Burden of Diabetes in Kansas
December 2011
Kansas Department of Health and Environment
Kansas Diabetes Prevention and Control Program
Department of Health
and Environment
Department of Health
and Environment
Mission
To protect and improve the health and environment of all Kansans
Vision
Healthy Kansans living in safe and sustainable environments
www.kdheks.gov
Burden of Diabetes in Kansas
Robert Moser, MD
Secretary, KDHE
Paula Clayton, M.S., R.D., L.D.
Director, Bureau of Health Promotion, KDHE
Kate Watson, M.A., M.P.A.
Program Manager, Kansas Diabetes Prevention and Control Program
Bureau of Health Promotion, KDHE
Report Preparation:
Ghazala Perveen, M.B.B.S., Ph.D., M.P.H.
Director for Science and Surveillance, Health Officer II
Bureau of Health Promotion, KDHE
Eric Cook-Wiens, M.P.H.
Advanced Epidemiologist, Kansas Diabetes Prevention and Control Program and Kansas
Heart Disease and Stroke Prevention Program
Bureau of Health Promotion, KDHE
This report was supported by cooperative agreement number 3U58DP001968-03W1 from
the Centers for Disease Control and Prevention. Its contents are solely the responsibility of
the authors and do not necessarily represent the official views of the Centers for Disease
Control and Prevention.
Contact Information
For Additional information please contact the Bureau of Health Promotion, Suite 230,
Kansas Department of Health and Environment, 1000 SW Jackson, Topeka, KS 66612, or call
(785)291-3742.
Con t en t s
Executive Summary
1
Introduction
3
C h a p t e r 1 : Mortality from Diabetes
5
C h a p t e r 2 : Prevalence of Diabetes
9
C h a p t e r 3 : Impact of Diabetes: Hospitalizations,
Complications and Cost
21
Hospitalizations
21
Complications
25
Cost
30
C h a p t e r 4 : Undiagnosed Diabetes, Pre-Diabetes and
Gestational Diabetes
31
Undiagnosed diabetes and diabetes testing among persons without diabetes 31
Pre-diabetes
33
Gestational Diabetes
35
C h a p t e r 5 : Diabetes Risk Factors
37
Trends in Obesity, High Blood Pressure, High Blood Cholesterol and Diabetes 38
Risk Factor Control among Kansans with Diabetes
39
Obesity
40
High Blood Pressure
43
High Blood Cholesterol among Those Tested for Blood Cholesterol
46
Physical Inactivity
49
High-Risk for Diabetes (Diabetes Risk Test Score)
56
C h a p t e r 6 : Preventive Care Practices / Quality of Care Indicators
59
Annual dilated eye exam
59
Daily self monitoring of blood glucose
61
Foot exam by a health professional at least once per year
63
Visit to a health professional for diabetes care at least once per year
65
Daily self-exam of feet
67
At least two tests of hemoglobin A1c each year
69
Taking a class in diabetes self-management
71
Annual influenza vaccination
73
Pneumonia Vaccination
75
Smoking Cessation
78
C h a p t e r 7 : Health Disparities and Social Determinants of
Diabetes Burden
79
Technical Notes
83
Description of Data Sources
83
Statistical Methods
85
County Population Density Peer Groups
86
Selected Category Crosswalks
87
References
89
Executive Summary
Diabetes is a common and costly chronic condition that can lead to devastating complications. The Burden of
Diabetes in Kansas, 2011 was created to provide current information on the status of diabetes, risk factors for
diabetes and complications of diabetes. Policy-makers, health care professionals, diabetes advocates, public
health professionals and others are invited to use this document to help guide and support their efforts to
reduce the impact of diabetes in Kansas.
Key Findings:
•In 2009, diabetes was the seventh leading cause of death in Kansas.
•Age-adjusted diabetes mortality rates in Kansas were significantly higher among non-Hispanic African
Americans, non-Hispanic American Indians/Alaska Natives and Hispanics as compared to non-Hispanic
whites.
•About 179,000 Kansas adults 18 years and older (8.4%) have been diagnosed with diabetes in 2010.
•During the period from 2000 through 2010, the percentage of Kansans 18 years and older diagnosed with
diabetes increased from 5.9% in 2000 to 8.4% in 2010, a 42% increase. •The age-adjusted prevalence of diabetes among non-Hispanic African American adults, non-Hispanic
American Indian or Alaska Native adults, non-Hispanic adults of other race or multiple race and Hispanic
adults were all significantly higher than for non-Hispanic white adults. •The prevalence of diabetes was significantly higher among those with lower annual household income and
lower levels of education.
•The prevalence of diabetes was higher among adult Kansans living with a disability as compared to those
living without a disability. This disparity in diabetes prevalence by disability status is present regardless of
gender, age, race, ethnicity, annual household income or education.
•Age-adjusted hospital discharge rates for diabetes listed as any primary or secondary diagnosis were much
higher in non-Hispanic African Americans than in any other racial or ethnic group in 2008.
•During the period from 2000 through 2009, the overall age-adjusted hospital discharge rate for coronary
heart disease (CHD) in Kansas decreased modestly. However, the percentage of CHD discharges with
diabetes listed as a secondary diagnosis increased. Thus, although overall age-adjusted CHD hospital
discharge rates are declining, the increasing burden of diabetes and it’s complications in Kansas is evident
in the increasing percentage of CHD hospitalizations that are diabetes related. A similar pattern was
observed in age-adjusted hospital discharge rates for stroke.
•In 2010, nearly half of persons living with end-stage renal disease had diabetes listed as the primary
diagnosis.
•The increasing trend in diabetes prevalence during the period from 2001 through 2010 was mirrored by
increases in the prevalence of obesity, high blood pressure and high blood cholesterol among those tested
for high blood cholesterol. The parallel increases in the prevalence of these four risk factors may signal a
future increase in the burden of heart disease and stroke.
1
•Diabetes prevalence was higher among Kansas adults who are obese as compared to those who are not
obese, higher among those who have high blood pressure as compared to those who do not have high
blood pressure, and higher among those who have been tested and diagnosed with high blood cholesterol
as compared to those who have been tested but do not have high blood cholesterol. Disparities in diabetes
prevalence with respect to race, ethnicity, annual household income, education and disability status
persisted regardless of risk factor status.
Summary of progress toward selected Healthy People objective targets in Kansas.
2010 Target
2020 Target
Kansas
Baseline
Kansas
Current
46 deaths per
100,000
65.8 deaths per
100,000
68.2 deaths
per 100,000
61.0 deaths
per 100,000
Increase the proportion of adults with diabetes who
have at least an annual foot examination.b
91%
74.8%
65.3%
69.9%
Increase the proportion of adults with diabetes who
have an annual dilated eye examination.b
76%
58.7%
66.0%
66.4%
Increase the proportion of adults with diabetes who
have a glycosylated hemoglobin measurement at
least twice a year.b
65%
71.1%
68.8%
72.1%
Increase the proportion of adults with diabetes who
perform self-blood glucose-monitoring at least once
daily.b
61%
70.4%
49.6%
57.1%
Increase the proportion of persons with diagnosed
diabetes who receive formal diabetes education.b
60%
62.5%
57.4%
56.3%
Selected Healthy People Objective
Reduce the diabetes death rate (per 100,000
persons).a
Source: 2010 targets are from the Healthy People 2010 Midcourse Review, U.S. Department of Health and Human Services. Healthy People 2020
targets are from the Healthy People 2020 website. http://www.healthypeople.gov/2020/default.aspx. Accessed 8/2011.
a
Kansas Baseline is from 2000 and Kansas Current is from 2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE. Death rates
were age-adjusted to the U.S. 2000 standard population using the direct method. See Technical Appendix for details on how rates were calculated. Diabetes was defined as ICD-10 codes E10-E14.
Kansas Baseline is from 2001 and Kansas Current is from 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, KDHE.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were ageadjusted to the 2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how
prevalence estimates were calculated.
b
2
Introduction
Diabetes is a common chronic condition marked by elevated levels of sugar in the blood. Diabetes is
a serious condition that can lead to devastating complications such as heart disease, stroke, kidney failure,
blindness, lower extremity amputation and premature death. Managing diabetes is complex and costly,
requiring a coordinated effort on the part of the person with diabetes, medical care providers, specialists,
clinical and public health systems and the community. Nevertheless, diabetes can be prevented by adopting
a healthy lifestyle including regular physical activity and a healthy diet. Complications of diabetes can be
prevented through early detection and appropriate clinical management.
The purpose of this report is to characterize the burden of diabetes in Kansas using comprehensive
population-based data sources. Policy-makers, health professionals, diabetes advocates, members of the
public health community and others are invited to use the information in this report to help guide and
support their efforts to reduce the burden of diabetes on individuals and communities in Kansas.
What is Diabetes?
Diabetes is chronic disease characterized by elevated blood sugar, also called blood glucose. High
levels of blood glucose result from inadequate production of insulin or a resistance to the effect of insulin, a
hormone produced by the pancreas. Under normal conditions, insulin is secreted by the pancreas to signal
cells to take up blood glucose, the primary fuel cells use to produce energy. In diabetes, this signal is absent
or ineffective resulting in high levels of glucose in the blood. Prolonged elevation of blood glucose can lead
to damage in a number of tissues and organs in the body. This damage can result in cardiovascular disease,
kidney disease, visual impairment and blindness, peripheral neuropathy and other complications.
There are 3 major types of diabetes: type-1, type-2 and gestational.
•Type-1 diabetes occurs when the body’s immune system attacks the cells in the pancreas that produce
insulin, the pancreatic beta cells. People with type-1 diabetes must receive insulin shots or use an insulin
pump. Type-1 diabetes cannot be prevented or cured, but can be managed effectively through daily blood
glucose monitoring, insulin injections and adopting a healthy lifestyle. •Type-2 diabetes occurs when cells in the body become resistant to the effects of insulin, a condition known
as insulin-resistance. Early in the disease process, insulin is produced by the pancreas, but over time, the
pancreas can stop producing insulin. Onset of type-2 diabetes is more gradual than in Type-1, but both
result in the body being unable to make efficient use of glucose. The vast majority (90%-95%) of people
with diabetes have type-2 diabetes.1
•Gestational diabetes is a form of glucose intolerance that can occur during pregnancy and can lead to
complications for the infant if not managed appropriately. While gestational diabetes usually goes away
after the baby is born, women who develop this condition during pregnancy have significantly increased
risk for developing diabetes later in life.
