complete description of the methods and operational definitions and for a discussion of the implications of the findings, see previous sections. Among the diabetic population, the age-standardized rates of hospital discharge for diabetic ketoacidosis (DKA) as a primary diagnosis and as any listed diagnosis increased between 1980 and 1984, decreased slightly in 1985, and then leveled off (Tables 7.7 and 7.9). DKA hospital discharge rates for both primary cause and any listed cause were highest among persons with diabetes younger than 45 years of age. Among the race-sex groups examined, discharge rates were highest among black males, followed by black females, white females, and white males (Tables 7.8-7.9). During the period 1980-1987, among persons with diabetes, mortality rates for DKA as both an underlying and any listed cause of death declined (Figure 1.10, Tables 7.17 and 7.19). These declines were followed by increases in 1988. Temporal trends were similar by age except for rates among persons younger than age 45, which showed little change between 1980 and 1987. The highest mortality rates for DKA as either an underlying or any listed cause of death were found among persons 75 years of age and older. Among the race-sex groups examined, mortality rates were highest among black males, followed by black females and then by whites, with little difference between the sexes (Tables 7.18 and 7.20). Detailed Tables 7.1-7.3 Discharges w/ Diabetic Ketoacidosis as Primary Diagnosis 7.1 10,000 Pop., by Age and Year, U.S., 80-88 Table 7.1 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 16 15 16 20 21 Rate 2.2 2.0 2.3 2.9 3.0 20-44 Number 21 23 24 31 37 Rate 2.5 2.7 2.6 3.4 4.0 45-64 Number 12 18 15 12 16 Rate 2.8 4.0 3.3 2.6 3.7 65+ Number 10 8 6 9 10 Rate 3.9 3.2 2.2 3.1 3.7 Total Number 59 64 60 72 85 Rate 2.6 2.8 2.6 3.1 3.6 Age-adjusted Rate 2.6 2.8 2.6 3.1 3.6 (a) In thousands Table 7.1 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 21 21 29 25 Rate 3.0 2.9 4.0 3.6 20-44 Number 32 37 39 39 Rate 3.4 3.8 4.0 4.0 45-64 Number 16 16 13 9 Rate 3.6 3.6 2.9 2.0 65+ Number 11 11 11 10 Rate 3.9 3.9 3.8 3.3 Total Number 81 85 93 84 Rate 3.4 3.5 3.8 3.4 Age-adjusted Rate 3.4 3.5 3.8 3.4 (a) In thousands 7.2 10,000 Pop., by Race, Sex, and Year, U.S., 80-88 Table 7.2 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Race, Sex and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number (a) 16 18 18 17 23 Rate 1.6 1.8 1.8 1.8 2.3 Age-adjusted Rate 1.7 1.8 1.8 1.8 2.3 Female Number 27 29 24 33 35 Rate 2.7 2.9 2.4 3.3 3.4 Age-adjusted Rate 2.7 2.8 2.4 3.3 3.4 Black Male Number 5 6 6 8 12 Rate 4.2 4.9 4.3 6.2 9.0 Age-adjusted Rate 4.8 5.6 4.6 6.1 9.8 Female Number 7 10 7 8 7 Rate 4.8 6.8 4.6 5.4 4.7 Age-adjusted Rate 5.0 7.1 4.9 5.7 5.1 Total Total Number 59 64 60 72 85 Rate 2.6 2.8 2.6 3.1 3.6 Age-adjusted Rate 2.6 2.8 2.6 3.1 3.6 (a) In thousands Table 7.2 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population, by Race, Sex and Year, United States, 1980-1984 Year 1985 1986 1987 1988 Race Sex White Male Number (a) 24 23 28 21 Rate 2.4 2.3 2.7 2.0 Age-adjusted Rate 2.4 2.3 2.8 2.0 Female Number 32 32 34 28 Rate 3.1 3.0 3.2 2.6 Age-adjusted Rate 3.1 3.0 3.2 2.7 Black Male Number 6 10 10 12 Rate 4.7 7.2 7.3 8.6 Age-adjusted Rate 4.6 7.4 7.8 8.5 Female Number 11 12 8 11 Rate 7.0 7.6 5.2 6.8 Age-adjusted Rate 7.4 8.0 5.6 6.7 Total Total Number 81 85 93 84 Rate 3.4 3.5 3.8 3.4 Age-adjusted Rate 3.4 3.5 3.8 3.4 (a) In thousands 7.3 10,000 Pop., by Region and Year, U.S., 80-88 Table 7.3 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number (a) 12 12 12 13 17 Rate 2.5 2.4 2.3 2.7 3.4 Adjusted Rate (b) 2.3 2.3 2.1 2.7 3.2 North Number 19 16 14 20 18 Central Rate 3.2 2.7 2.3 3.3 3.1 Adjusted Rate 3.0 2.7 2.1 3.2 2.9 South Number 19 24 24 23 30 Rate 2.5 3.2 3.0 2.9 3.7 Adjusted Rate 2.3 2.8 2.8 2.6 3.4 West Number 9 12 11 16 20 Rate 2.2 2.8 2.4 3.5 4.2 Adjusted Rate 2.1 2.9 2.3 3.3 3.9 (a) In thousands (b) Adjusted for age and race Table 7.3 Number of Discharges with Diabetic Ketoacidosis as Primary Diagnosis and Hospital Discharge Rate per 10,000 Population by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number (a) 16 15 16 14 Rate 3.1 3.1 3.1 2.9 Adjusted Rate (b) 3.0 2.8 3.0 2.8 North Number 17 21 24 24 Central Rate 2.9 3.6 4.0 4.1 Adjusted Rate 2.6 3.3 3.5 3.4 South Number 30 32 31 33 Rate 3.7 3.8 3.7 3.9 Adjusted Rate 3.4 3.2 3.3 3.3 West Number 18 17 22 13 Rate 3.8 3.5 4.4 2.5 Adjusted Rate 3.6 3.1 3.9 2.1 (a) In thousands (b) Adjusted for age and race 7.4-7.6 Discharges w/ Diabetic Detoacidosis as Listed Diagnosis 7.4 10,000 Pop., by Age and Year, U.S., 80-88 Table 7.4 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 Number (a) 17 16 17 22 23 Rate 2.4 2.2 2.4 3.1 3.2 20-44 Number 24 26 25 35 42 Rate 2.8 3.0 2.8 3.8 4.5 45-64 Number 15 21 18 14 22 Rate 3.3 4.7 4.0 3.2 4.9 65+ Number 15 11 9 12 18 Rate 5.7 4.3 3.5 4.5 6.5 Total Number 70 74 70 84 105 Rate 3.1 3.2 3.0 3.6 4.4 Age-adjusted Rate 3.1 3.2 3.0 3.6 4.4 (a) In thousands Table 7.4 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 Number (a) 22 22 29 26 Rate 3.1 3.1 4.0 3.7 20-44 Number 38 44 45 43 Rate 4.0 4.6 4.6 4.4 45-64 Number 20 22 19 17 Rate 4.6 4.8 4.2 3.7 65+ Number 18 19 17 17 Rate 6.3 6.7 5.8 5.5 Total Number 98 108 110 103 Rate 4.1 4.5 4.5 4.2 Age-adjusted Rate 4.1 4.4 4.5 4.2 (a) In thousands 7.5 10,000 Pop., by Race, Sex, and Year, U.S., 80-88 Table 7.5 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number (a) 19 20 21 20 29 Rate 2.0 2.1 2.2 2.1 2.9 Age-adjusted Rate 2.0 2.1 2.2 2.1 2.9 Female Number 31 35 28 39 45 Rate 3.1 3.5 2.7 3.8 4.4 Age-adjusted Rate 3.1 3.4 2.8 3.7 4.2 Black Male Number 6 6 7 9 13 Rate 4.9 5.0 5.0 7.1 9.5 Age-adjusted Rate 5.5 5.8 5.6 7.3 10.4 Female Number 8 11 7 9 8 Rate 5.9 7.5 5.1 6.0 5.2 Age-adjusted Rate 6.1 8.0 5.4 6.3 5.6 Total Total Number 70 74 70 84 105 Rate 3.1 3.2 3.0 3.6 4.4 Age-adjusted Rate 3.1 3.2 3.0 3.6 4.4 (a) In thousands Table 7.5 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number (a) 29 30 32 25 Rate 2.9 3.0 3.2 2.5 Age-adjusted Rate 3.0 3.0 3.2 2.5 Female Number 39 41 40 36 Rate 3.8 4.0 3.8 3.4 Age-adjusted Rate 3.7 3.8 3.7 3.4 Black Male Number 7 11 12 15 Rate 5.3 8.0 8.5 10.1 Age-adjusted Rate 5.2 8.2 9.4 10.5 Female Number 12 13 10 14 Rate 8.0 8.4 6.7 8.7 Age-adjusted Rate 8.6 8.8 7.4 8.9 Total Total Number 98 108 110 103 Rate 4.1 4.5 4.5 4.2 Age-adjusted Rate 4.1 4.4 4.5 4.2 (a) In thousands 7.6 10,000 Pop., by Region and Year, U.S., 80-88 Table 7.6 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number (a) 15 13 14 15 20 Rate 3.1 2.7 2.9 3.0 4.0 Adjusted Rate (b) 2.8 2.6 2.6 3.0 3.7 North Number 21 19 16 22 23 Central Rate 3.6 3.2 2.7 3.8 3.9 Adjusted Rate 3.4 3.3 2.5 3.6 3.7 South Number 23 29 28 28 39 Rate 3.0 3.7 3.5 3.5 4.8 Adjusted Rate 2.7 3.4 3.2 3.2 4.3 West Number 11 13 12 19 23 Rate 2.5 3.0 2.7 4.1 4.9 Adjusted Rate 2.4 3.1 2.6 3.6 4.5 (a) In thousands (b) Adjusted for age and race Table 7.6 Number of Discharges with Diabetic Ketoacidosis as Any Listed Diagnosis and Hospital Discharge Rate per 10,000 Population by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number (a) 19 19 20 18 Rate 3.9 3.7 3.9 3.6 Adjusted Rate (b) 3.7 3.4 3.6 3.5 North Number 19 27 28 29 Central Rate 3.3 4.5 4.6 4.9 Adjusted Rate 3.0 4.1 4.1 4.4 South Number 37 41 37 40 Rate 4.5 5.0 4.4 4.7 Adjusted Rate 4.1 4.3 3.9 4.2 West Number 22 21 25 15 Rate 4.6 4.3 5.1 3.0 Adjusted Rate 4.3 3.9 4.6 2.7 (a) In thousands (b) Adjusted for age and race 7.7-7.8 Discharge for Diabetic Ketoacidosis as Primary Diagonsis 7.7 1,000 Diabetic Pop., by Age and Year, U.S., 80-88 Table 7.7 Hospital Discharge Rate for Diabetic Ketoacidosis as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 36.6 39.7 40.3 51.5 58.6 20-44 5.2 7.1 5.7 4.5 6.9 45-64 4.2 3.6 2.5 3.9 3.6 Total 10.3 11.0 10.2 12.4 13.7 Age-adjusted Rate 10.3 11.3 10.4 12.4 14.6 Table 7.7 Hospital Discharge Rate for Diabetic Ketoacidosis as Primary Diagnosis per 1,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 51.7 55.2 49.9 59.3 20-44 6.9 5.7 5.2 3.8 45-64 3.8 3.9 3.9 3.6 Total 12.8 12.6 13.6 13.2 Age-adjusted Rate 13.4 13.6 12.5 13.4 7.8 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88 Table 7.8 Hospital Discharge Rate for Diabetic Ketoacidosis as Primary Diagnosis per 1,000 Diabetic Population, by Race, Sex and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Rate 7.5 8.1 8.5 8.3 10.9 Age-adjusted Rate 8.3 8.1 8.1 7.7 11.2 Female Rate 9.9 11.0 9.1 13.0 12.1 Age-adjusted Rate 9.9 11.6 9.1 14.0 13.3 Black Male Rate 15.2 18.5 16.7 23.5 30.9 Age-adjusted Rate 13.1 16.5 16.1 35.1 36.0 Female Rate 12.7 16.6 10.5 11.5 10.5 Age-adjusted Rate 11.3 16.4 11.5 11.8 10.7 Total Total Rate 10.3 11.0 10.2 12.4 13.7 Age-adjusted Rate 10.3 11.3 10.4 12.4 14.6 Table 7.8 Hospital Discharge Rate for Diabetic Ketoacidosis as Primary Diagnosis per 1,000 Diabetic Population, by Race, Sex and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Rate 10.3 8.8 10.0 8.7 Age-adjusted Rate 10.6 11.8 8.7 7.9 Female Rate 11.1 10.5 12.4 10.7 Age-adjusted Rate 11.3 9.9 12.0 12.9 Black Male Rate 15.4 23.9 23.4 26.6 Age-adjusted Rate 16.9 21.1 21.1 26.8 Female Rate 16.4 18.4 12.0 16.0 Age-adjusted Rate 18.4 21.0 12.4 14.7 Total Total Rate 12.8 12.6 13.6 13.2 Age-adjusted Rate 13.4 13.6 12.5 13.4 7.9-7.10 Discharge for Diabetic Ketoacidosis as Listed Diagnosis 7.9 1,000 Diabetic Pop., by Age and Year, U.S., 80-88 Table 7.9 Hospital Discharge Rate for Diabetic Ketoacidosis as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-19 40.7 44.0 43.3 56.6 65.1 20-44 6.1 8.3 7.0 5.6 9.2 45-64 6.1 4.9 4.0 5.7 6.4 Total 12.1 12.8 11.9 14.5 16.9 Age-adjusted Rate 12.1 13.1 12.1 14.5 17.8 Table 7.9 Hospital Discharge Rate for Diabetic Ketoacidosis as Any Listed Diagnosis per 1,000 Diabetic Population, by Age and Year, 1985-1988 Year 1985 1986 1987 1988 Age 0-19 57.3 63.5 53.7 63.7 20-44 8.8 7.6 7.5 6.8 45-64 6.1 6.8 6.0 6.0 Total 15.5 15.9 16.1 16.2 Age-adjusted Rate 16.1 17.0 15.0 16.4 7.10 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88 Table 7.10 Hospital Discharge Rate for Diabetic Ketoacidosis as Any Listed Diagnosis per 1,000 Diabetic Population, by Race, Sex and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Rate 9.1 9.3 10.0 9.7 13.7 Age-adjusted Rate 9.9 9.3 9.7 9.2 14.1 Female Rate 11.5 13.3 10.4 15.0 15.6 Age-adjusted Rate 11.5 14.0 10.4 16.1 16.7 Black Male Rate 17.7 19.0 19.5 26.9 32.3 Age-adjusted Rate 15.2 17.0 19.0 38.1 37.3 Female Rate 15.4 18.4 11.6 12.7 11.5 Age-adjusted Rate 14.1 18.3 12.8 13.0 11.8 Total Total Rate 12.1 12.8 11.9 14.5 16.9 Age-adjusted Rate 12.1 13.1 12.1 14.5 17.8 Table 7.10 Hospital Discharge Rate for Diabetic Ketoacidosis as Any Listed Diagnosis per 1,000 Diabetic Population, by Race, Sex and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Rate 12.7 11.6 11.6 10.7 Age-adjusted Rate 13.0 15.2 10.2 9.8 Female Rate 13.5 13.7 14.6 13.6 Age-adjusted Rate 13.8 13.0 14.3 16.0 Black Male Rate 17.4 26.7 27.3 31.3 Age-adjusted Rate 19.3 23.5 25.5 32.2 Female Rate 18.8 20.2 15.4 20.4 Age-adjusted Rate 20.8 22.9 15.8 19.5 Total Total Rate 15.5 15.9 16.1 16.2 Age-adjusted Rate 16.1 17.0 15.0 16.4 7.11-7.13 Deaths w/ Diabetic Ketoacidosis as Underlying Cause 7.11 Mortality Rate per 100,000 Pop., Age & Year, U.S., 80-88 Table 7.11 Number of Deaths with Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 321 309 308 334 352 Rate 0.20 0.19 0.19 0.21 0.22 45-64 Number 506 511 434 451 403 Rate 1.14 1.15 0.97 1.01 0.90 65-74 Number 392 334 384 318 374 Rate 2.50 2.10 2.37 1.93 2.23 75+ Number 553 552 574 566 553 Rate 5.50 5.35 5.40 5.18 4.93 Total Number 1772 1707 1700 1669 1682 Rate 0.78 0.74 0.73 0.71 0.71 Age-adjusted Rate 0.78 0.74 0.73 0.70 0.70 Table 7.11 Number of Deaths with Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 331 388 375 457 Rate 0.20 0.23 0.22 0.27 45-64 Number 407 396 404 435 Rate 0.91 0.88 0.89 0.95 65-74 Number 358 357 296 341 Rate 2.11 2.06 1.68 1.91 75+ Number 590 594 584 572 Rate 5.12 5.02 4.81 4.59 Total Number 1686 1735 1660 1805 Rate 0.71 0.72 0.68 0.73 Age-adjusted Rate 0.69 0.70 0.66 0.71 7.12 Mortality Rate per 100,000 Pop., Race,Sex,Year, U.S., 80-88 