Because it can be difficult to distinguish type-1 and type-2 diabetes in population-based data sources,
the analyses presented in this document refer to either type unless otherwise indicated.
3
This report documents the burden of diabetes in Kansas during the period from 2000 through 2010.
Chapter 1 focuses on mortality due to diabetes based on analysis of data from Kansas death certificates. Chapter 2 focuses on diabetes prevalence using data from the Kansas Behavioral Risk Factor Surveillance
System (BRFSS). Chapter 3 describes the impact of diabetes on Kansas in terms of hospitalizations,
complications and cost. Chapter 4 focuses on Kansans at high risk for developing diabetes including
information on diabetes testing, pre-diabetes prevalence and gestational diabetes. Chapter 5 discusses
prevalence and trends in risk factors for diabetes and complications from diabetes including obesity,
high blood pressure, high blood cholesterol, physical inactivity and other risk factors. Chapter 6 provides
information on preventive care practices and indicators of quality of care received by persons with diabetes.
Finally, Chapter 7 highlights observations from the previous chapters as they relate to health disparities and
social determinants of health.
4
Chapter 1
Mortality from Diabetes
In 2009, diabetes was the seventh leading cause of death in Kansas. Diabetes was listed as the underlying
cause of death for 628 Kansas residents in 2009. During the period from 2000 through 2009, the Kansas
age-adjusted diabetes mortality rate was not significantly different from that in the United States.2 There
was not a clear increasing or decreasing trend in diabetes mortality during the period 2000 to 2009 (Figure
1-1). However, the age-adjusted diabetes mortality rate in Kansas increased significantly during the previous
2 decades increasing from 15.3 per 100,000 persons (95% confidence interval: 13.7 to 16.9) in 1979 to 24.1
per 100,000 persons (95% confidence interval: 21.0 to 24.5) in 1998 (data source: CDC Wonder, accessed 18
January, 2011). Thus, the increasing trend in diabetes mortality during the previous two decades seems to
have attenuated during the period from 2000 to 2009, consistent with national trends (data not shown).
Please note, however, that the National Vital Statistics System shifted from the ninth to the tenth version of the
International Classification of Disease in 1999, so caution should be exercised when comparing mortality rates
from 1998 and earlier to more recent rates.
Figure 1-2. Age-adjusted diabetes mortality rate by gender and year, Kansas 2000-2009.
Age-Adjusted Diabetes Mortality
Rate per 100,000 Persons
30
25
20
15
10
Kansas
United States
5
0
Kansas
2000200120022003200420052006200720082009
23.525.126.223.023.323.624.722.722.720.2
United States
25.025.325.425.324.524.623.322.5
Year
Source: 2000-2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE. United States Department of Health and Human
Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Compressed Mortality File on CDC WONDER On-line
Database. Rates were age-adjusted to the U.S. 2000 standard population using the direct method. See Technical Appendix for details on how rates were
calculated. Diabetes was defined as ICD-10 codes E10-E14.
5
Age-adjusted diabetes mortality rates in Kansas were significantly higher among non-Hispanic African
Americans (47.4 deaths per 100,000 persons; 95% confidence interval: 41.9 to 53.5), non-Hispanic American
Indians/Alaska Natives (45.9 deaths per 100,000 persons; 95% confidence interval: 32.2 to 64.0) and Hispanics
(31.0 deaths per 100,000 persons; 95% confidence interval: 25.8 to 36.9) as compared to non-Hispanic whites
(20.9 deaths per 100,000 persons; 95% confidence interval: 20.2 to 21.7). For this analysis, mortality data from
5 years were combined so that the sample for each race and ethnicity group was large enough to compute a
reliable age-adjusted mortality rate.
Age-Adjusted Diabetes Mortality
Rate per 100,000 Persons
Figure 1-3. Age-adjusted diabetes mortality rate by race and ethnicity, Kansas 2005-2009.
70
60
50
40
30
47.4
20
20.9
10
0
45.9
White, nonHispanic
19.2
African American,
non-Hispanic
American Indian/
Alaska Native,
non-Hispanic
Asian/Pacific
Islander, nonHispanic
31.0
Hispanic, any
race
Race, Ethnicit y
Source: 2005-2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE.
Rates were age-adjusted to the U.S. 2000 standard population using the direct method. See Technical Appendix for details on how rates were
calculated. Diabetes was defined as ICD-10 codes E10-E14.
In Kansas, there were modest differences in age-adjusted diabetes mortality rates by county population
density (Figure 1-4). The age-adjusted mortality rate in urban counties (19.7 per 100,000 persons; 95%
confidence interval: 18.7 to 20.8) was significantly lower than the rate in rural (27.4 per 100,000; 95%
confidence interval: 25.2 to 29.9) and densely-settled rural counties (26.5 per 100,000, 95% confidence interval
24.5 to 28.7).
Figure 1-4. Age-adjusted diabetes mortality rate by county of residence population density peer group,
Kansas 2005-2009.
Age-Adjusted Diabetes
Mortality Rate
Lower 95% CI
Upper 95% CI
Urban
19.7
18.7
20.8
Semi-Urban
22.2
20.5
24.0
Densely-Settled Rural
26.5
24.5
28.7
Rural
27.4
25.2
29.9
Frontier
23.9
20.5
28.2
Peer Group
Source: 2005-2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE.
Rates were age-adjusted to the U.S. 2000 standard population using the direct method. See Technical Appendix for county population peer group
definitions and for details on how rates were calculated. Diabetes was defined as ICD-10 codes E10-E14.
6
During the period from 2005 through 2009, 3,492 Kansas deaths listed diabetes as the underlying cause
of death. However, to fully characterize the impact of diabetes on mortality it is important to consider deaths
from cardiovascular disease and other causes where diabetes may have been contributing cause of death.
Kansas death certificates can list up to 20 contributing causes of death in addition to the underlying cause of
death. During the period from 2005 through 2009, there were 9,956 Kansas deaths with diabetes listed as a
contributing cause. Among those, only 35% listed diabetes as the underlying cause of death. About 1 in 3
deaths listing diabetes as a contributing cause identified the underlying cause of death to be cardiovascular
disease (includes heart disease, stroke and other disease of the heart or blood vessels), which is a complication
of diabetes.
Figure 1-5. Underlying cause of death where diabetes is listed as a contributing cause of death,
Kansas 2005-2009.
Other
23.6%
Diabetes*
35.1%
Malignant
Neoplasms
10.0%
Cardiovascular
Disease
31.4%
Source: 2005-2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE.
For this chart the following ICD-10 code categories were used: Cardiovascular Disease was defined as I00-I99, Malignant Neoplasms was defined as
C00-C97, Diabetes was defined as E14-E14. Please note that these leading cause categories for CVD include coronary heart disease, stroke and all other
categories of CVD, deviating from the Leading Cause of Death categories defined by the National Center for Health Statistics.
*By definition, diabetes is listed as a contributing cause of death for all deaths where diabetes is listed as the underlying cause of death.
7
8
Chapter 2
Prevalence of Diabetes
About 179,000 Kansas adults 18 years and older (8.4%; 95% confidence interval: 8.1% to 9.0%) reported
they have been diagnosed with diabetes in 2010. During the period from 2000 through 2010, the percentage
of Kansans 18 years and older increased from 5.9% (95% confidence interval: 5.1% to 6.7%) in 2000 to 8.4%
(95% confidence interval: 8.1% to 9.0%) in 2010, a 42% increase (Figure 2-1). During the same period, the
median National diabetes prevalence increased from 6.1% in 2000 to 8.7% in 2010.3
Figure 2-1. Percentage of adults 18 years and older who have been diagnosed with diabetes,
Kansas 2000-2010.
9%
8%
8.1%
Prevalence of Diabetes (%)
7%
6%
5%
6.4%
5.9%
5.8%
6.0%
6.5%
6.9%
7.3%
8.5% 8.4%
7.3%
4%
3%
2%
1%
0%
20002001200220032004200520062007200820092010
Year
Source: 2000-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded.
9
10
The percentage of adults 18 years and older with diagnosed diabetes increases dramatically with age
(Figure 2-2). Nearly one in five (18.5%; 95% confidence interval: 16.9% to 20.0%) Kansans 65 years and older
have been diagnosed with diabetes. Overall, the prevalence of diabetes is 8.2% (95% confidence interval 7.4%
to 9.0%) among women 18 years and older and 8.6% (95% confidence interval: 7.7% to 9.6%) among men 18
years and older. Diabetes prevalence was higher among men ages 65 years and older (21.1%; 95% confidence
interval: 18.5% to 23.7%) as compared to women 65 years and older (16.5%; 95% confidence interval: 14.7%
to 18.3%). For all other age groups, the prevalence of diabetes was not significantly different for women as
compared to men.
Figure 2-2. Percentage of adults 18 years and older diagnosed with diabetes by age and gender,
Kansas 2010.
25%
Prevalence of Diabetes (%)
20%
Women
15%
Men
Total Population
10%
5%
0%
Women
Men
Total Population
18 to 34 Years
35 to 44 Years
45 to 64 Years
65 Years and Older
1.7%
1.6%
1.6%
4.2%
4.5%
4.4%
11.0%
11.6%
11.3%
16.5%
21.1%
18.5%
Age Group (Years)
Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Women
told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded.
11
In Kansas, diabetes prevalence is strongly associated with race and ethnicity. Figure 2-3 provides the
age-adjusted percentage of adults 18 years and older with diagnosed diabetes by race and ethnicity using
data from 2006 through 2010. Because of differences in the age composition of racial and ethnic subgroups
in Kansas, it is important to statistically adjust for age when comparing diabetes prevalence among racial
and ethnic subpopulations. The age-adjusted prevalence of diabetes among non-Hispanic African American
adults (13.3%; 95% confidence interval: 11.8% to 14.9%), non-Hispanic American Indian or Alaska Native adults
(18.7%; 95% confidence interval: 14.5% to 23.0%), non-Hispanic adults of other race or multiple race (10.1%;
95% confidence interval: 8.3% to 11.8%) and Hispanic adults (12.7%; 95% confidence interval: 11.2% to 14.3%)
were all significantly higher than for non-Hispanic white adults (7.2%; 95% confidence interval: 6.9% to 7.5%). Figure 2-3. Age-adjusted percentage of adults 18 years and older diagnosed with diabetes by race and
ethnicity, Kansas 2006-2010.