Table 7.12 Number of Deaths With Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number 582 535 569 504 553 Rate 0.61 0.56 0.59 0.52 0.56 Age-adjusted Rate 0.67 0.61 0.63 0.55 0.60 Female Number 733 755 743 749 695 Rate 0.73 0.75 0.73 0.73 0.67 Age-adjusted Rate 0.63 0.64 0.61 0.62 0.56 Black Male Number 185 160 157 187 192 Rate 1.46 1.24 1.20 1.41 1.42 Age-adjusted Rate 2.00 1.63 1.60 1.90 1.87 Female Number 246 237 212 213 219 Rate 1.74 1.65 1.46 1.44 1.46 Age-adjusted Rate 2.07 1.95 1.72 1.69 1.70 Total Total Number 1772 1707 1700 1669 1682 Rate 0.78 0.74 0.73 0.71 0.71 Age-adjusted Rate 0.78 0.74 0.73 0.70 0.70 Table 7.12 Number of Deaths With Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number 541 549 597 607 Rate 0.55 0.55 0.59 0.60 Age-adjusted Rate 0.58 0.58 0.62 0.62 Female Number 755 762 666 723 Rate 0.73 0.73 0.63 0.68 Age-adjusted Rate 0.60 0.60 0.51 0.55 Black Male Number 148 174 166 210 Rate 1.08 1.25 1.18 1.47 Age-adjusted Rate 1.44 1.59 1.51 1.80 Female Number 219 224 204 241 Rate 1.44 1.45 1.30 1.52 Age-adjusted Rate 1.67 1.69 1.51 1.73 Total Total Number 1686 1735 1660 1805 Rate 0.71 0.72 0.68 0.73 Age-adjusted Rate 0.69 0.70 0.66 0.71 7.13 Mortality Rate per 100,000 Pop., Region & Year, U.S., 80-88 Table 7.13 Number of Deaths With Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number 417 353 378 354 370 Rate 0.85 0.72 0.77 0.72 0.74 Adjusted Rate (a) 0.81 0.68 0.71 0.67 0.69 North Number 434 429 424 443 389 Central Rate 0.74 0.73 0.72 0.75 0.66 Adjusted Rate 0.75 0.73 0.71 0.75 0.65 South Number 645 652 608 598 645 Rate 0.85 0.85 0.77 0.75 0.80 Adjusted Rate 0.77 0.78 0.71 0.68 0.72 West Number 276 273 290 274 278 Rate 0.64 0.62 0.64 0.59 0.59 Adjusted Rate 0.75 0.73 0.73 0.68 0.69 (a) Adjusted for age and race Table 7.13 Number of Deaths With Diabetic Ketoacidosis as Underlying Cause and Mortality Rate per 100,000 Population, by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number 354 371 348 370 Rate 0.71 0.74 0.69 0.73 Adjusted Rate (a) 0.65 0.68 0.63 0.66 North Number 430 412 393 412 Central Rate 0.73 0.69 0.66 0.69 Adjusted Rate 0.70 0.67 0.64 0.68 South Number 614 663 617 667 Rate 0.75 0.80 0.74 0.78 Adjusted Rate 0.67 0.72 0.66 0.69 West Number 288 289 302 356 Rate 0.60 0.59 0.61 0.70 Adjusted Rate 0.67 0.66 0.69 0.80 (a) Adjusted for age and race 7.14-7.16 Deaths w/ Diabetic Ketoacidosis as Any Listed Cause 7.14 Mort. Rate per 100,000 Pop., by Age & Year, U.S., 80-88 Table 7.14 Number of Deaths with Diabetic Ketoacidosis as Any Listed Diagnosis and Mortality Rate per 100,000 Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 Number 413 391 393 413 442 Rate 0.26 0.25 0.24 0.25 0.27 45-64 Number 818 857 725 767 696 Rate 1.84 1.92 1.63 1.72 1.55 65-74 Number 719 665 699 653 748 Rate 4.59 4.18 4.32 3.96 4.47 75+ Number 965 940 948 1033 1045 Rate 9.60 9.11 8.92 9.45 9.31 Total Number 2915 2855 2765 2866 2931 Rate 1.28 1.24 1.19 1.22 1.24 Age-adjusted Rate 1.28 1.24 1.18 1.20 1.21 Table 7.14 Number of Deaths with Diabetic Ketoacidosis as Any Listed Diagnosis and Mortality Rate per 100,000 Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 Number 428 483 472 561 Rate 0.26 0.29 0.28 0.33 45-64 Number 720 694 669 741 Rate 1.60 1.54 1.48 1.61 65-74 Number 734 691 635 664 Rate 4.32 3.99 3.60 3.71 75+ Number 1097 1101 1102 1045 Rate 9.52 9.31 9.07 8.39 Total Number 2979 2969 2879 3012 Rate 1.25 1.23 1.18 1.23 Age-adjusted Rate 1.21 1.19 1.13 1.17 7.15 Mort. Rate per 100,000 Pop., Race, Sex, Year, U.S., 80-88 Table 7.15 Number of Deaths with Diabetic Ketoacidosis as Any Listed Cause and Mortality Rate per 100,000 Population, by Race Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Number 984 880 942 904 944 Rate 1.03 0.92 0.97 0.93 0.96 Age-adjusted Rate 1.13 1.00 1.05 1.00 1.03 Female Number 1234 1305 1208 1305 1277 Rate 1.23 1.29 1.19 1.28 1.24 Age-adjusted Rate 1.05 1.10 0.99 1.06 1.01 Black Male Number 270 265 244 282 300 Rate 2.13 2.06 1.87 2.12 2.23 Age-adjusted Rate 2.96 2.77 2.56 2.88 3.02 Female Number 391 376 340 341 369 Rate 2.77 2.62 2.33 2.31 2.46 Age-adjusted Rate 3.32 3.12 2.76 2.74 2.90 Total Total Number 2915 2855 2765 2866 2931 Rate 1.28 1.24 1.19 1.22 1.24 Age-adjusted Rate 1.28 1.24 1.18 1.20 1.21 Table 7.15 Number of Deaths with Diabetic Ketoacidosis as Any Listed Cause and Mortality Rate per 100,000 Population, by Race Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Number 990 972 989 1013 Rate 1.00 0.97 0.98 1.00 Age-adjusted Rate 1.07 1.03 1.03 1.03 Female Number 1327 1309 1213 1241 Rate 1.28 1.25 1.15 1.17 Age-adjusted Rate 1.04 1.01 0.91 0.93 Black Male Number 252 265 269 320 Rate 1.84 1.91 1.91 2.23 Age-adjusted Rate 2.55 2.50 2.53 2.85 Female Number 367 383 363 388 Rate 2.41 2.48 2.32 2.44 Age-adjusted Rate 2.82 2.90 2.71 2.81 Total Total Number 2979 2969 2879 3012 Rate 1.25 1.23 1.18 1.23 Age-adjusted Rate 1.21 1.19 1.13 1.17 7.16 Mort. Rate per 100,000 Pop., by Region & Year, U.S., 80-88 Table 7.16 Number of Deaths With Diabetic Ketoacidosis as Any Listed Cause and Mortality Rate per 100,000 Population, by Region and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Region Northeast Number 716 619 665 652 666 Rate 1.46 1.26 1.35 1.32 1.34 Adjusted Rate (a) 1.39 1.18 1.25 1.22 1.23 North Number 742 721 690 729 698 Central Rate 1.26 1.22 1.17 1.24 1.18 Adjusted Rate 1.29 1.23 1.16 1.22 1.16 South Number 996 1059 970 1039 1103 Rate 1.31 1.37 1.24 1.30 1.37 Adjusted Rate 1.21 1.27 1.13 1.20 1.24 West Number 461 456 440 446 464 Rate 1.06 1.03 0.97 0.97 0.99 Adjusted Rate 1.26 1.24 1.13 1.10 1.12 (a) Adjusted for age and race Table 7.16 Number of Deaths With Diabetic Ketoacidosis as Any Listed Cause and Mortality Rate per 100,000 Population, by Region and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Region Northeast Number 693 682 657 672 Rate 1.39 1.36 1.31 1.33 Adjusted Rate (a) 1.26 1.23 1.17 1.19 North Number 755 739 675 688 Central Rate 1.28 1.25 1.13 1.15 Adjusted Rate 1.23 1.20 1.09 1.11 South Number 1032 1077 1084 1113 Rate 1.26 1.30 1.29 1.31 Adjusted Rate 1.13 1.17 1.15 1.16 West Number 499 471 463 539 Rate 1.04 0.97 0.93 1.06 Adjusted Rate 1.17 1.10 1.07 1.20 (a) Adjusted for age and race 7.17-7.18 Mort. for Diabetic Ketoacidosis as Underlying Cause 7.17 100,000 Diabetic Population, by Age & Year, U.S., 80-88 Table 7.17 Mortality Rate for Diabetic Ketoacidosis as Underlying Cause per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 31.8 32.5 31.3 33.3 35.4 45-64 21.2 20.1 16.9 17.4 17.1 65-74 25.8 24.5 25.2 24.4 21.3 75+ 64.2 58.3 70.8 64.7 50.7 Total 30.6 29.4 28.9 28.9 27.1 Age-adjusted Rate 30.6 29.1 29.6 29.0 26.4 Table 7.17 Mortality Rate for Diabetic Ketoacidosis as Underlying Cause per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 31.9 37.1 27.5 41.8 45-64 17.5 13.9 15.8 17.7 65-74 19.3 22.4 17.4 20.0 75+ 53.6 46.3 48.9 52.3 Total 26.7 25.6 24.4 28.4 Age-adjusted Rate 25.9 25.0 23.2 27.7 7.18 100,000 Diabetic Population, Race, Sex, Year, U.S., 80-88 Table 7.18 Mortality Rate for Diabetic Ketoacidosis as Underlying Cause per 100,000 Diabetic Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Rate 28.0 24.7 27.2 24.3 26.6 Age-adjusted Rate 29.7 27.0 28.1 24.3 26.5 Female Rate 26.9 28.7 27.8 29.1 24.1 Age-adjusted Rate 25.2 26.2 26.9 27.9 22.0 Black Male Rate 52.9 47.0 46.5 53.3 48.8 Age-adjusted Rate 58.4 53.0 53.4 67.7 55.2 Female Rate 45.7 40.3 33.3 30.4 32.7 Age-adjusted Rate 47.3 41.7 36.7 32.0 33.1 Total Total Rate 30.6 29.4 28.9 28.9 27.1 Age-adjusted Rate 30.6 29.1 29.6 29.0 26.4 Table 7.18 Mortality Rate for Diabetic Ketoacidosis as Underlying Cause per 100,000 Diabetic Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Rate 23.6 21.4 21.7 25.7 Age-adjusted Rate 23.6 23.5 20.9 24.6 Female Rate 26.1 25.2 24.3 27.6 Age-adjusted Rate 23.5 22.5 22.0 25.8 Black Male Rate 35.4 41.8 37.8 45.3 Age-adjusted Rate 41.1 43.3 39.7 46.2 Female Rate 33.7 35.1 30.1 35.8 Age-adjusted Rate 33.5 35.0 28.9 34.2 Total Total Rate 26.7 25.6 24.4 28.4 Age-adjusted Rate 25.9 25.0 23.2 27.7 7.19-7.20 Mort. for Diabetic Ketoacidosis as Any Listed Cause 7.19 100,000 Diabetic Pop., by Age & Year, U.S., 80-88 Table 7.19 Mortality Rate for Diabetic Ketoacidosis as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Age 0-44 40.9 41.1 39.9 41.2 44.5 45-64 34.2 33.7 28.2 29.5 29.5 65-74 47.2 48.7 45.8 50.0 42.6 75+ 112.1 99.2 117.0 118.2 95.8 Total 50.4 49.2 47.0 49.6 47.3 Age-adjusted Rate 50.4 48.7 48.1 50.2 45.4 Table 7.19 Mortality Rate for Diabetic Ketoacidosis as Any Listed Cause per 100,000 Diabetic Population, by Age and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Age 0-44 41.2 46.1 34.6 51.4 45-64 30.9 24.4 26.2 30.1 65-74 39.7 43.4 37.3 39.0 75+ 99.7 85.7 92.3 95.5 Total 47.1 43.8 42.3 47.4 Age-adjusted Rate 45.2 42.3 40.4 45.9 7.20 100,000 Diabetic Pop., by Race, Sex, & Year, U.S., 80-88 Table 7.20 Mortality Rate for Diabetic Ketoacidosis as Any Listed Cause per 100,000 Diabetic Population, by Race, Sex, and Year, United States, 1980-1984 Year 1980 1981 1982 1983 1984 Race Sex White Male Rate 47.3 40.6 45.0 43.6 45.3 Age-adjusted Rate 49.7 44.4 46.8 44.3 44.8 Female Rate 45.3 49.6 45.2 50.7 44.4 Age-adjusted Rate 42.2 45.4 43.6 48.3 39.8 Black Male Rate 77.2 77.8 72.3 80.4 76.2 Age-adjusted Rate 86.8 89.0 83.8 98.7 86.1 Female Rate 72.6 64.0 53.5 48.7 55.2 Age-adjusted Rate 76.9 66.6 58.8 50.9 55.9 Total Total Rate 50.4 49.2 47.0 49.6 47.3 Age-adjusted Rate 50.4 48.7 48.1 50.2 45.4 Table 7.20 Mortality Rate for Diabetic Ketoacidosis as Any Listed Cause per 100,000 Diabetic Population, by Race, Sex, and Year, United States, 1985-1988 Year 1985 1986 1987 1988 Race Sex White Male Rate 43.1 37.9 35.9 42.9 Age-adjusted Rate 42.9 40.1 35.2 41.8 Female Rate 45.9 43.4 44.2 47.4 Age-adjusted Rate 40.9 38.8 39.9 43.2 Black Male Rate 60.3 63.6 61.3 69.0 Age-adjusted Rate 71.2 66.4 66.9 71.3 Female Rate 56.4 60.0 53.6 57.6 Age-adjusted Rate 55.8 59.5 51.9 55.5 Total Total Rate 47.1 43.8 42.3 47.4 Age-adjusted Rate 45.2 42.3 40.4 45.9 END-STAGE RENAL DISEASE Introduction End-stage renal disease (ESRD), which requires dialysis or transplantation for survival, is a leading complication of diabetes. Because Medicare supplies reimbursement for more than 90% of ESRD treatment in the United States, its information system is a basis for surveillance of ESRD (Eggers et al., 1984). To examine trends in treating ESRD attributed to diabetes (ESRD-DM) in the United States during 1980-1986, we evaluate the numbers and rates of ESRD by calendar year, age, sex, race, and state of residence. We present rates based on both general and diabetic population denominators. Methods Data on when ESRD treatment began were provided by the Bureau of Data Management and Strategy, Health Care Financing Administration, from the ESRD program's management and medical information system, which includes demographic information on beneficiaries treated for ESRD. This data set is frequently updated. Thus, the results in our tables differ slightly from those in other reports (U.S. Renal Data System, 1989; Eggers, 1988). We use the term "incidence" to mean initiation of treatment for ESRD. The Chronic Renal Disease Medical Evidence Report, filled out by treatment providers, is the source for the "primary diagnosis". While this designation was often missing in earlier years, since 1982 it is available for over 90% of cases. We used estimates of the resident population of the United States as the denominators in calculating general population rates of ESRD-DM. We used estimates of the diabetic population from the National Health Interview Survey (NHIS) in calculating rates among persons with diabetes (Chapter 2). We standardized rates according to the direct method. We used the 1980 U.S. resident population to standardize general population rates and the estimated 1980 U.S. diabetic population to standardize rates among persons with diabetes. Results The number of persons being treated for ESRD-DM increased from 5,955 in 1980 to 27,919 in 1986 (Table 8.1). The increase was greater for blacks and other races. During this period, their percentage of the total increased from 29.4% to 34.0%. The number of incident ESRD-DM cases steadily increased each