7.2%
Race, Ethnicity
White, non-Hispanic
Black/African American,
non-Hispanic
13.3%
American Indian/Alaska
Native, non-Hispanic
18.7%
Asian/Native Hawaiian/Pacific
Islander, non-Hispanic
7.3%
Other/Multiracial,
non-Hispanic
10.1%
Hispanic
12.7%
0%
5%
10%
15%
20%
25%
Age-Adjusted Prevalence of Diabetes (%)
Source: 2006-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded. Prevalence estimates were ageadjusted to the U.S. 2000 standard population. See Technical Appendix for details on how prevalence estimates were calculated. Error bars indicate
95% confidence intervals.
12
13
During the period from 2009 through 2010, the percentage of adults 18 years and older with diagnosed
diabetes was higher among persons with lower annual household income (Figure 2-4, hashed line). The
prevalence of diabetes was significantly lower among those with an annual household income of $50,000 or
more (5.9%; 95% confidence interval: 5.4% to 6.3%) as compared to all other income groups. Differences in
diabetes prevalence by annual household income are present in all age groups. Within each age group the
highest prevalence of diabetes occurs among those with annual household incomes below $15,000.
Figure 2-4. Percentage of adults 18 years and older diagnosed with diabetes by annual household
income and age, Kansas 2009-2010.
Age-Specific Prevalence of Diabetes (%)
30%
25%
20%
15%
10%
5%
0%
Below
$15,000
$15,000 to
$24,999
$25,000 to
$34,999
$35,000 to
$49,999
$50,000 or
higher
18 to 34 Years
5.9%
3.4%
2.1%
0.8%
0.7%
35 to 44 Years
8.9%
8.1%
5.4%
4.6%
3.2%
45 to 64 Years
21.1%
18.5%
13.3%
11.5%
8.5%
65 Years and Older
24.5%
21.6%
20.7%
18.1%
17.4%
Total
14.4%
13.6%
10.8%
8.4%
5.9%
Annual Household Income
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded.
14
During the period from 2009 through 2010, the percentage of adults 18 years and older with diagnosed
diabetes was higher among persons with lower levels of education (Figure 2-5, hashed line). The prevalence
of diabetes was significantly higher among persons who did not graduate from high school (13.2%; 95%
confidence interval: 11.2%% to 15.1%) as compared to all other levels of education. Differences in diabetes
prevalence by education are present in all age groups. Within each age group the highest prevalence of
diabetes occurs among those who didn’t graduate from high school. The lowest prevalence of diabetes occurs
among college or technical school graduates.
Figure 2-5. Percentage of adults 18 years and older diagnosed with diabetes by level of education and
age, Kansas 2009-2010.
25%
Age-Specific Prevalence
of Diabetes (%)
20%
15%
10%
5%
0%
Did Not Graduate
High School
High School
Graduate
Some Technical
Education or
College
College or
Technical
Education
Graduate
18 to 34 Years
4.1%
2.4%
1.9%
1.4%
35 to 44 Years
9.9%
4.6%
4.9%
3.1%
45 to 64 Years
19.6%
11.4%
12.4%
8.8%
65 Years and Older
23.0%
19.7%
20.2%
15.7%
Total
13.2%
9.6%
8.9%
6.4%
Level of Education
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded.
Kansans living with a disability are disproportionately affected by diabetes (Table 2-1). The Behavioral
Risk Factor Surveillance System defines disability as reporting an activity limitation due to physical, mental or
emotional problems or having a health problem that requires the use of special equipment such as a cane,
wheelchair, special bed, or special telephone. In 2010, the percentage of adults 18 years and older who report
living with a disability, 17.1% (95% confidence interval: 15.4% to 18.9%) have been diagnosed with diabetes
as compared to 5.9% (95% confidence interval: 5.3% to 6.5%) among those not living with a disability. This
disparity in diabetes prevalence by disability status is present regardless of gender, age, race, ethnicity, annual
household income or education.
15
Table 2-1. Percentage of adults 18 years and older diagnosed with diabetes by disability status and
selected demographic or social factors, Kansas 2010.
Living with a Disability
Selected Demographic
or Social Factor
Not Living with a Disability
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
17.1%
15.4% to 18.9%
5.9%
5.3% to 6.5%
Women
17.6%
15.3% to 19.9%
5.2%
4.5% to 5.9%
Men
16.6%
13.8% to 19.4%
6.6%
5.6% to 7.6%
18 to 34 Years
6.2%
0.5% to 11.9%
1.0%
0.3% to 1.7%
35 to 44 Years
10.9%
5.9% to 16.0%
3.1%
1.9% to 4.3%
45 to 64 Years
18.3%
15.7% to 21.0%
8.8%
7.6% to 10.1%
65 Years and Older
24.0%
21.3% to 26.6%
14.8%
13.0% to 16.7%
White, non-Hispanic
12.7%
11.8% to 13.6%
5.5%
5.3% to 5.8%
African American, non-Hispanic
18.4%
15.1% to 21.7%
11.4%
9.6% to 13.1%
Other/Multiracial, non-Hispanic
18.0%
14.4% to 21.7%
8.4%
6.8% to 9.9%
Hispanic
19.1%
14.2% to 23.9%
11.1%
9.4% to 12.7%
Below $15,000
21.4%
15.8% to 27.1%
8.1%
5.0% to 11.2%
$15,000 to $24,999
23.3%
17.7% to 28.9%
7.8%
5.7% to 9.9%
$25,000 to $34,999
14.8%
10.8% to 18.8%
8.0%
5.9% to 10.1%
$35,000 to $49,999
18.2%
13.8% to 22.7%
6.9%
5.3% to 8.5%
$50,000 or higher
11.9%
9.3% to 14.6%
4.2%
3.5% to 5.0%
Total
Gender
Age
Race, Ethnic Groups*
Annual Household Income
Education
Did Not Graduate High School
20.9%
13.7% to 28.0%
8.7%
5.7% to 11.8%
High School Graduate
18.3%
14.9% to 21.7%
6.3%
5.1% to 7.5%
Some Technical or College
17.7%
14.4% to 21.1%
6.3%
5.1% to 7.5%
College or Technical Graduate
14.2%
11.4% to 16.9%
5.0%
4.1% to 5.9%
Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Women
told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes were excluded. Disability is defined having any activity
limitation due to physical, mental or emotional problems or having a health problem that requires the use of special equipment such as a cane,
wheelchair, special bed, or special telephone.
* Age-adjusted rates are provided for race and ethnicity subgroups. Data from 2006 through 2010 were combined to compute age-adjusted rates. Prevalence estimates were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how prevalence estimates were
calculated. Error bars indicate 95% confidence intervals.
16
To examine differences in the percentage of adults 18 years and older with diabetes by rural or urban
environment, counties were stratified according to population density peer groups using groups defined by
the Kansas Office of Local and Rural Health (see technical appendix for a list of counties). The percentage of
adults 18 years and older with diabetes was similar for all population density peer groups in 2010.
Table 2-2. Percentage of adults 18 years and older with diagnosed diabetes by county population
density peer group, Kansas 2010.
County Population Density Peer Group
Frontier (<6 persons per square mile)
Prevalence of
Diabetes (%)
95% Confidence
Interval
8.6%
5.8% to 11.3%
Rural (6 to 19.9 persons per square mile)
8.2%
6.6% to 9.9%
Densely-Settled Rural (20 to 39.9 persons per square mile)
10.8%
8.7% to 12.9%
Semi-Urban (40 to 149.9 persons per square mile)
8.0%
6.5% to 9.5%
Urban (150 or more persons per square mile)
7.9%
7.1% to 8.8%
Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
The percentage of adults 18 years and older with diabetes was available for 60 counties in 2009 (Table
2-3). Because the 2009 sample was insufficient for producing individual county estimates for 45 counties,
counties were also grouped into 17 public health preparedness regions for analysis (Table 2-4). Public health
planners in Kansas are invited to use these county- and region-specific diabetes prevalence estimates for
planning and evaluating local policies and programs to reduce diabetes burden.
17
Table 2-3. Percentage of adults 18 years and older diagnosed with diabetes by county, Kansas 2009.
County
Prevalence of
Diabetes (95%
Confidence Interval)
County
Prevalence of
Diabetes (95%
Confidence Interval)
County
Prevalence of
Diabetes (95%
Confidence Interval)
Allen
8.5% (3.9% - 13.2%)
Greeley
* (*)
Osborne
* (*)
Anderson
* (*)
Greenwood
13.8% (1.2% - 26.4%)
Ottawa
* (*)
Atchison
7.8% (2.3% - 13.2%)
Hamilton
* (*)
Pawnee
10.7% (2.8% - 18.5%)
Barber
20.4% (5.8% - 35%)
Harper
12.2% (4.5% - 19.9%)
Phillips
7.8% (0.8% - 14.9%)
Barton
12.8% (7.3% - 18.3%)
Harvey
6.6% (3.3% - 9.9%)
Pottawatomie 4.7% (2% - 7.4%)
Bourbon
7.1% (1.5% - 12.8%)
Haskell
* (*)
Pratt
2.9% (0.4% - 5.4%)
Brown
9.6% (2.7% - 16.4%)
Hodgeman
* (*)
Rawlins
* (*)
Butler
7.2% (4.9% - 9.6%)
Jackson
9.3% (4% - 14.6%)
Reno
12.0% (8.7% - 15.3%)
Chase
* (*)
Jefferson
11.7% (5.1% - 18.4%)
Republic
* (*)
Chautauqua * (*)
Jewell
* (*)
Rice
17.6% (2.1% - 33.2%)
Cherokee
9.1% (4.4% - 13.9%)
Johnson
5.6% (4.7% - 6.4%)
Riley
8.3% (0% - 17.4%)
Cheyenne
* (*)
Kearny
* (*)
Rooks
* (*)
Clark
* (*)
Kingman
10.7% (3% - 18.5%)
Rush
* (*)
Clay
9.8% (3.1% - 16.6%)
Kiowa
* (*)
Russell
* (*)
Cloud
8.3% (2.6% - 14%)
Labette
9.7% (5% - 14.5%)
Saline
8.0% (4.7% - 11.3%)
Coffey
9.5% (3.6% - 15.3%)
Lane
* (*)
Scott
* (*)
Comanche
* (*)
Leavenworth
8.9% (6.2% - 11.7%)
Sedgwick
8.7% (7.7% - 9.7%)
Cowley
8.9% (5.1% - 12.8%)
Lincoln
* (*)
Seward
17.6% (0% - 38.9%)
Crawford
10.9% (6.2% - 15.7%)
Linn
11.7% (3.3% - 20.1%)
Shawnee
9.3% (7.8% - 10.8%)
Decatur
* (*)
Logan
* (*)
Sheridan
* (*)
Dickinson
12.0% (6.3% - 17.7%)
Lyon
6.9% (3.7% - 10.2%)
Sherman
* (*)
Doniphan
7.0% (0.2% - 13.9%)
McPherson
6.8% (3.4% - 10.1%)
Smith
* (*)
Douglas
6.8% (1.8% - 11.8%)
Marion
12.6% (1.6% - 23.5%)
Stafford
14.7% (4.9% - 24.5%)
Edwards
* (*)
Marshall
7.7% (2.4% - 13.1%)
Stanton
* (*)
Elk
* (*)
Meade
* (*)
Stevens
* (*)
Ellis
4.1% (1.5% - 6.7%)
Miami
6.2% (3.1% - 9.4%)
Sumner
10.2% (5.5% - 14.9%)
Ellsworth
10.2% (2.1% - 18.2%)
Mitchell
14.7% (4.2% - 25.2%)
Thomas
* (*)
Finney
6.7% (3.1% - 10.3%)
Montgomery
10.8% (6% - 15.6%)
Trego
* (*)
Ford
10.2% (4.7% - 15.7%)
Morris
11.1% (2.2% - 20.1%)
Wabaunsee
9.2% (1.8% - 16.5%)
Franklin
8.8% (4.9% - 12.7%)
Morton
* (*)
Wallace
* (*)
Geary
6.4% (2.6% - 10.2%)
Nemaha
7.7% (3.5% - 12%)
Washington
8.7% (1.9% - 15.4%)
Gove
* (*)
Neosho
11.3% (5.4% - 17.1%)
Wichita
* (*)
Graham
* (*)
Ness
* (*)
Wilson
12.3% (5.8% - 18.9%)
Grant
* (*)
Norton
* (*)
Woodson
* (*)
Gray
* (*)
Osage
9.9% (4.9% - 14.9%)
Wyandotte
12.2% (9.8% - 14.6%)
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
County level estimates are direct estimates of diabetes prevalence. Survey weights were adjusted through post-stratification to reflect the 2000 Census
age and gender composition for each county.
* Insufficient sample to produce an estimate.
18
Table 2-4. Percentage of adults 18 years and older diagnosed with diabetes by Kansas Public Health
Preparedness Region, Kansas 2009.
Region
Prevalence of
Diabetes (%)
95% Confidence Interval
Central Kansas Region
10.1%
7.7% to 12.6%
East Central Kansas Public Health Coalition
8.8%
6.9% to 10.8%
Ellis County Health Department
4.1%
1.5% to 6.7%
Kansas City Area Coalition
6.5%
5.8% to 7.2%
Lower 8 of SE Kansas Region
10.2%
8.3% to 12.1%
North Central Kansas Public Health Initiative
10.6%
7.9% to 13.3%
Northeast Corner Regionalization Initiative
8.8%
7.6% to 10%
Northwest BT Region
8.8%
5.6% to 11.9%
*
*
SEK Multi-County Region
7.7%
4.6% to 10.8%
Southwest Kansas Health Initiative
8.9%
4.1% to 13.7%
Southwest Surveillance Region
10.3%
6.4% to 14.3%
South Central Coalition
8.7%
5.8% to 11.5%
South Central Metro Region
8.5%
7.6% to 9.3%
West Central Public Health Initiative
9.2%
4.6% to 13.9%
Western Pyramid Region
7.3%
4.4% to 10.1%
Wildcat Region
6.3%
2.1% to 10.4%
Public Health Preparedness Region
Rush County Health Department
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Regional estimates are direct estimates of diabetes prevalence. Survey weights were adjusted through post-stratification to reflect the 2000 Census
age and gender composition for each group of counties.
* Insufficient sample to produce an estimate.
19
20
Chapter 3
Impact of Diabetes:
Hospitalizations,
Complications and Cost
Hospitalizations
Diabetes Hospitalizations, 2000-2009
Diabetes poses a significant challenge for the health care system in Kansas. Because diabetes can affect
multiple systems in the body, it is important to consider not only hospitalizations for which diabetes was the
primary diagnosis, but also hospitalizations with other primary diagnoses that list diabetes as a secondary
diagnosis (Table 3-1). In 2009, the age-adjusted hospital discharge rates for diabetes as the primary diagnosis
or as any listed diagnosis were 14.5 per 10,000 persons and 200.6 per 10,000 persons, respectively. During
the period from 2000 through 2009, the age-adjusted hospital discharge rate for discharges with a primary
diagnosis of diabetes declined moderately from 16.2 (95% confidence interval: 15.7 to 16.7) discharges per
10,000 persons in 2000 to 14.5 (95% confidence interval: 14.1 to 15.0) discharges per 10,000 persons in 2009. However, during the same period, the age-adjusted discharge rate for discharges with diabetes listed as a
primary or any secondary diagnosis increased from 153.9 (95% confidence interval: 152.5 to 155.4) discharges
per 10,000 persons in 2000 to 200.6 (95% confidence interval: 199.0 to 202.3) discharges per 10,000 persons in
2009.
Table 3-1. Hospital discharges, age-adjusted hospital discharge rates and median length of stay for
discharges with a primary diagnosis of diabetes and diabetes listed as any primary or secondary
diagnosis by year, Kansas 2000-2009.
Prevalence of Diabetes (%)
95% Confidence Interval
Diabetes Primary Diagnosis
Year
Count
Age-Adjusted
Discharge rate per
10,000 Persons
Median
Length of Stay
(days)
Count
Age-Adjusted
Discharge rate per
10,000 Persons
Median
Length of Stay
(days)
2000
4,377
16.2
4
42,134
153.9
4
2001
4,224
15.5
4
44,386
160.5
4
2002
4,180
15.2
4
46,456
166.5
4
2003
4,373
15.9
3
50,072
178.6
4
2004
4,435
15.9
3
53,708
189.2
4
2005
4,444
15.8
3
55,707
193.7
4
2006
4,475
15.8
3
57,290
197.5
4
2007
4,385
15.4
3
58,503
199.8
4
2008
4,357
15.2
3
60,679
203.8
4
2009*
4,204
14.5
3
59,978
200.6
4
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Rates were age-adjusted to the U.S. 2000 standard population using
the direct method. See Technical Appendix for details on how rates were calculated. Diabetes was defined as ICD-9 codes 250.0-250.9. Records were
excluded if age could not be calculated.
* At the time of report development, hospital discharge records for the October 2009 through December 2009 were considered provisional.
21
Diabetes Hospitalizations by Age and Gender
The number of hospital discharges for diabetes increases dramatically with age (Figure 3-1). Among
hospital discharges for persons ages 15-24 years, 25-34 years, 35-44 years and 45-54 years, the hospital
discharge rate was higher among females than among males. However, among those ages 65-74 years and 75
years and older, the hospital discharge rate was higher among males than females. The difference in hospital
discharge rates was highest among those aged 75 years and older, with 1,310.1 (95% confidence interval:
1,283.4 to 1,336.8) discharges per 10,000 men as compared to 1,020.7 (95% confidence interval: 1,002.4 to
1039.1) discharges per 10,000 women in 2008.
Figure 3-1. Age-specific hospital discharge rate for diabetes listed as any primary or secondary
diagnosis by age and gender, Kansas 2008.
Hospital Discharge Rate per 10,000 Persons
1400.0
1200.0
1000.0
800.0
Female
600.0
Male
Total
400.0
200.0
0.0
14 Years
and
Younger
15 to 24
Years
25 to 34
Years
35 to 44
Years
45 to 54
Years
55 to 64
Years
65 to 74
Years
75 Years
and Older
Female
6.0
27.3
54.5
108.4
202.7
398.4
734.8
1020.7
Male
5.7
15.5
29.3
77.5
181.1
380.1
797.5
1310.1
Total
5.9
21.12
41.5
92.85
191.94
389.37
763.96
1130.1
Age Group
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Diabetes was defined as ICD-9 codes 250.0-250.9. Records were excluded
if age could not be calculated.
22
Diabetes Hospitalizations by Race and Ethnicity
Age-adjusted hospital discharge rates for diabetes listed as any primary or secondary diagnosis were
much higher in non-Hispanic African Americans than in any other racial or ethnic group in 2008 (Table 3-2).
The large disparity between non-Hispanic African Americans and non-Hispanic whites parallels the disparities
observed in prevalence. The age-adjusted hospital discharge rate for diabetes listed as any primary or
secondary diagnosis for Hispanics was also significantly higher than for non-Hispanic whites. The observed
hospital discharge rates for non-Hispanic American Indian or Alaska Native and non-Hispanic Asian (including
native Hawaiian and other pacific islander) were lower than for non-Hispanic whites. This result for nonHispanic American Indian or Alaska Natives was surprising because this group has a very high prevalence of
diabetes. The reason for this apparent discrepancy is unknown, but may be related to different methodologies
for capturing race (for example, by anonymous self-reported telephone-based survey versus through hospital
discharge records) or because persons from this racial subgroup may be more likely to receive inpatient care
through federal hospitals or other health systems that do not report data to the Kansas Hospital Association.
Please see the technical appendix for more information about the Kansas Hospital Association inpatient
database.
Table3-2. Age-Adjusted hospital discharge rate for diabetes listed as any primary or secondary
diagnosis by race and ethnicity, Kansas 2008.
Race and Ethnicity
Count
Age-Adjusted Discharge
Rate per 10,000 Persons
95% Confidence Interval
White, non-Hispanic
46,175
173.3
171.7 to 174.9
African American, non-Hispanic
5,260
402.7
391.6 to 414.1
American Indian/Alaska Native, non-Hispanic
227
99.7
86.6 to 114.6
Asian or NHOPI, non-Hispanic*
539
145.7
132.7 to 159.9
2,258
184.1
175.8 to 192.7
Hispanic
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Rates were age-adjusted to the U.S. 2000 standard population using
the direct method. See Technical Appendix for details on how rates were calculated. Diabetes was defined as ICD-9 codes 250.0-250.9. Records were
excluded if age could not be calculated.
*Includes non-Hispanic person who identified their race as Asian, Native Hawaiian or other pacific islander (NHOPI).