year from 2,202 in 1980 to 8,994 in 1986 (Figure 8.1). The age-adjusted incidence rate of ESRD-DM increased from 9.6 to 36.7 per 1,000,000 (Table 8.2). This increase was more prominent among older age groups (Figure 8.2). The rate of increase was similar among different sex and race groups (Figure 8.3, Tables 8.3-8.8). The 1986 incidence rate of ESRD-DM in the resident population increased with age, except for the 75+ group (Table 8.2). For males, the age-adjusted incidence among blacks was 2.9 times and among other races 3.4 times the incidence among whites (Tables 8.3, 8.5, and 8.7). For females, the black and other race rate ratios were 4.3 and 4.4, respectively (Tables 8.4, 8.6, and 8.8). The sex differences varied by race: the incidence among white males was 1.2 times that for white females, whereas the incidence for black males was 0.8 times that of black females. Using the estimated diabetic population in the denominator, the age-adjusted incidence rate per 100,000 of ESRD-DM increased from 37.9 in 1980 to 138.0 in 1986 (Table 8.9). This increase was also more prominent in older age groups (Figure 8.4), whereas the rate of increase was similar for the different sex and race groups (Figure 8.5 and Tables 8.10-8.13). In 1986, compared with white females, the age-adjusted incidence ratios were 2.2 for black females, 2.1 for black males, and 1.3 for white males. The largest age-specific male-female ratio (2.8) was for whites less than 45 years old. We present the state-specific prevalence and incidence of ESRD-DM (Tables 8.14-8.15). We also present the age- and race-standardized incidence rates by state and grouped by quartile based on the average annual rates for the years 1980-1986 (Figure 8.6). Discussion There has been a striking increase in treatment for ESRD-DM in the United States. In 1982, the classification of primary etiology of ESRD in the Medicare system improved (U.S. Renal Data System, 1989). From 1982 through 1986, the proportion of new ESRD treatment attributed to diabetes increased from 23.0% to 28.9%. In this period, the incidence of ESRD-DM increased 11.8% per year. Rates of ESRD-DM based on general population denominators are influenced by diabetes prevalence in the population, disease severity, and treatment access and use. From 1982 to 1986, in the general population, the rates of ESRD-DM increased most in older age groups, reflecting both the higher prevalence of diabetes with increasing age, as well as the more frequent occurrence of complications with increasing age. Rates of ESRD-DM calculated using the population of people known to have diabetes as the denominator are not affected by prevalence of diabetes, but rather are dependent on disease severity and health care utilization. From 1982 to 1986, the rates of ESRD-DM per 100,000 persons with diabetes increased by 67.5%. The age-specific rates of ESRD-DM were highest in the youngest age group (0-44 years old), reflecting the higher proportion with insulin-dependent relative to non-insulin-dependent diabetes mellitus (NIDDM). The rates increased most, however, in older age groups, suggesting that ESRD related to NIDDM is a faster growing public health problem (Centers for Disease Control, 1989). We noted some differences in ESRD-DM according to race and sex. When calculated using general population denominators, the incidence of ESRD-DM was higher among blacks than among whites. The incidence was highest among black females and lowest among white males. The rates for black males were about 3 times those for white males, and the rates for black females were about 4 times those for white females. When ESRD-DM rates were calculated using diabetic population denominators, the rates for black males and females were more than twice those for white males and females, respectively. These results suggest that the higher rates of ESRD-DM seen among blacks in the general population are not only due to higher prevalence of diabetes among blacks relative to whites. Differences in severity of diabetes and higher prevalence of hypertension are potential co-factors that might account for the higher rates seen in blacks. The large male-female ratio in whites in the less than 45-year age group suggests that males are at particular risk for ESRD associated with IDDM. The methods we used had some limitations that need to be considered when interpreting our results. First, ESRD is defined by treatment with dialysis or transplantation. In two recent population studies, approximately 30% of persons with advanced renal failure received neither therapy (Humphrey et al., 1989; Nelson et al., 1988). Regarding the observed increase in ESRD-DM, we cannot distinguish increased disease incidence from increased availability and use of treatment. Renal mortality investigations (Geiss et al., 1985) and additional cohort studies may clarify disease incidence trends. Second, because Medicare reimburses approximately 90% of treatment for ESRD in the United States, its ESRD program incidence slightly underestimates the U.S. total. Third, diabetes as the primary diagnosis of ESRD may be imprecisely classified. In one clinical series, 8% of advanced renal disease among persons with diabetes was attributed to other etiologies (Balakuntalam et al., 1983). Fourth, the rates using the diabetic population were calculated from estimates derived from the NHIS and, thus, represent persons with diagnosed diabetes. Approximately one-half of persons with diabetes, however, do not know they have the disease (Harris et al., 1987). Despite these limitations, the Medicare ESRD program provides useful indicators of the morbidity and public health burden related to ESRD-DM in the United States. The rapidly increasing number of persons treated for ESRD represents growing costs (estimated $4.4 billion in 1987, more than $1 billion for ESRD-DM) (U.S. Renal Data System, 1989 of renal disease and improving blood pressure control in persons with diabetes (Herman et al., 1989). Recent studies of ESRD in Mexican-Americans in Texas (Pugh et al., 1988) and Native Americans in the United States (Newman et al., in press), have revealed excessive incidence of ESRD-DM among these groups compared with the corresponding white populations. In addition to blacks, these populations are appropriate high-risk target groups for public health interventions. Update This section updates data presented in previous sections in light of three additional years of Medicare data on end-stage renal disease. In addition, Medicare data on end-stage renal disease for years 1980-1986 have been updated in the detailed tables. Based on treatment reimbursed by the Medicare program, the number of new U.S. cases of end-stage renal disease attributed to diabetes (ESRD-DM) increased fivefold during the 1980s, from 2,220 in 1980 to 13,332 in 1989 (Table 8.2). Similarly, the age-standardized incidence rate of ESRD-DM among persons with diabetes increased from 38.39 to 201.98 per 100,000 diabetic population (Table 8.9). Age differences in incidence rates tended to decrease during this decade (Table 8.9). Rates were higher among blacks than among whites (Figure 1.11, Tables 8.10-8.13). Among both races, males had higher rates than females, until 1985, when rates for black females rates began to exceed those for black males. Detailed Tables 8.1 Persons Undergoing Treatment for End-stage Renal Disease Table 8.1 Number of Persons Undergoing Treatment for End-Stage Renal Disease (ESRD) Related to Diabetes, by Race, Sex, and Year, United States, 1980-1985 Race and Sex 1980 1981 1982 1983 1984 1985 White Males 2361 3189 4423 5649 7074 8567 White Females 1767 2620 3748 4939 6135 8816 Black Males 631 915 1275 1725 2148 2777 Black Females 909 1318 1943 2609 3379 4142 Other Males 15 41 106 187 268 349 Other Females 21 57 143 231 312 439 Total 5704 8140 11638 15340 19316 23699 Table 8.1 Number of Persons Undergoing Treatment for End-Stage Renal Disease (ESRD) Related to Diabetes, by Race, Sex, and Year, United States, 1986-1989 Race and Sex 1986 1987 1988 1989 White Males 10079 11494 12978 14965 White Females 8816 10260 11737 13669 Black Males 3341 3818 4457 5090 Black Females 4886 5773 6564 7608 Other Males 436 541 658 787 Other Females 566 655 816 988 Total 28124 32541 37210 43107 8.2-8.8 Persons Initiating Treatment for ESRD Rel. to Diabetes 8.2 1,000,000 Pop., Age & Year, U.S., 80-89 Table 8.2 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 415 615 798 824 950 1053 Rate 3.2 4.6 6.0 6.2 7.1 7.9 35-44 Number 334 523 673 808 979 1066 Rate 12.9 19.8 24.0 27.6 32.1 33.6 45-54 Number 421 653 919 1042 1179 1401 Rate 18.5 28.9 40.9 46.4 52.4 62.0 55-64 Number 598 1017 1430 1703 2044 2282 Rate 27.5 46.3 64.7 76.6 91.7 102.3 65-74 Number 375 679 903 1169 1456 1779 Rate 24.0 42.7 55.8 70.9 87.0 104.6 75+ Number 77 96 200 250 360 479 Rate 7.7 9.3 18.8 22.9 32.1 41.6 Total Number 2220 3583 4923 5796 6968 8060 Rate 9.8 15.6 21.2 24.7 29.5 33.8 Age-adjusted Rate 9.8 15.6 21.2 24.6 29.2 33.4 Table 8.2 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 1080 1077 1018 1204 Rate 8.1 8.0 7.6 9.0 35-44 Number 1199 1233 1316 1499 Rate 36.3 35.9 37.3 41.1 45-54 Number 1553 1683 1897 2245 Rate 68.1 72.3 78.5 90.2 55-64 Number 2527 2859 3142 3593 Rate 113.8 129.9 144.1 166.4 65-74 Number 2221 2512 2975 3619 Rate 128.2 142.2 166.3 199.1 75+ Number 576 745 832 1172 Rate 48.7 61.3 66.8 91.6 Total Number 9156 10109 11180 13332 Rate 38.0 41.5 45.5 53.7 Age-adjusted Rate 37.5 40.9 44.7 52.6 8.3 1,000,000 Pop., Age & Year, U.S., 80-89, White Males Table 8.3 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, White Males, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 195 285 391 375 458 477 Rate 3.5 5.1 7.0 6.7 8.2 8.5 35-44 Number 176 264 339 389 501 518 Rate 15.9 23.3 28.1 30.9 38.2 38.0 45-54 Number 166 257 308 351 433 497 Rate 17.0 26.6 32.1 36.7 45.3 51.9 55-64 Number 184 253 412 516 622 703 Rate 20.1 27.4 44.4 55.4 66.5 75.2 65-74 Number 118 182 287 327 417 538 Rate 19.3 29.2 45.1 50.4 63.2 80.0 75+ Number 25 28 53 84 115 135 Rate 7.7 8.4 15.6 24.1 32.1 36.8 Total Number 864 1269 1790 2042 2546 2868 Rate 9.1 13.2 18.5 20.9 25.9 29.0 Age-adjusted Rate 9.1 13.2 18.5 20.9 25.7 28.8 Table 8.3 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, White Males, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 523 503 471 565 Rate 9.3 9.0 8.4 10.1 35-44 Number 564 602 631 691 Rate 39.8 41.0 41.9 44.4 45-54 Number 540 568 672 800 Rate 55.9 57.7 65.6 75.8 55-64 Number 788 871 937 1088 Rate 84.9 95.0 103.2 121.2 65-74 Number 657 719 868 1137 Rate 95.5 102.3 121.9 156.8 75+ Number 178 226 268 352 Rate 47.3 58.4 67.4 85.9 Total Number 3250 3489 3847 4633 Rate 32.6 34.7 37.9 45.3 Age-adjusted Rate 32.3 34.3 37.4 44.7 8.4 1,000,000 Pop., Age & Year, U.S., 80-89, White Females Table 8.4 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, White Females, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 151 235 290 323 351 408 Rate 2.8 4.3 5.3 5.9 6.5 7.5 35-44 Number 97 163 194 247 261 292 Rate 8.6 14.1 15.8 19.3 19.6 21.2 45-54 Number 99 173 282 287 318 368 Rate 9.7 17.1 28.1 28.8 31.9 36.9 55-64 Number 178 354 468 547 681 696 Rate 17.2 34.0 44.8 52.3 65.1 66.7 65-74 Number 112 224 327 444 522 631 Rate 14.0 27.7 39.8 53.3 61.9 74.0 75+ Number 29 33 61 87 123 193 Rate 4.9 5.4 9.7 13.4 18.5 28.3 Total Number 666 1182 1622 1935 2256 2588 Rate 6.7 11.7 16.0 18.9 21.9 24.9 Age-adjusted Rate 6.4 11.2 15.2 17.8 20.5 23.2 Table 8.4 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, White Females, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 393 397 362 435 Rate 7.3 7.3 6.7 8.1 35-44 Number 377 367 372 417 Rate 26.4 24.8 24.6 26.7 45-54 Number 427 437 498 568 Rate 42.6 42.8 47.0 52.0 55-64 Number 804 881 1014 1160 Rate 77.8 86.4 100.9 117.2 65-74 Number 811 936 1132 1358 Rate 93.7 106.5 127.7 151.4 75+ Number 194 309 323 459 Rate 27.8 43.1 44.1 61.2 Total Number 3006 3327 3701 4397 Rate 28.8 31.6 34.9 41.2 Age-adjusted Rate 26.6 28.9 31.8 37.3 8.5 1,000,000 Pop., Age & Year, U.S., 80-89, Black Males Table 8.5 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Black Males, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 31 46 47 54 72 85 Rate 3.6 5.2 5.3 6.0 7.9 9.2 35-44 Number 28 47 68 86 93 121 Rate 22.5 37.1 51.3 62.3 64.3 80.0 45-54 Number 56 86 118 162 165 227 Rate 54.5 83.3 113.7 154.4 155.3 210.9 55-64 Number 70 122 173 185 217 283 Rate 81.5 139.3 193.5 203.0 234.2 301.2 65-74 Number 35 76 80 120 143 175 Rate 61.4 131.3 136.0 200.7 235.2 282.0 75+ Number 3 11 27 18 33 47 Rate 10.6 37.9 90.5 58.8 105.1 146.9 Total Number 223 388 513 625 723 938 Rate 17.6 30.1 39.2 47.1 53.7 68.6 Age-adjusted Rate 22.6 39.6 52.1 61.8 70.7 90.3 Table 8.5 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Black Males, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 68 72 83 90 Rate 7.3 7.7 8.8 9.4 35-44 Number 125 123 157 167 Rate 78.5 74.1 90.5 91.9 45-54 Number 234 265 281 350 Rate 214.3 237.4 245.5 299.2 55-64 Number 307 326 404 441 Rate 322.8 339.4 417.1 452.5 65-74 Number 211 220 265 291 Rate 333.5 340.5 401.4 430.7 75+ Number 42 47 63 85 Rate 128.4 140.4 184.8 243.2 Total Number 987 1053 1253 1424 Rate 71.0 74.6 87.5 97.9 Age-adjusted Rate 94.2 98.8 115.7 129.6 8.6 1,000,000 Pop., Age & Year, U.S., 80-89, Black Females Table 8.6 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Black Females, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 13 29 58 61 57 64 Rate 1.4 3.2 6.2 6.5 6.0 6.7 35-44 Number 21 36 54 71 97 103 Rate 14.0 23.6 33.8 42.7 55.8 56.7 45-54 Number 72 106 164 188 223 229 Rate 57.2 83.6 128.5 145.6 170.6 172.7 55-64 Number 128 218 311 368 428 501 Rate 120.2 201.4 282.6 329.4 378.3 437.7 65-74 Number 71 141 182 227 324 346 Rate 91.0 177.4 225.3 276.7 389.4 409.9 75+ Number 13 15 52 51 72 75 Rate 27.6 30.8 102.9 97.7 133.3 134.8 Total Number 318 545 821 966 1201 1318 Rate 22.5 38.0 56.3 65.3 80.1 86.7 Age-adjusted Rate 27.1 45.7 67.4 78.1 95.8 103.7 Table 8.6 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Black Females, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 75 79 81 92 Rate 7.8 8.2 8.3 9.4 35-44 Number 94 116 109 159 Rate 49.3 58.2 52.5 73.3 45-54 Number 260 321 328 396 Rate 192.9 233.5 232.3 273.5 55-64 Number 512 623 599 692 Rate 442.6 535.1 511.8 589.1 65-74 Number 431 498 568 651 Rate 502.5 571.5 641.5 722.9 75+ Number 126 128 127 211 Rate 218.9 215.8 207.8 335.7 Total Number 1498 1765 1812 2201 Rate 97.1 112.8 114.1 136.6 Age-adjusted Rate 116.1 134.9 136.4 162.2 8.7 1,000,000 Pop., Age & Year,U.S.,80-89, Non-Black/White Males Table 8.7 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Other than White or Black Males, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 1 5 3 3 4 8 Rate 0.6 2.7 1.5 1.4 1.8 3.5 35-44 Number 1 3 11 5 16 14 Rate 3.0 8.4 28.3 12.0 35.6 29.1 45-54 Number 0 2 23 27 23 39 Rate 0.0 8.7 93.3 103.3 82.2 130.3 55-64 Number 3 10 17 36 36 36 Rate 20.0 62.2 98.8 197.7 186.1 177.2 65-74 Number 1 6 9 22 16 29 Rate 10.5 59.7 82.9 193.9 132.6 227.0 75+ Number 0 0 4 6 9 13 Rate 0.0 0.0 72.9 100.2 140.3 182.3 Total Number 6 26 67 99 104 139 Rate 2.3 9.4 22.6 31.7 31.6 40.0 Age-adjusted Rate 3.3 13.4 31.8 49.2 46.5 59.0 Table 8.7 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Other than White or Black Males, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 10 7 7 4 Rate 4.2 2.8 2.7 1.5 35-44 Number 18 16 25 33 Rate 34.6 28.7 42.0 51.8 45-54 Number 38 43 55 71 Rate 118.2 125.8 150.4 181.6 55-64 Number 39 54 70 70 Rate 181.4 240.7 297.7 284.9 65-74 Number 29 49 51 56 Rate 210.7 331.6 319.4 332.0 75+ Number 15 11 21 27 Rate 196.5 135.1 234.9 288.1 Total Number 149 180 229 261 Rate 40.7 46.9 56.9 62.0 Age-adjusted Rate 58.8 69.3 82.3 87.8 8.8 1,000,000 Pop., Age/Year,U.S.,80-89, Non-White/Black Females Table 8.8 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Other than White or Black Females, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-34 Number 3 4 7 6 7 5 Rate 1.7 2.1 3.5 2.9 3.2 2.2 35-44 Number 2 2 7 8 10 14 Rate 5.6 5.2 16.6 17.5 20.1 26.0 45-54 Number 6 8 19 23 12 35 Rate 23.8 30.0 67.6 77.7 38.6 106.1 55-64 Number 1 15 41 40 55 50 Rate 5.8 79.9 200.9 180.9 231.5 196.6 65-74 Number 0 6 11 24 29 53 Rate 0.0 54.3 89.8 181.0 202.9 341.8 75+ Number 0 1 2 3 6 16 Rate 0.0 15.7 29.1 39.7 73.4 176.2 Total Number 12 36 87 104 119 173 Rate 4.5 12.5 28.3 32.0 34.7 47.8 Age-adjusted Rate 4.6 16.9 37.4 43.0 47.4 65.0 Table 8.8 Number of Persons Initiating Treatment for ESRD Related to Diabetes and Rate per 1,000,000 Population, by Age and Year, Other than White or Black Females, United States, 1986-1989 Age 1986 1987 1988 1989 0-34 Number 5 7 12 11 Rate 2.1 2.9 4.8 4.2 35-44 Number 14 5 16 21 Rate 24.1 8.1 24.2 29.8 45-54 Number 42 37 48 47 Rate 119.8 99.4 120.6 110.4 55-64 Number 60 77 91 112 Rate 221.1 266.6 298.7 353.7 65-74 Number 64 63 77 95 Rate 376.6 344.0 387.0 444.6 75+ Number 15 19 24 32 Rate 153.4 177.8 203.6 246.9 Total Number 200 208 268 318 Rate 52.4 51.9 63.7 72.2 Age-adjusted Rate 69.8 69.6 81.8 92.3 8.9-8.13 Rate Initiation of Treatment for ESRD Rel. to Diabetes 8.9 100,000 Diabetic Pop., Age & Year, U.S., 80-89 Table 8.9 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-44 74.19 119.52 149.51 162.83 193.99 204.13 45-64 42.64 65.64 91.52 105.61 136.64 158.08 65-74 24.63 49.75 59.20 89.57 82.88 96.11 75+ 8.94 10.13 24.68 28.60 33.02 43.52 Total 38.39 61.68 83.63 100.26 112.39 127.54 Age-adjusted Rate 38.39 62.60 83.18 99.91 117.07 132.74 Table 8.9 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, United States, 1980-1989 Age 1986 1987 1988 1989 0-44 217.68 169.37 213.73 220.91 45-64 143.29 178.01 204.83 215.65 65-74 139.41 147.53 174.59 221.76 75+ 44.85 62.42 76.05 106.90 Total 135.21 148.41 176.06 200.21 Age-adjusted Rate 140.59 151.26 179.24 201.98 8.10 100,000 Diabetic Pop., Age & Year, U.S., 80-89, White Males Table 8.10 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-44 119.23 148.75 189.92 187.26 271.14 253.87 45-64 38.15 50.14 73.69 94.22 129.69 137.41 65-74 19.84 32.90 66.79 78.50 70.48 79.22 75+ 9.78 12.27 17.62 25.59 35.50 38.53 Total 41.56 58.54 85.56 98.51 122.24 124.98 Age-adjusted Rate 43.26 57.18 83.81 96.10 124.77 127.69 Table 8.10 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, White Males, United States, 1986-1989 Age 1986 1987 1988 1989 0-44 360.98 191.02 227.77 302.37 45-64 107.38 136.72 171.85 174.78 65-74 105.12 101.98 155.69 212.40 75+ 43.95 53.81 69.47 136.78 Total 126.56 126.60 162.77 202.47 Age-adjusted Rate 141.61 124.71 162.11 201.30 8.11 100,000 Diabetic Pop., Age/Year, U.S., 80-89, White Females Table 8.11 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1985 Age 1980 1981 1982 1983 1984 1985 0-44 52.12 94.78 101.88 141.23 139.51 139.87 45-64 28.27 52.83 76.09 77.16 95.61 116.50 65-74 14.95 36.31 41.68 70.52 65.05 71.27 75+ 5.59 5.54 14.35 18.99 20.75 32.51 Total 24.45 44.95 60.74 75.23 78.37 89.46 Age-adjusted Rate 25.55 48.76 62.34 77.93 84.08 96.16 Table 8.11 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, White Females, United States, 1980-1985 Age 1986 1987 1988 1989 0-44 130.35 149.50 206.39 155.64 45-64 114.95 137.99 163.84 165.42 65-74 119.86 125.71 136.85 169.58 75+ 28.49 57.72 63.09 71.25 Total 99.56 121.15 141.39 144.78 Age-adjusted Rate 106.05 124.81 149.16 150.78 8.12 100,000 Diabetic Pop., Age & Year, U.S., 80-89, Black Males Table 8.12 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1984 Age 1980 1981 1982 1983 1984 1985 0-44 80.83 144.48 186.39 381.41 298.90 327.95 45-64 67.71 112.15 161.66 169.88 177.36 229.66 65-74 56.86 112.38 113.26 140.68 162.13 177.13 75+ 10.23 47.76 108.10 73.71 94.12 136.85 Total 63.72 113.95 152.08 178.22 183.58 224.39 Age-adjusted Rate 58.58 108.26 145.26 184.80 182.17 219.17 Table 8.12 Rate of Initiation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, Black Males, United States, 1980-1989 Age 1986 1987 1988 1989 0-44 232.59 214.71 298.11 311.56 45-64 265.43 281.95 277.53 286.57 65-74 232.76 212.11 312.04 335.94 75+ 107.41 134.40 122.52 156.68 Total 236.95 239.79 270.23 285.15 Age-adjusted Rate 227.56 229.85 267.12 284.58 8.13 100,000 Diabetic Pop., Age/Year, U.S., 80-89, Black Females Table 8.13 Rate of Invitation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1989 Age 1980 1981 1982 1983 1984 1985 0-44 30.33 67.20 130.55 113.75 141.39 182.83 45-64 79.53 114.19 147.37 184.77 231.30 282.07 65-74 68.65 102.96 113.82 113.57 173.88 189.22 75+ 18.26 21.29 76.70 61.01 78.13 63.71 Total 59.09 92.71 129.13 137.92 179.56 202.54 Age-adjusted Rate 58.95 89.20 125.08 135.19 177.67 207.78 Table 8.13 Rate of Invitation of Treatment for ESRD Related to Diabetes per 100,000 Diabetic Population, by Age and Year, Black Females, United States, 1980-1989 Age 1986 1987 1988 1989 0-44 193.93 179.03 140.70 191.17 45-64 275.29 337.51 381.03 481.14 65-74 299.53 349.52 367.44 369.56 75+ 99.65 87.31 90.33 156.38 Total 234.83 260.44 269.04 329.24 Age-adjusted Rate 241.31 275.74 292.20 352.77 8.14 Undergoing Treatment for ESRD, State of Residence & Year Table 8.14 Number of People Undergoing Treatment for End-stage Renal Disease Related to Diabetes, by State of Residence and Year, 1980-1985 1980 1981 1982 1983 1984 1985 Alabama 74 93 127 187 258 316 Alaska 4 4 6 8 13 15 Arizona 123 144 198 280 354 417 Arkansas 21 37 59 91 132 165 California 506 875 1315 1791 2243 2805 Colorado 67 76 101 149 187 233 Connecticut 115 149 190 239 306 389 Delaware 20 25 36 37 47 65 Dist of Columbia 43 61 89 109 140 194 Florida 188 360 557 737 947 1165 Georgia 168 268 379 464 569 695 Hawaii 74 95 108 109 106 137 Idaho 16 19 30 43 51 55 Illinois 327 458 623 799 952 1180 Indiana 144 205 249 344 406 473 Iowa 59 92 127 174 215 273 Kansas 60 83 120 153 193 225 Kentucky 70 96 135 184 249 296 Louisian 84 127 182 227 310 389 Maine 17 24 36 48 55 73 Maryland 92 153 219 280 368 482 Massachusetts 199 250 306 357 402 442 Michigan 200 310 439 595 726 891 Minnesota 144 197 267 342 429 496 Mississippi 47 75 109 139 194 244 Missouri 60 125 218 288 372 479 Montana 16 25 27 35 53 65 Nebraska 55 78 91 113 127 137 Nevada 12 18 33 41 50 60 New Hampshire 16 21 29 39 49 57 New Jersey 233 325 452 615 738 869 New Mexico 23 32 62 104 138 154 New York 455 636 901 1140 1397 1635 North Carolina 171 218 301 393 486 641 North Dakota 20 21 26 41 55 57 Ohio 378 496 645 800 953 1158 Oklahoma 67 89 135 182 237 275 Oregon 35 55 102 150 170 219 Pennsylvania 457 535 672 832 1085 1288 Rhode Island 20 32 36 44 55 70 South Carolina 93 132 186 244 322 437 South Dakota 14 27 35 44 62 81 Tennessee 66 101 159 237 305 359 Texas 415 601 892 1159 1447 1802 Utah 55 72 83 106 157 186 Vermont 13 20 34 31 36 46 Virginia 156 201 289 396 521 660 Washington 107 121 155 194 266 362 West Virginia 42 56 78 119 144 170 Wisconsin 196 226 300 360 446 499 Wyoming 7 11 19 21 26 35 Table 8.14 Number of People Undergoing Treatment for End-stage Renal Disease Related to Diabetes, by State of Residence and Year, 1986-1989 1986 1987 1988 1989 Alabama 383 488 542 683 Alaska 20 26 29 39 Arizona 526 606 725 855 Arkansas 200 238 293 341 California 3422 3836 4241 5056 Colorado 326 388 441 512 Connecticut 430 491 512 571 Delaware 81 97 131 163 Dist of Columbia 205 208 220 231 Florida 1440 1752 1945 2129 Georgia 818 970 1076 1256 Hawaii 178 246 293 330 Idaho 75 91 115 132 Illinois 1408 1598 1762 1953 Indiana 515 644 753 814 Iowa 318 336 369 427 Kansas 236 252 307 340 Kentucky 354 416 461 518 Louisiana 482 570 717 883 Maine 79 105 116 129 Maryland 544 623 693 839 Massachusetts 507 551 604 726 Michigan 1086 1204 1378 1640 Minnesota 582 678 748 839 Mississippi 278 319 396 475 Missouri 549 634 741 861 Montana 75 90 110 144 Nebraska 160 182 211 264 Nevada 84 113 122 157 New Hampshire 68 89 101 128 New Jersey 1029 1111 1222 1356 New Mexico 195 226 293 347 New York 1969 2257 2597 2907 North Carolina 751 905 1012 1196 North Dakota 70 88 103 132 Ohio 1365 1593 1841 2022 Oklahoma 346 402 516 591 Oregon 267 335 379 432 Pennsylvania 1515 1756 2005 2254 Rhode Island 72 96 116 136 South Carolina 509 579 661 768 South Dakota 89 105 128 136 Tennessee 436 527 612 751 Texas 2079 2450 2936 3568 Utah 220 242 277 303 Vermont 55 60 65 76 Virginia 732 808 919 1061 Washington 413 475 577 691 West Virginia 206 244 280 311 Wisconsin 582 671 772 915 Wyoming 37 46 47 58 8.15 Initiating Treatment for ESRD, State of Residence & Year Table 8.15 Number of Persons