Primary Source of Payment for Diabetes-Related Hospitalizations
In Kansas, for patients younger than 65 years, the leading sources of payment for hospitalizations for
diabetes listed as any primary or secondary diagnosis were commercial or private insurance plans (41.5%),
Medicare (28.4%) and Medicaid (16.1%). For patients 65 years and older, Medicare was listed as the primary
source of payment for the vast majority of diabetes-related inpatient stays (92.4%). Table 3-3. Primary source of payment for diabetes-related hospitalizations, Kansas 2008.
Percentage of Discharges Among
Persons Ages 0 to 64 Years
Percentage of Discharges Among
Persons Ages 65 Years and Older
Medicare
28.4%
92.4%
Payer
Commercial/Private Insurance
41.5%
6.0%
Self Pay
8.5%
0.3%
Medicaid
16.1%
0.7%
Other
5.5%
0.6%
Source: 2008 Hospital Discharge Database, Kansas Hospital Association. Diabetes was defined as ICD-9 codes 250.0-250.9. Records with any listed
diabetes diagnosis are included (as primary or secondary diagnosis).
23
Hospitalizations for Diabetes Manifestations
Table 4 provides the number of discharges for each category of diabetes manifestation (as documented
in the 4th digit of the ICD-9-CM code 250.X) for hospitalizations where diabetes was listed as the primary
cause. In 2008, the diabetes manifestation associated with the largest number of hospitalizations was
ketoacidosis, accounting for 29.4% of hospitalizations with a primary diagnosis of diabetes (Table 3-4). The
diabetes manifestation associated with the largest median length of stay was peripheral circulatory disorderrelated hospitalizations (7 days). Hospitalizations for diabetes-associated ketoacidosis were more common in
young age groups (Figure 3-2).
Table 3-4. Type of diabetes manifestation for hospitalizations with a primary diabetes diagnosis,
Kansas 2008.
Discharges
Percent
Median Length of
Stay (days)
Ketoacidosis (250.1)
1287
29.4%
3
Other Specified Manifestation (250.8)
1046
23.9%
3
No Mention of Complication (250.0)
751
17.1%
3
Neurological Manifestations (250.6)
614
14.0%
4
Peripheral Circulatory Disorders (250.7)
301
6.9%
7
Renal Manifestations (250.4)
187
4.3%
5
Hyperosmolarity (250.2)
92
2.1%
3
Unspecified Complication (250.9)
58
1.3%
2
Other Coma (250.3)
37
0.8%
3
Ophthalmic Manifestations (250.5)
12
0.3%
3
Primary Diagnosis (ICD-9 Code)
Source: 2008 Hospital Discharge Database, Kansas Hospital Association. Diabetes was defined as ICD-9 codes 250.0-250.9. Figure 3-2. Hospital discharges with a primary diagnosis diabetes-related ketoacidosis, Kansas 2008.
Number of Hospital Discharges
400
355
350
300
250
200
220
161
198
193
150
75
100
45
50
32
0
14 Years
and Younger
15 to 24
Years
25 to 34
Years
35 to 44
Years
45 to 54
Years
55 to 64
Years
65 to 74
Years
75 Years
and Older
Age Group (Years)
Source: 2008 Hospital Discharge Database, Kansas Hospital Association. Diabetes was defined as ICD-9 codes 250.0-250.9. Records were excluded if age
could not be calculated.
24
Complications
Coronary Heart Disease
Coronary heart disease (CHD) occurs when the arteries that supply blood to the heart harden and narrow.
This process, called atherosclerosis, involves cholesterol and other fatty substances, cells, calcium and blood
clotting factors building up and depositing on the inner lining of an artery. These plaques may also break off
from the wall and enter the blood stream as a clot or thrombus which can cause acute myocardial infarction
or heart attack. Elevated glucose in the blood and in the cells of blood vessel walls accelerates the process of
atherosclerosis in a number of ways putting persons with diabetes at very high risk for developing coronary
heart disease and heart attack.
During the period from 2000 to 2008, the number of hospital discharges for CHD declined significantly,
consistent with broader trends in cardiovascular disease morbidity and mortality in Kansas.4 Consistent with
these trends, the age-adjusted CHD discharge rate with diabetes listed as a secondary diagnosis decreased
from 17.3 per 10,000 persons (95% confidence interval: 16.8 to 17.8) in 2000 to 11.4 per 10,000 persons (95%
confidence interval: 11.1 to 11.8) in 2009 (Table 3-5). During the same period, however, the percentage of CHD
discharges with diabetes listed as a secondary diagnosis increased from 26.3% in 2000 to 35.6% in 2009. Thus,
although age-adjusted CHD hospital discharge rates are declining, the increasing burden of diabetes in Kansas
is evident in the increasing percentage of CHD hospitalizations that are diabetes related. These trends may
signal a future increase in CHD hospitalizations possibly due to the increasing prevalence of diabetes.
Table 3-5. Coronary (ischemic) heart disease (CHD) inpatient hospital discharges with diabetes as a
secondary diagnosis, Kansas 2000-2009.
Year
Total Number of
CHD Discharges
Number of CHD Discharges
with Diabetes as a
Secondary Diagnosis
Percent of CHD Discharges
with Diabetes as a
Secondary Diagnosis (%)
Age-Adjusted CHD
Discharge Rate per 10,000
Persons with Diabetes as a
Secondary Diagnosis
2000
17,818
4,678
26.3%
17.3
2001
18,129
4,590
25.3%
16.8
2002
16,594
4,657
28.1%
16.8
2003
15,587
4,578
29.4%
16.4
2004
14,992
4,674
31.2%
16.5
2005
14,205
4,433
31.2%
15.4
2006
13,949
4,543
32.6%
15.6
2007
12,433
4,242
34.1%
14.4
2008
11,443
3,902
34.1%
13.0
2009*
9,729
3,468
35.6%
11.4
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Age-adjusted rates were age-adjusted to the U.S. 2000 standard
population using the direct method. See Technical Appendix for details on how rates were calculated. Records were excluded if age could not be
calculated. Diabetes was defined as ICD-9 codes 250.0-250.9 as any secondary diagnosis. Coronary (ischemic) heart disease was defined as ICD-9
codes 410-414, 429.2 as primary diagnosis only.
* At the time of report development, hospital discharge records for the October 2009 through December 2009 were considered provisional.
25
Stroke
Stroke, also called cerebrovascular disease or brain attack, occurs when the blood supply to the brain is
interrupted. Stroke can be caused either by a blockage of blood flow by a clot (ischemic stroke) or by rupture
of a blood vessel leading to bleeding in or around the brain (hemorrhagic stroke). Diabetes accelerates
atherosclerosis, a disease process that causes blood vessels, including those in the brain, to harden and narrow
greatly increasing risk for having a stroke, particularly ischemic stroke.
In Kansas, stroke morbidity and mortality declined during the period from 2000 to 2008 following the
pattern observed in CHD mortality and morbidity.4 However, this declining trend was not evident in the ageadjusted stroke hospital discharge rate with diabetes as a secondary diagnosis (Table 3-6). The age-adjusted
stroke discharge rate in 2008 (6.1 per 10,000 persons; 95% confidence interval: 5.9 to 6.4) was not significantly
different from the rate in 2000 (5.8 per 10,000 persons; 95% confidence interval: 5.5 to 6.1). The increasing
prevalence of diabetes in Kansas may explain why declines in stroke hospitalizations are not observed among
those cases where diabetes is listed as any secondary diagnosis. Similar to the pattern observed in CHD
discharges, the percentage of stroke discharges with diabetes listed as a secondary diagnosis increased from
22.5% in 2000 to 31.1% in 2009.
Table 3-6. Stroke inpatient hospital discharges with diabetes as a secondary diagnosis,
Kansas 2000-2009.
Number of Stroke
Percent of Stroke
Discharges with Diabetes as Discharges with Diabetes as
a Secondary Diagnosis
a Secondary Diagnosis (%)
Age-Adjusted Stroke
Discharge Rate per 10,000
Persons with Diabetes as a
Secondary Diagnosis
Year
Total Number
of Stroke
Discharges
2000
7,142
1,606
22.5%
5.8
2001
6,977
1,552
22.2%
5.5
2002
6,887
1,553
22.5%
5.5
2003
6,415
1,530
23.9%
5.4
2004
6,431
1,594
24.8%
5.6
2005
6,357
1,635
25.7%
5.6
2006
6,236
1,726
27.7%
5.9
2007
6,092
1,612
26.5%
5.5
2008
6,242
1,859
29.8%
6.1
2009*
5,877
1,825
31.1%
6.0
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Age-adjusted rates were age-adjusted to the U.S. 2000 standard
population using the direct method. See Technical Appendix for details on how rates were calculated. Records were excluded if age could not be
calculated. Diabetes was defined as ICD-9 codes 250.0-250.9 as any secondary diagnosis. Stroke was defined as ICD-9 codes 430-434, 436-438 as
primary diagnosis only.
* At the time of report development, hospital discharge records for the October 2009 through December 2009 were considered provisional.
26
Heart Failure
Diabetes is one of the most common causes of heart failure—a condition that occurs when the heart
cannot supply sufficient oxygenated blood to other organs and tissues in the body.5 The age-adjusted heart
failure discharge rate with diabetes listed as a secondary diagnosis increased from 10.9 per 10,000 persons
(95% confidence interval: 10.5 to 11.3) in 2000 to 12.2 per 10,000 persons (95% confidence interval: 11.8 to
12.6) in 2004 (Table 3-7). However, the age-adjusted heart failure discharge rate declined during subsequent
years to 9.9 per 10,000 persons (95% confidence interval: 9.6 to 10.3) in 2009. Throughout the period from
2000 to 2009, more than 1 in 3 heart failure discharges listed diabetes as one of the secondary diagnoses.
Table 3-7. Heart Failure inpatient hospital discharges with diabetes listed as a secondary diagnosis,
Kansas 2000-2009.