Initiating Treatment for End-stage Renal Disease Related to Diabetes and Rate per 100,000 Population, by State of Residence and Year, 1980-1983 State 1980 1981 1982 1983 No. Rate No. Rate No. Rate No. Rate Alabama 23 0.59 38 0.97 59 1.50 85 2.14 Alaska 2 0.49 0 0.00 4 0.90 2 0.41 Arizona 46 1.68 41 1.46 83 2.88 114 3.86 Arkansas 6 0.26 21 0.91 28 1.21 46 1.98 California 188 0.79 446 1.84 588 2.37 707 2.79 Colorado 24 0.83 25 0.84 41 1.33 65 2.06 Connecticut 26 0.84 61 1.95 62 1.98 94 2.99 Delaware 7 1.18 12 2.01 14 2.33 10 1.65 Dist of Columbia 11 1.72 23 3.63 43 6.86 38 6.09 Florida 94 0.95 189 1.85 250 2.39 279 2.59 Georgia 46 0.84 127 2.28 149 2.64 149 2.60 Hawaii 23 2.35 36 3.67 32 3.21 31 3.04 Idaho 8 0.84 9 0.93 15 1.53 21 2.12 Illinois 136 1.19 185 1.61 253 2.20 288 2.51 Indiana 43 0.78 78 1.42 77 1.40 132 2.41 Iowa 26 0.89 48 1.64 50 1.72 69 2.38 Kansas 19 0.80 32 1.34 52 2.16 50 2.06 Kentucky 36 0.98 45 1.22 50 1.35 76 2.05 Louisiana 32 0.76 57 1.33 76 1.73 72 1.62 Maine 7 0.62 11 0.97 15 1.32 17 1.48 Maryland 33 0.78 74 1.74 93 2.18 113 2.63 Massachusetts 61 1.06 78 1.36 101 1.76 104 1.81 Michigan 71 0.77 149 1.62 181 1.98 233 2.57 Minnesota 29 0.71 63 1.53 82 1.98 111 2.68 Mississippi 23 0.91 34 1.34 44 1.71 46 1.78 Missouri 16 0.33 72 1.46 116 2.35 101 2.03 Montana 4 0.51 14 1.76 4 0.50 12 1.47 Nebraska 14 0.89 32 2.02 27 1.70 35 2.19 Nevada 3 0.37 9 1.06 15 1.71 14 1.56 New Hampshire 6 0.65 8 0.85 10 1.05 14 1.46 New Jersey 87 1.18 133 1.80 200 2.69 233 3.12 New Mexico 10 0.76 13 0.97 36 2.63 51 3.64 New York 189 1.08 273 1.55 382 2.17 434 2.46 North Carolina 68 1.15 79 1.33 123 2.04 147 2.42 North Dakota 4 0.61 5 0.76 7 1.04 15 2.20 Ohio 143 1.32 198 1.83 254 2.36 278 2.59 Oklahoma 26 0.85 39 1.25 64 1.98 77 2.32 Oregon 18 0.68 24 0.90 55 2.06 57 2.14 Pennsylvania 176 1.48 184 1.55 253 2.13 305 2.56 Rhode Island 9 0.95 13 1.37 13 1.36 15 1.57 South Carolina 42 1.34 52 1.63 76 2.36 88 2.70 South Dakota 1 0.14 15 2.17 9 1.30 18 2.58 Tennessee 33 0.72 45 0.97 74 1.59 93 1.98 Texas 131 0.91 252 1.71 388 2.52 414 2.62 Utah 31 2.11 32 2.11 26 1.67 41 2.57 Vermont 5 0.98 7 1.36 15 2.88 4 0.76 Virginia 59 1.10 73 1.34 120 2.19 167 3.00 Washington 44 1.06 39 0.92 58 1.36 71 1.65 West Virginia 19 0.97 22 1.12 33 1.68 54 2.75 Wisconsin 61 1.30 63 1.33 113 2.38 101 2.13 Wyoming 1 0.21 5 1.01 10 1.96 5 0.97 Table 8.15 Number of Persons Initiating Treatment for End-stage Renal Disease Related to Diabetes and Rate per 100,000 Population, by State of Residence and Year, 1984-1986 State 1984 1985 1986 No. Rate No. Rate No. Rate Alabama 100 2.50 110 2.74 131 3.23 Alaska 6 1.19 3 0.57 11 2.07 Arizona 122 4.01 135 4.28 182 5.55 Arkansas 61 2.60 63 2.67 71 3.00 California 790 3.06 1010 3.83 1164 4.31 Colorado 70 2.19 79 2.44 128 3.92 Connecticut 106 3.36 150 4.73 130 4.07 Delaware 18 2.93 24 3.86 30 4.74 Dist of Columbia 46 7.37 70 11.23 53 8.48 Florida 348 3.15 409 3.60 539 4.61 Georgia 189 3.23 216 3.62 256 4.20 Hawaii 27 2.61 57 5.42 75 7.04 Idaho 18 1.80 16 1.59 28 2.79 Illinois 329 2.86 433 3.75 458 3.97 Indiana 126 2.29 150 2.73 153 2.78 Iowa 65 2.24 86 2.98 101 3.54 Kansas 67 2.74 64 2.61 51 2.07 Kentucky 107 2.87 95 2.55 112 3.01 Louisiana 132 2.96 120 2.68 175 3.89 Maine 20 1.73 23 1.97 25 2.13 Maryland 136 3.13 179 4.07 160 3.59 Massachusetts 113 1.95 118 2.03 154 2.64 Michigan 268 2.96 306 3.37 371 4.06 Minnesota 134 3.22 128 3.05 147 3.49 Mississippi 74 2.85 80 3.06 86 3.28 Missouri 135 2.70 172 3.42 166 3.28 Montana 19 2.31 20 2.42 19 2.33 Nebraska 33 2.06 39 2.43 45 2.82 Nevada 18 1.96 23 2.46 35 3.62 New Hampshire 15 1.53 21 2.10 18 1.75 New Jersey 249 3.32 303 4.01 345 4.52 New Mexico 46 3.22 45 3.10 74 5.00 New York 509 2.87 517 2.91 666 3.74 North Carolina 173 2.80 232 3.70 228 3.60 North Dakota 17 2.48 11 1.61 22 3.24 Ohio 337 3.14 388 3.61 437 4.07 Oklahoma 89 2.69 95 2.87 126 3.81 Oregon 51 1.91 74 2.76 84 3.11 Pennsylvania 424 3.57 425 3.58 504 4.24 Rhode Island 20 2.08 23 2.38 20 2.05 South Carolina 123 3.73 163 4.89 151 4.47 South Dakota 23 3.26 31 4.38 21 2.97 Tennessee 112 2.37 119 2.50 135 2.81 Texas 529 3.29 609 3.72 638 3.82 Utah 60 3.69 50 3.04 61 3.67 Vermont 10 1.89 16 2.99 11 2.03 Virginia 202 3.58 233 4.09 197 3.40 Washington 98 2.25 134 3.04 110 2.46 West Virginia 55 2.82 55 2.84 83 4.33 Wisconsin 141 2.96 123 2.58 162 3.39 Wyoming 8 1.56 15 2.94 7 1.38 Table 8.15 Number of Persons Initiating Treatment for End-stage Renal Disease Related to Diabetes and Rate per 100,000 Population, by State of Residence and Year, 1987-1989 State 1987 1988 1989 No. Rate No. Rate No. Rate Alabama 169 4.14 167 4.05 234 5.68 Alaska 9 1.71 8 1.48 17 3.22 Arizona 184 5.43 222 6.31 271 7.62 Arkansas 104 4.35 100 4.16 115 4.78 California 1190 4.30 1239 4.39 1696 5.83 Colorado 117 3.55 131 3.92 159 4.79 Connecticut 149 4.64 125 3.86 166 5.13 Delaware 29 4.50 44 6.75 53 7.88 Dist of Columbia 42 6.75 42 6.78 59 9.76 Florida 584 4.86 575 4.68 605 4.78 Georgia 308 4.95 290 4.55 390 6.06 Hawaii 103 9.52 97 8.81 98 8.79 Idaho 31 3.11 36 3.58 44 4.34 Illinois 490 4.23 496 4.27 548 4.70 Indiana 224 4.05 238 4.29 219 3.92 Iowa 72 2.54 98 3.49 124 4.37 Kansas 76 3.07 90 3.62 100 3.98 Kentucky 140 3.76 134 3.59 142 3.81 Louisiana 187 4.19 247 5.51 317 7.23 Maine 39 3.29 29 2.42 33 2.70 Maryland 192 4.23 195 4.24 270 5.75 Massachusetts 146 2.49 161 2.74 245 4.14 Michigan 345 3.75 444 4.80 548 5.91 Minnesota 182 4.29 170 3.98 198 4.55 Mississippi 98 3.73 125 4.72 147 5.61 Missouri 207 4.06 222 4.32 263 5.10 Montana 26 3.21 29 3.59 49 6.08 Nebraska 52 3.26 64 4.02 83 5.15 Nevada 43 4.27 38 3.69 55 4.95 New Hampshire 30 2.84 29 2.67 39 3.52 New Jersey 338 4.41 394 5.09 425 5.49 New Mexico 64 4.27 115 7.46 102 6.67 New York 688 3.86 811 4.55 866 4.82 North Carolina 295 4.60 285 4.38 383 5.83 North Dakota 26 3.87 32 4.78 47 7.12 Ohio 496 4.60 540 5.00 550 5.04 Oklahoma 129 3.94 193 5.89 179 5.55 Oregon 105 3.86 107 3.91 126 4.47 Pennsylvania 536 4.49 581 4.87 659 5.47 Rhode Island 39 3.96 45 4.56 42 4.21 South Carolina 180 5.26 192 5.54 241 6.86 South Dakota 34 4.79 39 5.49 28 3.92 Tennessee 178 3.67 189 3.86 254 5.14 Texas 756 4.50 930 5.44 1169 6.88 Utah 61 3.63 71 4.15 62 3.63 Vermont 15 2.74 15 2.71 22 3.88 Virginia 209 3.54 272 4.54 315 5.17 Washington 124 2.73 179 3.90 213 4.47 West Virginia 75 3.95 88 4.67 90 4.85 Wisconsin 179 3.72 206 4.28 253 5.20 Wyoming 14 2.86 11 2.23 19 4.00DISABILITY Introduction Disability, an important component of the morbidity associated with diabetes, reflects the inability of persons to perform their social roles and to function independently. The disruption of social functioning caused by disability has profound social and economic costs for both society and the afflicted individuals. Measuring disability among people with diabetes provides another means of assessing the health burden of the disease. In this chapter, we present data on the prevalence of disability among non-institutionalized persons with diagnosed diabetes. Using National Health Interview Survey (NHIS) data, we examine trends from 1983 through 1989, and where possible, we present data categorized by age, race, and sex. Data for the non-institutionalized population of the U.S. have been published in Current Estimates from the National Health Interview Survey, a series of publications of the National Center for Health Statistics (Vital and Health Statistics, Series 13). Methods Disability indicators were derived from the 1983-1989 NHIS. (See Chapter 2, Prevalence and Incidence, for a description of NHIS methodology.) In 1982, the core of the NHIS interview underwent substantial changes in the measurement of several health-related variables, including changes in disability indicators. Since disability indicator data prior to these changes are not comparable to data collected after these changes, the present analysis begins with 1983 NHIS data. Although the NHIS provides a stable source of annual estimates of disability, it does not sample the institutionalized U.S. population, which accounts for a significant proportion of all disability. Therefore, estimates of disability derived from NHIS underestimate the total amount of disability. This chapter analyzes four disability indicators used in the NHIS: activity limitation, work limitation, need for assistance in personal care and other routine activities, and activity restriction. These indicators are defined below. For the analyses of the first three indicators, we pooled three years of data to develop more precise estimates. These estimates were obtained by calculating three-year moving averages among the one-sixth subsamples asked about diabetes. For analyses of activity restriction, we also pooled three years of data to develop more precise estimates, but used the full rather than the one- sixth samples. This decision resulted in more conservative estimates of the number of persons with restricted activity (i.e., full sample estimates were roughly 10% lower than one-sixth sample estimates). Calculation of rates and their relative standard errors were performed using the SESUDAAN computer software package (Shah, 1981). Rates were age-adjusted by direct standardization, using estimates of the 1980 diabetic population as the standard. Definitions of the major disability indicators examined in this chapter are as follows and are briefly repeated in the results section. Activity Limitation In the NHIS, activity limitation reflects a long-term reduction in activity resulting from one or more chronic diseases or impairments. Persons reporting more than one cause of activity limitation are asked to indicate the primary cause of the limitation. Activity limitation reflects a person's capacity to perform activities normal for a person's age-sex group. Major activities normal for a person's age-sex group are defined as (1) "ordinary play" for children under 5 years of age, (2) "going to school" for children 5 to 17 years of age, (3) "working at a job or business" or "keeping house" for persons 18-69 years of age, and (4) independent performance of basic life activities (e.g., bathing, eating, shopping) for persons 70 years of age and older. In terms of these activities, persons can be categorized as being (1) unable to perform their major activity, (2) able to perform their major activity but limited in the kind or amount of this activity, (3) not limited in major activity but limited in other activities, and (4) not limited in activity. Using these categories, our analysis of activity limitation examines persons limited in activity (categories 1-3), limited in major activity (categories 1-2), and unable to perform major activity (category 1). Our analysis also examines the proportion of respondents who attribute activity limitation to their having diabetes. Work Limitation Persons between the ages of 18 and 69 are asked about their ability to work at a job or business. Responses can classify persons into four work limitation categories (which parallel the four activity limitation categories described in the preceding paragraph): (1) persons unable to work, (2) persons limited in kind or amount of work, (3) persons limited in other activities, and (4) persons not limited. Our analysis examines persons limited in work (categories 1-2) and persons unable to work (category 1). Our analysis also examines the proportion of respondents who attribute work limitation to their having diabetes. Need for Assistance in Personal Care and Other Routine Activities Beginning with the 1984 NHIS, persons between the ages of 5 and 59 who report an activity limitation and persons between the ages of 60 and 69 (regardless of activity limitation) are asked whether they need help in performing personal care (e.g., eating, bathing, dressing) or are limited in performing other routine activities (e.g., shopping, doing household chores). Responses to these questions are combined as a measure of the need for personal assistance in personal care and other routine activities. Because of sample size limitations, we only present crude rates of this measure. Activity Restriction Activity restriction refers to a reduction in activity due to either short-term or long-term conditions. It is measured