Number of Heart Failure
Percent of Heart Failure
Discharges with Diabetes as Discharges with Diabetes as
a Secondary Diagnosis
a Secondary Diagnosis (%)
Age-Adjusted Heart Failure
Discharge Rate per 10,000
Persons with Diabetes as a
Secondary Diagnosis
Year
Total Number
of Heart Failure
Discharges
2000
8,592
3,020
35.1%
10.9
2001
8,904
3,115
35.0%
11.1
2002
8,898
3,225
36.2%
11.4
2003
8,726
3,353
38.4%
11.7
2004
8,966
3,536
39.4%
12.2
2005
8,756
3,410
38.9%
11.6
2006
8,281
3,138
37.9%
10.6
2007
8,068
3,205
39.7%
10.7
2008
7,399
3,024
40.9%
9.9
2009*
8,290
3,045
36.7%
9.9
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Age-adjusted rates were age-adjusted to the U.S. 2000 standard
population using the direct method. See Technical Appendix for details on how rates were calculated. Records were excluded if age could not be
calculated. Diabetes was defined as ICD-9 codes 250.0-250.9 as any secondary diagnosis. Heart failure was defined as ICD-9 code 428 as primary
diagnosis only.
* At the time of report development, hospital discharge records for the October 2009 through December 2009 were considered provisional.
27
Lower extremity conditions
Lower extremity conditions are common outcomes of poorly controlled diabetes and can lead to
non-traumatic lower extremity amputation. Major lower extremity conditions related to diabetes include
peripheral arterial disease, ulcer, inflammation or infection and neuropathy. Table 3-8 provides counts of
lower extremity amputation procedures and lower extremity conditions with diabetes listed as a secondary
diagnosis. The age-adjusted hospital discharge rates for lower extremity conditions with diabetes listed as
a secondary diagnosis did not show increasing or decreasing trends during the period from 2000 to 2009.
However, recent trends in diabetes prevalence may signal future increases in hospitalizations for these
conditions and underscore the importance of efforts to help persons with diabetes to control their condition.
Table 3-8. Hospital discharges and age-adjusted hospital discharge rates for lower extremity
amputation and selected lower extremity conditions with diabetes as any listed secondary diagnosis,
Kansas 2000-2009.
Lower Extremity
Amputations
Lower Extremity
Peripheral Arterial
Disease
Lower Extremity
Ulcer, Inflammation or
Infection
Lower Extremity
Neuropathy
Year
Count
Age-Adjusted
Rate per
10,000 Persons
Count
Age-Adjusted
Rate per
10,000 Persons
Count
Age-Adjusted
Rate per
10,000 Persons
Count
Age-Adjusted
Rate per
10,000 Persons
2000
592
2.18
813
2.97
736
2.72
624
2.35
2001
564
2.05
731
2.64
758
2.76
552
2.05
2002
593
2.14
731
2.62
845
3.05
583
2.14
2003
607
2.18
791
2.84
944
3.38
614
2.25
2004
614
2.15
773
2.71
982
3.45
647
2.34
2005
602
2.09
884
3.08
1065
3.72
608
2.17
2006
633
2.19
935
3.19
1092
3.78
592
2.09
2007
561
1.91
816
2.76
1117
3.81
606
2.10
2008
628
2.11
765
2.56
1163
3.89
624
2.17
2009*
571
1.91
685
2.26
1206
4.07
562
1.95
Source: 2000-2009 Hospital Discharge Database, Kansas Hospital Association. Age-adjusted rates were age-adjusted to the U.S. 2000 standard
population using the direct method. See Technical Appendix for details on how rates were calculated. Records were excluded if age could not be
calculated. Diabetes was defined as ICD-9 codes 250.0-250.9 as any secondary diagnosis. Lower extremity amputation was defined as ICD-9 procedure
code 84.1 as any listed procedure. Lower extremity peripheral arterial disease was defined as ICD-9 codes 250.7, 440.2, 442.3, 443.8-443.9 or 444.22 as
primary diagnosis. Lower extremity ulcer, inflammation or infection was defined as ICD-9 codes 454, 707.1, 680.6-680.7, 681.1, 682.6-682.7, 711.05711.07, 730.05-730.07, 730.15-730.17, 730.25-730.27, 730.35-730.37, 730.85-730.87, 730.95-930.97 or 785.4 as primary diagnosis. Lower extremity
neuropathy was defined as ICD-9 codes 337.1, 357.2, 355, 358.1, 713.5, 094.0 or 280.6 as primary diagnosis. Lower extremity diagnosis codes were
chosen according to the CDC diabetes program data and trends website (accessed 15 March, 2011).6
* At the time of report development, hospital discharge records for the October 2009 through December 2009 were considered provisional.
28
Diabetic Retinopathy
Diabetic retinopathy is a leading cause of blindness and visual impairment in the United States.7 It is
characterized by leakage or blockage of the small blood vessels in the retina leading to visual impairment. In
Kansas, about 17.6% (95% confidence interval: 15.3% to 19.8%) of adults 18 years and older with diabetes have
retinopathy (Table 3-9). The percentage of Kansas adults with diabetes who have retinopathy did not vary
significantly among gender and age groups, but was higher among those living with a disability (22.1%; 95%
confidence interval: 18.4% to 25.7%) as compared to those not living with a disability (14.0%; 95% confidence
interval: 11.2% to 16.8%). The prevalence of diabetic retinopathy in Kansas did not change significantly during
the period from 2000 through 2010 (data not shown). Blindness can be prevented in persons with diabetic
retinopathy if the condition is identified and treated in its early stages.5 Therefore, efforts in Kansas to promote
regular dilated eye examinations in persons with diabetes are important for reducing the burden of blindness
and visual impairment in this sub-population.
Table 3-9. Percentage of adults 18 years and older with diabetes reporting retinopathy by gender, age
and disability status, Kansas 2009-2010.
Selected Factor
Retinopathy (%)
95% Confidence Interval
17.6%
15.3% to 19.8%
Women
17.5%
14.6% to 20.3%
Men
17.6%
14.1% to 21.2%
18 to 44 Years
21.1%
12.6% to 29.5%
45 to 64 Years
15.6%
12.6% to 18.5%
65 Years and Older
18.2%
15.4% to 21.0%
Living with a Disability
22.1%
18.4% to 25.7%
Not Living with a Disability
14.0%
11.2% to 16.8%
Total
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
Chronic Kidney Disease and End-Stage Renal Disease (ESRD)
Diabetes is a leading cause of chronic kidney disease—a progressive condition that occurs when the
kidneys cannot filter blood optimally causing waste products to build up in the body which can lead to other
serious health problems. More than 35% of adults 20 years and older with diabetes in the United States have
chronic kidney disease.8 If chronic kidney disease progresses to the point of kidney failure, called end-stage
renal disease (ESRD), the only treatment options are kidney dialysis or kidney transplant. Table 3-10 provides
the number of newly diagnosed ESRD patients and those living with ESRD treated by dialysis in Kansas for the
period 2000 through 2010. In 2010, nearly half of persons living with ESRD had diabetes listed as the primary
diagnosis (46.4% of new ESRD patients and 43.8% of those living with ESRD on dialysis). 29
Table 3-10. Newly diagnosed ESRD patients and living ESRD patients receiving kidney dialysis,
Kansas 2000-2009.
Newly Diagnosed ESRD Patients
Year
Diabetes as
a Primary
Diagnosis
Total
Living ESRD dialysis patients
Percent with Diabetes as
a Primary Diagnosis (%)
Diabetes as
a Primary
Diagnosis
Total
Percent with Diabetes as
a Primary Diagnosis (%)
2000
328
680
48.2%
848
1984
42.7%
2001
312
680
45.9%
876
2036
43.0%
2002
316
694
45.5%
906
2085
43.5%
2003
293
669
43.8%
927
2120
43.7%
2004
318
695
45.8%
924
2108
43.8%
2005
322
778
41.4%
956
2275
42.0%
2006
348
792
43.9%
1001
2325
43.1%
2007
304
763
39.8%
1011
2384
42.4%
2008
337
762
44.2%
1041
2405
43.3%
2009
376
816
46.1%
1116
2554
43.7%
2010
382
824
46.4%
1130
2579
43.8%
Source: Heartland Kidney Network 2000 through 2010 Annual Reports. Available on the following website:
http://www.heartlandkidney.org/information/annual_rpts.html. Accessed 10 August, 2011.
Cost
While it is difficult to estimate the economic
impact of diabetes in Kansas directly, a
national study estimated that diabetes cost
the United States $174 billion in 2007.9 Based
on those national estimates, the cost of
diabetes in Kansas was estimated to be $1.5
billion for 2007, including $1 billion in excess
medical expenditures and $500 million in
reduced productivity.
Figure 3-3. Excess medical expenditures and
reduced productivity due to diabetes, Kansas 2007.
Reduced
Productivity
$500 Million
Excess
Medical
Expenditures
$1 Billion
Source: Kansas cost estimates are extrapolated based on 2007 National
estimates of diabetes costs of $174 billion based on the 2007 Kansas
diabetes prevalence, 7.3% of adults 18 years and older. 30
Chapter 4
Undiagnosed Diabetes,
Pre-Diabetes and
Gestational Diabetes
Pre-diabetes and gestational diabetes are conditions associated with impaired glucose that are
associated with high risk of developing diabetes. However, evidence from large clinical trials shows that
diabetes can still be prevented among persons with pre-diabetes and gestational diabetes through lifestyle
modification and through early medical intervention.10 This chapter provides information about diabetes
testing and diagnosis, pre-diabetes and gestational diabetes in Kansas.
Undiagnosed diabetes and diabetes testing among persons without diabetes
Nationally, about 1 in 4 persons with diabetes have never been diagnosed with diabetes (18.8 million
diagnosed, 7.0 million undiagnosed).1 The percentage of persons with undiagnosed diabetes in Kansas is likely
to be similar to the national estimate, although statewide data are not available. Early detection and diagnosis
of diabetes is important for preventing complications from the disease. Table 4-1 provides estimates for the
percentage of persons without diabetes who report receiving a test for diabetes in the past 3 years. About
half (54.0%; 95% confidence interval: 52.8% to 55.2%) of adults 18 years and older without diabetes report a
diabetes test in the past 3 years. The percentage of adults 18 years and older without diabetes that received a
test in the past 3 years increased with age from 23.6% (95% confidence interval 18.9% to 28.4%) among those
ages 18 to 24 years to 68.1% (95% confidence interval: 66.4% to 69.8%) among those ages 65 years and older. To assess the prevalence of diabetes testing among persons without diabetes in racial and ethnic
population subgroups, prevalence estimates were age-adjusted to account for differences in the underlying
age distribution among different racial and ethnic population subgroups. The age-adjusted prevalence of
diabetes testing was higher in non-Hispanic African Americans without diabetes (62.9%; 95% confidence
interval: 56.8% to 69.0%) as compared to non-Hispanic whites without diabetes (52.0%; 95% confidence
interval: 50.8% to 53.3%). The percentage of adults 18 years and older without diabetes that received a diabetes test in the past
3 years was lower among those with an annual household income below $15,000 (40.1%; 95% confidence
interval: 35.1% to 45.0%) as compared to all other household income levels. The prevalence of having a
diabetes test was also lower among those with less education. Among those with less than high school
education, 41.8% (95% confidence interval: 36.8% to 46.7%) have been tested for diabetes in the past 3
years, lower than all other education levels. The percentage of adults 18 years and older without diabetes
that received a diabetes test in the past 3 years was higher among those living with a disability (64.2%; 95%
confidence interval: 61.8% to 66.5%) as compared to those living without a disability (51.8%; 95% confidence
interval: 50.4% to 53.1%).
31
Table 4-1. Percentage of adults 18 years and older without diabetes who received a test for diabetes in
the past 3 years by selected demographic and social factors, Kansas 2009-2010.
Percent of Adults 18 Years and
Older Tested in the Past 3 Years
95% Confidence
Interval
54.0%
52.8% to 55.2%
Women
55.8%
54.3% to 57.2%
Men
52.2%
50.3% to 54.1%
23.6%
18.9% to 28.4%
Selected Demographic or Social Factor
Total
Gender
Age
18 to 24 Years
25 to 34 Years
45.7%
42.4% to 48.9%
34 to 44 Years
52.5%
49.8% to 55.1%
45 to 64 Years
61.6%
60.1% to 63.1%
65 Years and Older
68.1%
66.4% to 69.8%
White, non-Hispanic
52.0%
50.8% to 53.3%
African American, non-Hispanic
62.9%
56.8% to 69.0%
Other/Multiracial, non-Hispanic
57.4%
51.6% to 63.2%
Hispanic
54.2%
49.2% to 59.1%
Below $15,000
40.1%
35.1% to 45.0%
$15,000 to $24,999
51.2%
47.7% to 54.6%
$25,000 to $34,999
55.9%
52.3% to 59.6%
$35,000 to $49,999
56.1%
53.2% to 59.0%
$50,000 or higher
56.9%
55.1% to 58.6%
Race, Ethnicity*
Annual Household Income
Education
Did not graduate high school
41.8%
36.8% to 46.7%
High school graduate
49.6%
47.4% to 51.9%
Some technical education or college
54.6%
52.4% to 56.9%
College or technical education graduate
58.7%
56.8% to 60.5%
Living with a Disability
64.2%
61.8% to 66.5%
Not living with a disability
51.8%
50.4% to 53.1%
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Adults
with diagnosed diabetes and women told only during pregnancy that they had diabetes or borderline diabetes were excluded.
* Age-adjusted rates are provided for race and ethnicity subgroups. Prevalence estimates were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how prevalence estimates were calculated.
32
Pre-diabetes
Pre-diabetes is a category of increased risk for diabetes and is detected through laboratory tests for
impaired fasting glucose (fasting plasma glucose levels 100-125 mg/dL), impaired glucose tolerance (plasma
glucose levels of 140-199 mg/dL resulting from a 2-hour glucose tolerance test) or hemoglobin A1c (5.76.4%).11 Recent data from the Kansas Behavioral Risk Factor Surveillance System show that about 5.6%
of adults ages 18 years and older who do not have diabetes have been diagnosed with pre-diabetes by a
health professional (Table 4-2). The percentage of adults with pre-diabetes is higher among adults ages 45
to 64 years (7.2%; 95% confidence interval: 6.5% to 8.0%) and ages 65 years and older (7.6%; 95% confidence
interval: 6.7% to 8.6%) as compared to those ages 34 to 44 years (4.8%; 95% confidence interval: 3.7% to
6.0%) and 18 to 34 years (3.2%; 95% confidence interval: 2.1% to 4.3%). The prevalence of pre-diabetes was
higher among adults living with a disability (11.4%; 95% confidence interval: 9.8% to 12.9%) as compared to
those not living with a disability (4.3%; 95% confidence interval: 3.8% to 4.7%). Unlike the trend with diabetes
prevalence, the age-adjusted prevalence of pre-diabetes did not vary significantly among racial and ethnic
subgroups. The percentage of adults 18 years and older with pre-diabetes did not vary significantly among
gender or education groups.
33
Table 4-2. Percentage of adults 18 years and older diagnosed with pre-diabetes by selected
demographic and social factors, Kansas 2009-2010.
Percent of Adults 18 Years and
Older Diagnosed with Pre-Diabetes
95% Confidence
Interval
5.6%
5.1% to 6.1%
Women
6.3%
5.6% to 7.0%
Men
4.9%
4.2% to 5.6%
18 to 34 Years
3.2%
2.1% to 4.3%
34 to 44 Years
4.8%
3.7% to 6.0%
45 to 64 Years
7.2%
6.5% to 8.0%
65 Years and Older
7.6%
6.7% to 8.6%
White, non-Hispanic
5.4%
4.9% to 5.9%
African American, non-Hispanic
5.8%
3.5% to 8.1%
Other/Multiracial, non-Hispanic
8.7%
5.3% to 12.0%
Hispanic
5.3%
3.1% to 7.5%
Below $15,000
7.2%
4.6% to 9.7%
$15,000 to $24,999
8.1%
6.4% to 9.8%
$25,000 to $34,999
7.1%
5.4% to 8.8%
$35,000 to $49,999
5.2%
3.9% to 6.5%
$50,000 or higher
4.8%
4.1% to 5.5%
Did not graduate high school
5.6%
3.6% to 7.5%
High school graduate
5.6%
4.7% to 6.5%
Some technical education or college
6.3%
5.2% to 7.3%
College or technical education graduate
5.1%
4.3% to 5.9%
Living with a Disability
11.4%
9.8% to 12.9%
Not living with a disability
4.3%
3.8% to 4.7%
Selected Demographic or Social Factor
Total
Gender
Age
Race, Ethnicity*
Annual Household Income
Education
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Women
told only during pregnancy that they had pre-diabetes or borderline diabetes were excluded.
* Age-adjusted rates are provided for race and ethnicity subgroups using the following age groups: 18-44 years, 45 to 64 years and 65 years and older. Prevalence estimates were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how prevalence estimates were
calculated. Error bars indicate 95% confidence intervals.
34
Gestational Diabetes
Gestational diabetes or glucose intolerance associated with pregnancy can lead to complications
during labor and delivery and is also associated with certain adverse fetal outcomes such as hypoglycemia
and jaundice. Gestational diabetes also significantly increases the lifetime risk of developing diabetes after
the pregnancy.11 Recent guidelines for diagnosing gestational diabetes recommend that all women not
known to have diabetes undergo an oral glucose tolerance test at 24-28 weeks of gestation. Women who
screen positive for diabetes at their first prenatal visit should receive a diagnosis of overt diabetes rather than
gestational diabetes.
In Kansas, the percentage of births with gestational diabetes ranged from 3.5% in 2005 to 4.1% in
2009 (Table 4-3). However, trends should be interpreted with caution because of changing standards for
diagnosing gestational diabetes. Before 2004, the Kansas birth certificate did not allow for differentiating
gestational diabetes and pre-existing diabetes.
Table 4-3. Number and percentage of live births in Kansas with Gestational Diabetes.
Year
Total births
Births with Gestational Diabetes
Percentage of Births with
Gestational Diabetes (%)
2005
39,701
1,378
3.5%
2006
40,896
1,399
3.4%
2007
41,951
1,630
3.9%
2008
41,815
1,569
3.8%
2009
41,388
1,679
4.1%
Sources: Percentages for all births in Kansas were from 2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE.
35
In Kansas, the percentage of pregnancies with gestational diabetes increases with maternal age,
increasing from 1.5% among mothers ages 15 to 17 years to 9.6% of mothers 40 years and older (Table 6). The percentage of gestational diabetes pregnancies was particularly high among births to mothers of Asian
or Pacific Islander race, a health disparity that has been observed elsewhere.12 Table 4-4 also provides the
percentage of pregnancies with gestational diabetes among women receiving services from the Kansas
Women, Infants and Children Program (WIC). Kansas WIC is a nutrition program that provides nutrition and
health education, healthy food and other services to Kansas families that qualify—those with an annual
household income that is equal to or lower than 185% of the federal poverty guidelines.13 On average, the
percentage of pregnancies with gestational diabetes is slightly higher for those receiving WIC services as
compared to all Kansas births, regardless of age, race or ethnicity.
Table 4-4. Percentage of pregnancies with reported gestational diabetes among pregnancies covered
by the Kansas Women, Infants and Children (WIC) Program and among all births by age, race and
ethnicity, Kansas 2009.
Selected demographic factor
Percentage of pregnancies with
reported gestational diabetes (%)
2009 Kansas WIC
2009 Kansas (all births)
6.4%
4.1%
n/a
n/a
15-17 Years
2.2%
1.5%
18-19 Years
2.5%
1.7%
20-29 Years
5.3%
3.2%
30-39 Years
14.6%
6.2%
40 Years and Older
16.3%
9.6%
White, non-Hispanic
5.6%
3.7%
African American, non-Hispanic
4.6%
3.0%
Hispanic
8.2%
4.9%
American Indian/Alaska Native
9.0%
4.8%
Asian/Pacific Islander
8.9%
7.7%
Multiple Races
6.2%
6.0%
n/a
5.4%
Total
Age
14 Years and Younger
Race, Ethnicity*
All Other/Unknown
Sources: Percentages for all births in Kansas were from 2009 Kansas Vital Statistics, Center for Health and Environmental Statistics, KDHE.
Percentages for 2009 Kansas WIC births were from 2009 Pregnancy Nutrition Surveillance Reports available online: http://www.kdheks.gov/nws-wic/
download/2009_PNSS_tables_Kansas.pdf (accessed 28 March, 2011).
*Please note that some Hispanic births may be counted among the following categories: American Indian/Alaska Native, Asian/Pacific Islander,
Multiple races and All Other/Unknown. For the purposes of this report, any overlap with Hispanic births is considered negligible.
n/a indicates that the percentage cannot be provided because of an insufficient number of births in the category.