in NHIS as school-loss days (among children between the ages of 5 and 17), work-loss days (among the currently employed between the ages of 18 and 69), cut-down days (days in which persons reduce or cut down on the things they usually do), and bed days. The total number of restricted activity days is the total number of days that a person experiences at least one of the above types of days. Because of small sample sizes, we only present data on total restricted activity days and bed days. Results Activity Limitation Limited in Activity Unable to perform major activity, or limited in the kind or amount of major activity, or limited in other activities normal for a person's age-sex group In the United States, approximately half of all persons with diabetes reported that they were limited in activity (Table 9.1). Among persons with diabetes, the number increased from 3.1 million in 1983 to 3.3 million in 1989, but the proportion decreased from 53% to 50% (Figure 9.1, Table 9.1). This decline over time occurred primarily among persons 65 years of age and older. In each year, the proportion reporting that they were limited in activity increased with increasing age, with a tendency to level off after age 64. In general, rates of being limited in activity were greater among blacks than among whites, and among females than among males (Figure 9.2, Tables 9.2- 9.5). Rates among black males averaged 1.3 times that of white males, and rates among black females averaged 1.2 times that of white females. From 1983 to 1989, rates were relatively stable among white males and decreased 7% among white females. Rates decreased 10% among black males and 12% among black females. Marked decreases were noted for white males over 74 years of age, for black males under 45 years of age and between the ages of 65 and 74 years, and for females between 65 and 74 years of age. Between 1983 and 1989, the proportion of persons with diabetes reporting being limited in activity due to diabetes averaged 34% percent (Table 9.6). Thus, 60% of all those limited in activity attribute it to diabetes. This attribution of being limited in activity due to diabetes was more common among blacks than whites and among females than males (Table 9.7). Between 1983 and 1989, the age-adjusted prevalence of those limited in activity due to diabetes decreased modestly, largely because of a 27% decrease in rates among black males and an 21% decrease in rates among black females. Limited in Major Activity Unable to perform major activity or limited in the kind or amount of major activity normal for a person's age-sex group Almost 40% of all persons with diabetes (approximately 75% of those limited in activity) reported being limited in their major activity (Table 9.8). The age-adjusted prevalence decreased slightly over the seven-year period, primarily because of decreases among persons 75 years of age and older. Being limited in major activity was most often reported by those 45 to 74 years of age. Although no clear temporal trends among age-specific rates were evident for whites, dramatic decreases were noted for blacks under the age of 45 years and over the age of 74 (Tables 9.9-9.10). The prevalence of being limited in major activity varied by race and sex (Figure 9.3, Table 9.11). The age-adjusted prevalence was higher among blacks than whites. Over the seven-year period, age-adjusted rates decreased 19% among black females. By 1988, the rate among black females approached that of white females, but the rate among black males in 1989 was 1.3 times that of white males. Unable to Perform Major Activity Unable to perform the major activity normal for a person's age-sex group About 20% of persons with diabetes reported that they are unable to perform their major activity (Table 9.12). This proportion fluctuated very little over the seven-year period but varied by age. It increased considerably from persons younger than 45 years of age to persons between 45 and 64 years, and then leveled off or declined for persons 65 years of age or older. Age-specific trends differed by race (Tables 9.13-9.14). The only temporal trend evident among whites was an increase in rates among those under 45 years of age. Among blacks, rates increased for those under 75 years of age, particularly for those between the ages of 65 and 74. These increases were offset by dramatic decreases for blacks older than 74 years of age. Race-sex differences were also noted (Figure 9.4, Table 9.15). In general, rates among males were greater than rates among females, and rates among blacks were greater than rates among whites. For the seven-year period, the age-adjusted rate averaged 35.5% for black males, 26.8% for black females, 20.4% for white males, and 16.4% for white females. Work Limitation Work Limitation Among Persons Between the Ages of 18 and 69 Limited in Work Unable to work, or limited in kind or amount of work Among persons with diabetes between the ages of 18 and 69, the prevalence of being limited in work was high (averaging 43%) but decreased modestly over the seven-year period (Table 9.16). The rate was greatest among black females, followed in descending order by black males, white females, and white males. Over half of those limited in work attributed their limitation to having diabetes (Table 9.17). Unable to Work Unable to work at a job or business Persons unable to work accounted for over 70% of all those limited in work (Table 9.18). As with the prevalence of being limited in work, the prevalence of being unable to work was greatest among black females, followed in descending order by black males, white females, and white males. With the exception of white males, the prevalence was lower in 1989 than in 1983 for all race-sex groups (Figure 9.5). Need for Assistance in Personal Care and Other Routine Activitie Unable to perform personal care needs (e.g., eating, bathing, dressing) or limited in performing other routine activities (e.g., shopping, housekeeping) Approximately 13% of persons with diabetes between the ages of 5 and 69 required help with personal care or other routine activities. Rates were similar for black males and white males, but were somewhat greater for black females than white females (Table 9.19). Rates for black females and white females averaged, respectively, 2.8 and 1.6 times that of their male counterparts. Activity Restriction Total Restricted Activity Days Number of days a person experiences at least one the of four types of restricted activity days (i.e., bed days, work-loss days, school-loss days, and cut-down days) The total number of restricted activity days due to both acute and chronic conditions among people with diabetes increased from 199 million days in 1983 to 233 million days in 1989 (Figure 9.6, Table 9.20). Between 1983 and 1989, the age-adjusted rate was relatively stable, averaged 34 days, and generally increased with increasing age. In this time period, the number of restricted activity days was 1.4 times greater among blacks than among whites (Figure 9.7, Tables 9.21-9.22). Among blacks, the number of days per person decreased markedly for those under 45 years of age and over 74 years of age, but increased for those between the ages of 65 and 74. Bed Days Inpatient hospital days or days in which a person stayed in bed for more than half a day because of illness or injury About half of all restricted activity days among persons with diabetes were bed days (Figure 9.6, Table 9.23). Between 1983 and 1989, the number of bed days was 1.5 times greater among blacks than among whites (Figure 9.7, Tables 9.24-9.25). Age-specific trends over time were not observed among whites, but increases among blacks between 45 and 74 years of age were partially offset by decreases among those younger than 45 years and older than 74 years.Discussion For the period 1983-1989, the prevalence of disability among non-institutionalized people with diabetes was high. About 50% of persons with diabetes reported being limited in activity; about 40% of persons with diabetes reported being limited in their major activity; and about 20% reported being unable to perform their major activity. The prevalence of work limitation was of similar magnitude. Forty-three percent reported being limited in work and 30% reported being unable to work. In addition, 13% of persons with diabetes between the ages of 5 and 69 required help with personal care or other routine activities. More than 60% of respondents attribute being limited in activity and in work to their diabetes. Since diabetes-related disability is often due to complications that may not be perceived as diabetes-related, however, this proportion is likely to be underestimated. Regardless of type of limitation, the prevalence of disability was greater among blacks than whites. This disparity may reflect greater severity of disease among blacks, poorer access to health care, greater likelihood of types of work or activity that do not accommodate physical disability, fewer work options based on skills, training, or opportunity, or some combination of these factors. With the exception of inability to perform major activity, measures of activity limitation were higher among females than males. The higher prevalence of these types of disability among females may be due to the same factors suggested above to explain the higher prevalence among blacks. Females may have a lower prevalence of inability to perform their major activity because they have changed their major activity from work at a job or business to managing a household or other activities that may be more accommodating or less physically demanding. Inability to perform major activity and inability to work are two of the most severe forms of disability examined. Examination of temporal trends of inability to perform major activity suggests that this type of disability is increasing for persons with diabetes under the age of 45. In contrast, for persons over 74 years of age, the prevalence of inability to perform major activity decreased (due primarily to a dramatic decrease among blacks). This finding might be explained by improved health status or increased institutional care and increased mortality among diabetic persons. Although the prevalence of inability to work could not be examined by age, there was a paradoxical trend toward decreasing prevalence among those aged 18-69. Restricted activity days, because they measure both acute and chronic disability, provide the most inclusive but least descriptive disability information. Between 1983 and 1989, persons with diabetes averaged 34 restricted activity days per year. Half of these days were bed days. In all age categories, blacks averaged a greater number of restricted activity days than whites. This disparity could be explained by poorer health among blacks with diabetes or by more difficult daily activities for blacks, with a resulting increase in the need to restrict activity. In general, the prevalence of disability among non-institutionalized persons with diabetes is very high but appears to be declining among the elderly, blacks, and white females. Despite these declines, the actual number of persons reporting disability is increasing, because of the increasing prevalence of diabetes. Although some measures of disability show evidence of improvement, decreasing the net burden of disability presented by diabetes will remain a challenge. Detailed Tables 9.1-9.5 Limited in Activity, Persons with Diabetes 9.1 Limited in Activity, by Age & Year Table 9.1 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1983-1986 Age 1983 1984 1985 1986 0-44 Number (a) 368 363 387 351 Rate 36.7 36.5 37.3 33.6 45-64 Number 1327 1232 1244 1512 Rate 51.1 52.2 53.4 53.1 65-74 Number 805 1068 1089 934 Rate 61.7 60.8 58.8 58.7 75+ Number 564 690 684 727 Rate 64.5 63.3 62.1 56.6 Total Number 3065 3354 3403 3525 Rate 53.0 54.1 53.9 52.1 Adjusted Rate (b) 53.4 53.4 53.3 51.7 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.1 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1987-1989 Age 1987 1988 1989 0-44 Number (a) 461 352 432 Rate 33.8 32.2 35.3 45-64 Number 1329 1252 1383 Rate 52.1 50.9 51.1 65-74 Number 952 927 854 Rate 55.9 54.4 52.3 75+ Number 654 609 663 Rate 54.8 55.7 60.4 Total Number 3397 3140 3332 Rate 49.9 49.4 50.0 Adjusted Rate (b) 50.3 49.3 50.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.2 Limited in Activity, by Age & Year, White Males Table 9.2 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, White Males, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 129 115 120 93 Rate 31.7 32.4 30.5 31.0 45-64 Number 387 358 429 612 Rate 42.1 44.0 49.1 49.5 65-74 Number 207 316 360 341 Rate 49.8 53.4 53.1 54.5 75+ Number 197 195 205 203 Rate 60.1 60.3 58.5 50.1 Total Number 921 985 1114 1249 Adjusted Rate (b) 44.4 47.3 48.5 48.6 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.2 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, White Males, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 193 160 156 Rate 33.4 33.2 37.5 45-64 Number 498 428 478 Rate 47.3 45.8 44.3 65-74 Number 383 320 317 Rate 54.3 57.5 59.1 75+ Number 187 171 115 Rate 44.6 44.4 44.7 Total Number 1261 1080 1066 Adjusted Rate (b) 45.8 45.7 46.6 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.3 Limited in Activity, by Age & Year, White Females Table 9.3 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, White Females, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 145 154 180 180 Rate 36.0 35.1 36.0 30.5 45-64 Number 585 590 501 596 Rate 54.1 56.5 54.9 55.6 65-74 Number 399 488 516 399 Rate 63.4 60.8 58.3 59.0 75+ Number 302 375 364 393 Rate 65.9 63.2 61.3 57.7 Total Number 1432 1607 1561 1568 Rate 55.7 55.8 54.0 51.9 Adjusted Rate (b) 55.2 54.9 53.4 52.4 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.3 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, White Females, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 159 112 198 Rate 31.1 31.5 36.1 45-64 Number 516 510 585 Rate 54.0 55.3 56.0 65-74 Number 398 424 371 Rate 53.5 51.2 46.4 75+ Number 309 311 430 Rate 57.6 60.7 66.7 Total Number 1382 1357 1584 Rate 50.3 51.8 52.2 Adjusted Rate (b) 50.4 50.9 51.6 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.4 Limited in Activity, by Age & Year, Black Males Table 9.4 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, Black Males, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 19 29 30 44 Rate 51.5 51.7 47.9 52.5 45-64 Number 121 113 122 102 Rate 59.5 52.3 54.8 50.2 65-74 Number 79 75 76 63 Rate 92.4 85.4 77.1 69.7 75+ Number 11 14 13 24 Rate 47.0 39.8 38.6 62.4 Total Number 231 230 241 234 Rate 65.8 58.5 57.7 56.1 Adjusted Rate (b) 64.9 59.0 57.0 57.6 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.4 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, Black Males, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 41 29 24 Rate 44.8 36.0 28.8 45-64 Number 121 145 183 Rate 58.0 58.7 66.3 65-74 Number 70 56 57 Rate 67.0 66.2 66.3 75+ Number 24 31 31 Rate 67.2 61.1 57.1 Total Number 255 261 295 Rate 58.1 56.4 59.1 Adjusted Rate (b) 59.4 57.1 58.4 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.5 Limited in Activity, by Age & Year, Black Females Table 9.5 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, Black Females, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 52 50 56 43 Rate 45.2 46.2 61.8 49.3 45-64 Number 195 177 173 179 Rate 64.9 62.9 66.7 63.8 65-74 Number 142 136 132 102 Rate 71.2 72.9 72.0 71.0 75+ Number 65 75 94 79 Rate 78.2 81.4 79.5 62.6 Total Number 455 438 454 403 Rate 65.0 65.5 69.8 63.2 Adjusted Rate (b) 65.1 65.4 69.2 63.0 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.5 Prevalence of Being Limited in Activity Among Persons with Diabetes, per 100 Diabetic Population, by Age and Year, Black Females, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 46 46 48 Rate 42.3 34.4 36.6 45-64 Number 190 147 133 Rate 67.8 60.3 58.7 65-74 Number 97 91 105 Rate 67.8 58.6 59.5 75+ Number 95 86 101 Rate 64.6 61.2 74.5 Total Number 427 370 386 Rate 63.0 54.9 57.8 Adjusted Rate (b) 62.9 55.5 57.4 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.6-9.7 Limited in Activity Attributed to Diabetes 9.6 Limited in Activity, by Age & Year Table 9.6 Prevalence of Being Limited in Activity Attributed to Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 240 243 240 236 Rate 23.9 24.4 23.2 22.5 45-64 Number 900 854 890 1116 Rate 34.6 36.2 38.2 39.2 65-74 Number 512 677 622 548 Rate 39.2 38.6 33.6 34.4 75+ Number 305 431 475 531 Rate 34.9 39.6 43.2 41.4 Total Number 1957 2205 2227 2432 Rate 33.9 35.6 35.2 35.9 Adjusted Rate (b) 34.0 35.3 35.1 35.4 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.6 Prevalence of Being Limited in Activity Attributed to Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 299 232 287 Rate 21.9 21.3 23.5 45-64 Number 947 882 923 Rate 37.1 35.9 34.1 65-74 Number 567 605 549 Rate 33.3 35.5 33.7 75+ Number 434 319 321 Rate 36.4 29.2 29.3 Total Number 2247 2039 2081 Rate 33.0 32.1 31.2 Adjusted Rate (b) 33.3 32.2 31.4 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.7 Limited in Activity, by Race, Sex, & Year Table 9.7 Prevalence of Being Limited in Activity Attributed to Diabetes, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Number (a) 566 612 696 797 Rate 27.3 29.4 30.3 31.1 Adjusted Rate (b) 27.4 29.3 30.6 30.2 White Females Number 838 995 1014 1076 Rate 32.6 34.6 35.0 35.6 Adjusted Rate (b) 32.6 34.1 34.6 35.8 Black Males Number 187 179 166 177 Rate 53.2 45.4 39.6 42.6 Adjusted Rate (b) 53.7 44.8 38.0 41.9 Black Females Number 358 355 327 312 Rate 51.1 53.0 50.2 49.0 Adjusted Rate (b) 51.2 52.9 49.8 49.2 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.7 Prevalence of Being Limited in Activity Attributed to Diabetes, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Number (a) 808 676 691 Rate 29.3 28.6 30.2 Adjusted Rate (b) 29.6 29.2 29.5 White Females Number 894 853 932 Rate 32.5 32.6 30.7 Adjusted Rate (b) 32.9 32.3 30.6 Black Males Number 191 188 201 Rate 43.4 40.6 40.3 Adjusted Rate (b) 44.8 41.1 39.4 Black Females Number 298 277 271 Rate 44.0 41.1 40.5 Adjusted Rate (b) 44.1 41.9 40.2 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.8-9.11 Limited in Major Activity 9.8 By Age & Year Table 9.8 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 287 280 262 238 Rate 28.6 28.2 25.2 22.7 45-64 Number 1111 1042 1104 1314 Rate 42.8 44.2 47.4 46.1 65-74 Number 535 737 772 688 Rate 41.0 42.0 41.7 43.2 75+ Number 395 470 448 459 Rate 45.2 43.1 40.7 35.7 Total Number 2328 2529 2586 2698 Rate 40.3 40.8 40.9 39.8 Adjusted Rate (b) 40.2 40.6 41.0 39.7 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.8 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 321 283 350 Rate 23.5 25.9 28.6 45-64 Number 1115 999 1099 Rate 43.7 40.6 40.6 65-74 Number 726 737 676 Rate 42.6 43.3 41.4 75+ Number 408 366 400 Rate 34.2 33.4 36.5 Total Number 2570 2384 2525 Rate 37.7 37.5 37.9 Adjusted Rate (b) 38.5 37.7 38.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.9 By Age & Year, Whites Table 9.9 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Whites, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 214 212 202 180 Rate 26.4 26.7 22.6 20.1 45-64 Number 829 801 814 1032 Rate 41.4 43.1 45.6 44.7 65-74 Number 408 552 599 527 Rate 39.0 39.6 38.3 40.5 75+ Number 326 371 360 358 Rate 41.3 40.5 38.1 32.9 Total Number 1778 1936 1975 2097 Rate 38.2 39.0 38.1 37.5 Adjusted Rate (b) 38.2 38.9 38.5 37.6 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.9 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Whites, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 231 219 294 Rate 21.2 26.1 30.5 45-64 Number 853 744 845 Rate 42.5 40.1 39.8 65-74 Number 577 582 533 Rate 39.8 42.0 39.9 75+ Number 299 292 336 Rate 31.0 32.4 37.4 Total Number 1960 1838 2009 Rate 35.6 36.9 37.7 Adjusted Rate (b) 36.4 37.0 37.9 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.10 By Age & Year, Blacks Table 9.10 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Blacks, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 54 54 60 64 Rate 35.2 32.6 39.0 37.4 45-64 Number 256 244 273 261 Rate 50.6 49.1 56.7 53.8 65-74 Number 140 148 163 138 Rate 49.0 53.8 57.8 58.7 75+ Number 76 80 83 77 Rate 70.2 62.6 54.4 46.4 Total Number 527 526 579 539 Rate 49.9 49.4 54.1 51.1 Adjusted Rate (b) 50.4 49.5 53.6 51.1 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.10 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Blacks, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 71 58 51 Rate 35.3 26.6 23.9 45-64 Number 260 236 253 Rate 53.2 48.2 50.4 65-74 Number 140 126 137 Rate 56.7 52.5 52.2 75+ Number 80 69 61 Rate 44.4 35.8 32.3 Total Number 551 488 502 Rate 49.3 42.9 43.0 Adjusted Rate (b) 49.7 43.7 43.5 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.11 By Race, Sex, & Year Table 9.11 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Number (a) 711 728 781 904 Rate 34.3 35.0 34.0 35.2 Adjusted Rate (b) 34.1 35.1 34.3 34.0 White Females Number 1065 1213 1194 1200 Rate 41.4 42.1 41.3 39.8 Adjusted Rate 41.1 41.8 41.7 40.5 Black Males Number 196 192 205 207 Rate 55.8 48.7 49.1 49.6 Adjusted Rate 55.5 48.3 46.2 49.9 Black Females Number 332 333 373 332 Rate 47.4 49.8 57.3 52.1 Adjusted Rate 48.3 49.8 56.7 51.7 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.11 Prevalence of Being Limited in Major Activity Among People with Diabetes, per 100 Diabetic Population, by Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Number (a) 920 840 855 Rate 33.4 35.5 37.4 Adjusted Rate (b) 34.2 36.4 37.2 White Females Number 1036 989 1174 Rate 37.7 37.8 38.6 Adjusted Rate 38.3 37.5 38.4 Black Males Number 222 229 246 Rate 50.5 49.4 49.2 Adjusted Rate 50.5 49.6 47.8 Black Females Number 329 260 257 Rate 48.6 38.5 38.4 Adjusted Rate 48.8 39.8 39.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.12-9.15 Unable to Perform Major Activity 9.12 By Age & Year Table 9.12 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, By Age and Year, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 88 84 74 79 Rate 8.8 8.4 7.1 7.5 45-64 Number 594 561 623 739 Rate 22.8 23.8 26.7 26.0 65-74 Number 245 355 380 383 Rate 18.8 20.2 20.5 24.0 75+ Number 198 203 234 234 Rate 22.6 18.7 21.2 18.2 Total Number 1125 1204 1311 1435 Rate 19.5 19.4 20.7 21.2 Adjusted Rate (b) 19.3 19.4 20.9 21.1 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.12 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, By Age and Year, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 139 125 165 Rate 10.2 11.5 13.5 45-64 Number 617 541 586 Rate 24.2 22.0 21.7 65-74 Number 414 424 371 Rate 24.3 24.9 22.7 75+ Number 245 183 203 Rate 20.5 16.8 18.5 Total Number 1414 1274 1326 Rate 20.8 20.1 19.9 Adjusted Rate (b) 21.2 20.1 20.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.13 By Age & Year, Whites Table 9.13 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Whites, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 67 63 53 56 Rate 8.3 7.9 5.9 6.3 45-64 Number 432 404 425 541 Rate 21.6 21.7 23.8 23.5 65-74 Number 192 259 279 277 Rate 18.3 18.6 17.8 21.2 75+ Number 136 141 189 194 Rate 17.2 15.3 20.1 17.8 Total Number 826 867 946 1068 Rate 17.8 17.5 18.2 19.1 Adjusted Rate (b) 17.7 17.5 18.5 19.0 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.13 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Whites, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 95 84 120 Rate 8.8 10.1 12.4 45-64 Number 461 377 417 Rate 23.0 20.3 19.6 65-74 Number 309 319 269 Rate 21.3 23.0 20.1 75+ Number 185 131 150 Rate 19.2 14.5 16.7 Total Number 1050 912 956 Rate 19.1 18.3 18.0 Adjusted Rate (b) 19.5 18.4 18.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.14 By Age & Year, Blacks Table 9.14 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Blacks, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 18 19 22 22 Rate 11.9 11.7 14.1 12.9 45-64 Number 149 160 194 180 Rate 29.4 32.3 40.3 37.3 65-74 Number 64 80 92 94 Rate 22.4 29.2 32.5 40.0 75+ Number 63 52 46 38 Rate 58.3 41.2 30.6 23.0 Total Number 294 313 354 334 Rate 27.9 29.4 33.1 31.7 Adjusted Rate (b) 28.8 29.2 32.2 31.6 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.14 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, by Age and Year, Blacks, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 32 36 39 Rate 16.2 16.7 18.4 45-64 Number 155 157 170 Rate 31.7 32.0 34.0 65-74 Number 98 89 95 Rate 39.8 37.2 36.0 75+ Number 52 53 51 Rate 28.9 27.6 26.7 Total Number 338 335 355 Rate 30.3 29.4 30.4 Adjusted Rate (b) 30.7 30.0 30.7 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.15 By Race, Sex, & Year Table 9.15 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Number (a) 364 393 455 594 Rate 17.5 18.8 19.8 23.2 Adjusted Rate (b) 17.7 18.9 20.1 21.7 White Females Number 462 473 490 489 Rate 18.0 16.4 16.9 16.2 Adjusted Rate 17.7 16.4 16.6 15.9 Black Males Number 133 142 143 152 Rate 37.9 35.9 34.2 36.6 Adjusted Rate 35.1 34.1 31.2 38.0 Black Females Number 160 172 211 182 Rate 22.9 25.7 32.4 28.5 Adjusted Rate 24.3 25.7 32.1 28.3 (a) In thousands; three-year moving average. (b) Adjusted for age. Tables 9.15 Prevalence of Being Unable to Perform Major Activity Among People with Diabetes, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Number (a) 585 493 475 Rate 21.2 20.9 20.7 Adjusted Rate (b) 21.9 21.7 20.7 White Females Number 468 410 485 Rate 17.0 15.7 16.0 Adjusted Rate 16.8 15.4 16.0 Black Males Number 152 179 180 Rate 34.6 38.5 36.0 Adjusted Rate 36.2 38.9 34.7 Black Females Number 186 157 176 Rate 27.5 23.3 26.3 Adjusted Rate 27.6 23.7 26.2 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.16-9.17 Limited in Work Between 18 & 69 Years of Age 9.16 Persons with Diabetes, By Race, Sex, & Year Table 9.16 Prevalence of Being Limited in Work Among Persons with Diabetes Between 18 and 69 Years of age, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Rate (a) 36.5 38.3 40.3 40.4 White Females Rate 45.8 47.1 43.6 42.8 Black Males Rate 58.8 48.9 49.0 46.9 Black Females Rate 52.6 54.2 61.0 58.3 Total Rate 43.9 44.8 44.2 43.4 (a) Three-year moving average. Table 9.16 Prevalence of Being Limited in Work Among Persons with Diabetes Between 18 and 69 Years of age, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Rate (a) 39.2 39.1 38.4 White Females Rate 39.9 41.0 40.3 Black Males Rate 49.9 50.2 52.1 Black Females Rate 56.3 48.2 46.8 Total Rate 41.5 41.0 40.5 (a) Three-year moving average. 9.17 Attributed to Diabetes, By Race, Sex, & Year Table 9.17 Prevalence of Being Limited in Work Attributed to Diabetes Among Persons with Diabetes Between 18 and 69 Years of Age, per 100 Diabetic Population, by Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Rate (a) 23.1 25.5 28.3 27.5 White Females Rate 26.7 28.5 25.2 27.1 Black Males Rate 50.4 44.0 42.2 42.4 Black Females Rate 36.5 39.4 41.8 43.9 Total Rate 27.9 29.8 29.2 29.9 (a) Three-year moving average. Table 9.17 Prevalence of Being Limited in Work Attributed to Diabetes Among Persons with Diabetes Between 18 and 69 Years of Age, per 100 Diabetic Population, by Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Rate (a) 26.7 26.7 27.2 White Females Rate 24.0 25.2 22.1 Black Males Rate 35.6 35.0 33.8 Black Females Rate 37.7 32.9 29.7 Total Rate 27.1 26.8 25.3 (a) Three-year moving average. 9.18 Unable to Work, Ages 18-69 Table 9.18 Prevalence of Being Unable to Work Among Persons with Diabetes Between 18 and 69 Years of Age, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1983 1984 1985 1986 White Males Rate (a) 21.4 23.4 25.9 26.9 White Females Rate 33.7 33.7 29.9 31.3 Black Males Rate 48.0 37.7 34.9 31.2 Black Females Rate 45.8 48.8 52.2 48.4 Total Rate 31.4 31.8 30.8 31.0 (a) Three-year moving average. Table 9.18 Prevalence of Being Unable to Work Among Persons with Diabetes Between 18 and 69 Years of Age, per 100 Diabetic Population, By Race, Sex, and Year, United States, 1983-1989 Race and Sex 1987 1988 1989 White Males Rate (a) 26.0 24.8 23.3 White Females Rate 30.1 28.9 26.7 Black Males Rate 34.4 39.1 38.9 Black Females Rate 44.2 38.4 39.0 Total Rate 29.8 28.6 27.3 (a) Three-year moving average. 9.19 Needing Help with Personal Care, Ages 5-69 Table 9.19 Prevalence of Needing Help with Personal Care or Limited in Performing Other Routine Activities Among Persons with Diabetes Between 5 and 69 Years of Age, per 100 Diabetic Persons, by Race, Sex, and Year, United States, 1984-1989 Race and Sex 1984 1985 1986 1987 1988 1989 White Males Rate (a) 8.2 9.6 9.5 9.9 9.2 9.8 White Females Rate 17.2 15.2 15.0 13.3 14.6 15.1 Black Males Rate 6.0 7.9 4.8 7.1 8.7 11.6 Black Females Rate 20.8 26.3 25.8 21.4 16.6 16.4 Total Rate 13.4 13.6 13.1 12.1 12.0 12.7 (a) Three-year moving average. 9.20-9.22 Total Number of Restricted Activity Days 9.20 By Age & Year Table 9.20 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 24183 20034 17457 16900 Average 24.1 20.1 16.8 16.1 45-64 Number 83860 79898 78594 97646 Average 32.3 33.9 33.7 34.3 65-74 Number 48300 61025 61454 57268 Average 37.0 34.7 33.2 35.9 75+ Number 42752 49041 46983 51225 Average 48.9 45.0 42.7 39.9 Total Number 199095 209998 204488 223039 Average 34.4 33.9 32.4 32.9 Adjusted Average (b) 34.6 33.4 32.0 32.4 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.20 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 24717 22495 27520 Average 18.1 20.6 22.5 45-64 Number 87668 82516 90119 Average 34.4 33.5 33.3 65-74 Number 66655 70747 68099 Average 39.1 41.5 41.7 75+ Number 48708 46135 47072 Average 40.8 42.2 42.9 Total Number 227747 221893 232811 Average 33.4 34.9 35.0 Adjusted Average (b) 33.7 34.7 35.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.21 By Age & Year, Whites Table 9.21 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People With Diabetes, by Age and Year, Whites, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 16468 13792 12279 11695 Average 20.3 17.4 13.7 13.1 45-64 Number 59083 56364 52798 69812 Average 29.5 30.3 29.6 30.3 65-74 Number 39051 47737 51459 44831 Average 37.3 34.2 32.9 34.4 75+ Number 36386 39538 40614 44336 Average 46.1 43.1 43.0 40.8 Total Number 150988 157430 157150 170675 Average 32.5 31.7 30.3 30.5 Adjusted Rate (b) 32.4 31.0 29.7 29.9 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.21 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People With Diabetes, by Age and Year, Whites, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 17202 15752 21272 Average 15.8 18.8 22.1 45-64 Number 62289 57106 65150 Average 31.0 30.7 30.7 65-74 Number 54947 54912 53549 Average 37.9 39.6 40.1 75+ Number 40020 37179 36037 Average 41.6 41.2 40.1 Total Number 174457 164948 176007 Average 31.7 33.1 33.1 Adjusted Rate (b) 31.8 32.5 33.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.22 By Age & Year, Blacks Table 9.22 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Blacks, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 6104 5330 4884 5203 Average 39.6 32.3 31.6 30.6 45-64 Number 22765 24086 24834 24684 Average 45.0 48.5 51.7 51.0 65-74 Number 9956 10511 9239 11009 Average 34.8 38.1 32.7 46.9 75+ Number 6940 7282 6155 6148 Average 64.3 57.3 40.5 37.2 Total Number 45766 47209 45111 47043 Average 43.4 44.3 42.2 44.6 Adjusted Rate (b) 44.2 44.2 41.5 44.3 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.22 Total Number of Restricted Activity Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Blacks, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 5497 5985 5615 Average 27.5 27.6 26.2 45-64 Number 23905 23010 23550 Average 48.8 47.0 47.0 65-74 Number 11433 13485 13940 Average 46.4 56.3 53.0 75+ Number 6374 8319 9223 Average 35.2 43.4 48.8 Total Number 47208 50798 52329 Average 42.3 44.7 44.8 Adjusted Rate (b) 42.5 45.5 45.2 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.23-9.25 Total Number of Bed Days 9.23 By Age & Year Table 9.23 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Bed Days per Person Among People with Diabetes, by Age and Year, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 13896 10878 9014 7960 Average 13.9 10.9 8.7 7.6 45-64 Number 39851 35580 33607 43473 Average 15.3 15.1 14.4 15.3 65-74 Number 24731 30801 29748 28953 Average 19.0 17.5 16.1 18.2 75+ Number 26539 27271 27681 27900 Average 30.4 25.0 25.1 21.7 Total Number 105017 104531 100050 108286 Average 18.2 16.9 15.8 16.0 Adjusted Rate (b) 18.3 16.5 15.5 15.7 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.23 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Bed Days per Person Among People with Diabetes, by Age and Year, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 12559 11784 14918 Average 9.2 10.8 12.2 45-64 Number 43790 43349 47081 Average 17.2 17.6 17.4 65-74 Number 35092 36821 35229 Average 20.6 21.6 21.6 75+ Number 27525 23087 23137 Average 23.1 21.1 21.1 Total Number 118966 115041 120366 Average 17.5 18.1 18.1 Adjusted Rate (b) 17.6 18.0 18.1 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.24 By Age & Year, Whites Table 9.24 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Whites, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 8968 6981 5578 4884 Average 11.0 8.8 6.2 5.5 45-64 Number 28854 24217 21414 28688 Average 14.4 13.0 12.0 12.4 65-74 Number 20161 23040 24053 21716 Average 19.3 16.5 15.4 16.7 75+ Number 23599 22867 24787 24571 Average 29.9 24.9 26.2 22.6 Total Number 81582 77106 75832 79859 Average 17.5 15.5 14.6 14.3 Adjusted Rate (b) 17.4 15.0 14.0 13.8 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.24 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Whites, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 8345 8321 11693 Average 7.7 9.9 12.1 45-64 Number 30446 28914 33436 Average 15.2 15.6 15.7 65-74 Number 29370 28851 27968 Average 20.3 20.8 20.9 75+ Number 22701 18360 17462 Average 23.6 20.3 19.4 Total Number 90863 84446 90559 Average 16.5 16.9 17.0 Adjusted Rate (b) 16.5 16.7 17.0 (a) In thousands; three-year moving average. (b) Adjusted for age. 9.25 By Age & Year, Blacks Table 9.25 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Blacks, United States, 1983-1989 Age 1983 1984 1985 1986 0-44 Number (a) 3663 3194 3012 3070 Average 23.8 19.3 19.5 18.0 45-64 Number 9781 11336 11694 13031 Average 19.3 22.8 24.3 26.9 65-74 Number 4710 6204 5243 6756 Average 16.4 22.5 18.6 28.8 75+ Number 3283 3139 2719 2969 Average 30.4 24.7 17.9 18.0 Total Number 21437 23872 22668 25825 Average 20.3 22.4 21.2 24.5 Adjusted Rate (b) 21.0 22.4 21.0 24.5 (a) In thousands; three-year moving average. (b) Adjusted for age. Table 9.25 Total Number of Bed Days Due to Acute and Chronic Conditions and Average Number of Days per Person Among People with Diabetes, by Age and Year, Blacks, United States, 1983-1989 Age 1987 1988 1989 0-44 Number (a) 3118 3179 3106 Average 15.6 14.7 14.5 45-64 Number 13033 13714 13333 Average 26.6 28.0 26.6 65-74 Number 5925 7178 7605 Average 24.1 30.0 28.9 75+ Number 3575 4174 4470 Average 19.8 21.8 23.7 Total Number 25650 28245 28514 Average 23.0 24.8 24.4 Adjusted Rate (b) 23.0 25.3 24.6 (a) In thousands; three-year moving average. (b) Adjusted for age. CONCLUSIONS Diabetes mellitus is a major cause of morbidity and premature mortality in the United States. Surveillance data describing the magnitude of the disease burden of diabetes and its complications can be used to help formulate health care policy, target high-risk groups, develop strategies to reduce the burden associated with diabetes, and evaluate progress in disease prevention and control. We have established a diabetes surveillance system to serve such purposes. This system compiles and analyzes periodic and representative data on the disease burden associated with diabetes and its complications in the United States. The results of these analyzes have been summarized in Chapters 2 through 9. Although national data are available for many of the complications of diabetes, there are some important gaps. Diabetes is the leading cause of new cases of blindness among adults in the United States, but recent national data are not available on eye disease and blindness related to diabetes. And although women with diabetes are known to be at increased risk for adverse outcomes of pregnancy, national data are not available for monitoring pregnancy outcomes among these women. Nor are periodic, national data available on health care practices and behaviors that could prevent many of the complications of diabetes. 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