36
Chapter 5
Diabetes Risk Factors
A number of factors significantly increase a person’s risk for developing diabetes or increase risk for
complications among persons who have diabetes. Some of these risk factors cannot be modified. Nonmodifiable risk factors for Type-2 diabetes include increasing age, race and ethnicity, family history of diabetes
and prior history of gestational diabetes. Modifiable risk factors for Type-2 diabetes include certain health
conditions such as overweight and obesity, high blood pressure and high blood cholesterol that can be
controlled or even prevented and unhealthy behaviors such as physical inactivity.14 Risk factors for Type-1
diabetes are less well defined. Preventing complications related to either Type-1 or Type-2 diabetes involves
preventive care practices (see Preventive Care Practices chapter) and control of modifiable risk factors such as
obesity, high blood pressure, high blood cholesterol, physical inactivity, tobacco use and unhealthy diet. This
chapter focuses on the burden of common preventable risk factors for diabetes and its complications.
• Trends in Obesity, High Blood Pressure, High Blood Cholesterol and Diabetes
• Risk Factor Control among Kansans with Diabetes (obesity, high blood pressure, physical inactivity, current
smoking and fruit and vegetable consumption).
• Obesity
• High blood pressure
• High Blood Cholesterol among Those Tested for Blood Cholesterol
• Physical Inactivity
• High-Risk for Diabetes (Diabetes Risk Test Score)
37
Trends in Obesity, High Blood Pressure, High Blood Cholesterol and Diabetes
During the past decade, the increase in diabetes prevalence has increased in parallel with increases in
obesity, high blood pressure and high blood cholesterol (Figure 5-1). During the period from 2001 through
2010, the prevalence of obesity (defined as a body mass index of 30 kg/m2 or higher) among Kansans 18 years
and older increased from 21.6% (95% confidence interval: 20.2% to 23.0%) in 2001 to 30.1% (95% confidence
interval 28.8% to 31.5%) in 2009. High blood pressure increased from 23.9% (95% confidence interval: 22.5%
to 25.3%) in 2001 to 28.7% (27.9% to 29.5%) in 2009. The prevalence of high cholesterol among those tested
for blood cholesterol increased from 29.2% (95% confidence interval: 27.6% to 30.9%) in 2001 to 38.6% (95%
confidence interval: 37.6% to 39.5%) in 2009. Each of these conditions is a major risk factor for cardiovascular
disease. The parallel increases in the prevalence of these four risk factors may signal a future increase in
diabetes complications, particularly heart disease and stroke.
Figure 5-1. Percentage of adults 18 years and older who are overweight, have high blood pressure,
high blood cholesterol (among those tested) or diabetes, Kansas 2001-2010.
Obese
High Blood Pressure
High Blood Cholesterol*
Diabetes
45%
40%
Prevalence (%)
35%
30%
25%
20%
15%
10%
5%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Obese
21.6%
22.9%
23.0%
23.3%
24.0%
26.1%
27.8%
28.2%
28.9%
30.1%
High Blood Pressure
23.9%
23.3%
25.3%
24.2%
26.8%
30.3%
28.7%
High Blood Cholesterol* 29.2%
29.4%
33.1%
33.4%
36.6%
38.1%
38.6%
6.0%
6.5%
6.9%
7.3%
8.1%
8.5%
Diabetes
5.8%
6.4%
7.3%
8.4%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Obese is defined as Body Mass Index 30 or higher. Questions related to high blood pressure and high blood cholesterol were not included in the
survey for 2002 and 2006. Questions regarding high blood pressure and high blood cholesterol were asked on one branch of the BRFSS survey to
approximately half of all respondents in 2004 and 2008.
* Prevalence of high blood cholesterol among those tested for blood cholesterol. Respondents who have not been tested for blood cholesterol were
excluded.
38
Risk Factor Control among Kansans with Diabetes
Persons diagnosed with diabetes have elevated risk for heart disease, stroke, kidney disease, blindness,
nerve damage and other complications. In addition to certain preventive care practices (see chapter on
preventive care practices), persons with diabetes should try to control modifiable risk factors for diabetes
complications including obesity, high blood pressure, high blood cholesterol, physical inactivity, smoking
and eating an unhealthy diet. Figure 5-1 provides the prevalence of these modifiable risk factors by diabetes
status. The prevalence of obesity, high blood pressure, high blood cholesterol and physical inactivity (either
no leisure time physical activity or participating in less than 150 minutes per week or no moderate and/or
vigorous physical activity) are all dramatically higher among persons with diabetes than among persons
without diabetes. It is important to note that each of these factors increases risk both for complications
from diabetes as well as risk for developing diabetes. Thus, it highlights the need to address these common
modifiable risk factors both in the community as well as in a clinical context for persons with diabetes.
While tobacco use is not always listed as a risk factor for developing diabetes, it increases the risk
for complications from diabetes. Quitting smoking is an important element in controlling diabetes and
preventing complications among persons with diabetes who smoke.11 The percentage of adults 18 years and
older who are current tobacco users among persons with diabetes (16.9%; 95% confidence interval: 13.3% to
20.4%) is similar to the prevalence among persons without diabetes (17.0%; 95% confidence interval: 15.8%
to 18.3%). Similarly, a healthy diet including fruits and vegetables is important for controlling diabetes and
preventing complications.11 The percentage of adults 18 years and older who consume fruits and vegetables
5 or more times per day among persons with diabetes (78.4%; 95% confidence interval: 76.0% to 80.8%) is
only slightly lower than among persons without diabetes (81.7%; 95% confidence interval: 80.9% to 82.4%). Tobacco use cessation and efforts to increase fruit and vegetable consumption as part of a healthy diet among
persons with diabetes are high priorities for preventing complications and should be addressed through both
community efforts and through clinical management of persons with diabetes.
Table 5-1. Percentage of Kansans 18 years and older with selected modifiable risk factors by diabetes
status, Kansas 2010.
Among Persons with Diabetes
Among Persons without Diabetes
Prevalence of Risk
Factor (%)
95% Confidence
Interval
Prevalence of Risk
Factor (%)
95% Confidence
Interval
Obesity
57.8%
54.0% to 61.6%
27.6%
26.1% to 29.0%
High blood pressure
64.5%
61.6% to 67.4%
25.3%
24.5% to 26.1%
High blood cholesterol
(among those tested)
60.8%
58.2% to 63.3%
36.0%
35.0% to 36.9%
No leisure physical activity
35.6%
32.1% to 39.2%
22.9%
21.6% to 24.2%
Less than 150 minutes/week or
no moderate and/or vigorous
physical activity
52.9%
50.1% to 55.7%
34.3%
33.3% to 35.3%
Current smoking
16.9%
13.3% to 20.4%
17.0%
15.8% to 18.3%
Consumption of fruits and
vegetables fewer than 5 times
per day
78.4%
76.0% to 80.8%
81.7%
80.9% to 82.4%
Risk Factor
Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. Obese
is defined as Body Mass Index 30 or higher. Estimates for high blood pressure, high blood cholesterol, minutes per week of moderate and/or vigorous
physical activity and fruit and vegetable consumption are from the 2009 survey. Leisure time physical activity is defined as participation in any
physical activity or exercise, other than at a regular job, such as running, calisthenics, golf, gardening or walking for exercise. Prevalence of high blood
cholesterol among those tested for blood cholesterol. Respondents who have not been tested for blood cholesterol were excluded.
39
Obesity
Obesity is perhaps the most well-established modifiable risk factor for diabetes. Weight loss is
recommended for all overweight or obese individuals who have diabetes or are at risk for diabetes.11 In 2010,
nearly 1 in 3 (30.1% or about 640 thousand) Kansas adults 18 years and older were obese (defined as a body
mass index of 30 kg/m2 or higher). An additional 34.4% of Kansas adults 18 years and older were overweight
(defined as a body mass index between 25 and 29 kg/m2). Two in 3 (64.5% or about 1.4 million) Kansas adults
are either overweight or obese.
In Kansas, the percentage of men 18 years and older who were obese (32.0%; 95% confidence interval:
29.8% to 34.2%) was significantly higher than the percentage among women (28.2%; 95% confidence interval:
26.6% to 29.8%). The percentage of obese adults was highest among those aged 35 to 44 years (35.8%; 95%
confidence interval: 32.3% to 39.2%). To assess the prevalence of obesity by race and ethnicity, prevalence
estimates were age-adjusted to account for differences in the underlying age distribution among different
racial and ethnic population subgroups. The age-adjusted prevalence of obesity was higher among nonHispanic African Americans (39.2%; 95% confidence interval: 32.2% to 46.1%) as compared to non-Hispanic
whites (29.2%; 95% confidence interval: 27.7% to 30.8%). The prevalence of obesity was significantly lower among adult Kansans with an annual household
income of $50,000 or more (24.9%; 95% confidence interval: 24.9% to 28.7%) as compared to all other income
categories. Similarly, the prevalence of obesity was lower among Kansans with higher levels of education.
Among Kansas adults 18 years and older with a college or technical degree the prevalence of obesity was
26.2% (95% confidence interval: 24.2% to 28.1%) as compared to 31.6% (95% confidence interval: 28.9% to
34.4%) among high school graduates. The percentage of obese adults 18 years and older was higher among
persons living with a disability (41.8%; 95% confidence interval: 39.1% to 44.5%) as compared to those living
without a disability (26.7%; 95% confidence interval: 25.2% to 28.3%).
40
Diabetes Prevalence by Obesity Status
The prevalence of diabetes is significantly higher among Kansas adults 18 years and older who are
obese (16.1%; 95% confidence interval: 15.2% to 17.0%) as compared to those who are not obese (5.4%; 95%
confidence interval: 5.0% to 5.7%). Disparities in diabetes prevalence are evident in both obese and nonobese Kansas adults 18 years and older (Table 5-3). Examining the intersection between obesity and other
factors can reveal particularly acute disparities in diabetes prevalence. For example, among obese Kansas
adults living with a disability, the prevalence of diabetes is 27.5% (95% confidence interval: 25.5% to 29.5%)
as compared to 4.1% (95% confidence interval: 3.7% to 4.5%) among non-obese Kansas adults not living with
a disability. This comparison underscores the importance of targeted efforts to reduce diabetes burden by
addressing multiple risk factors in high-risk population subgroups.
Table 5-2. Percentage of adults 18 years and older who are obese (BMI 30 or higher) by selected
demographic and social factors, Kansas 2009-2010.
Percent of Adults 18 Years and
Older who are Obese
95% Confidence Interval
30.1%
28.8% to 31.5%
Women
28.2%
26.6% to 29.8%
Men
32.0%
29.8% to 34.2%
18 to 24
14.2%
8.8% to 19.5%
25 to 34
31.0%
26.9% to 35.0%
34 to 44
35.8%
32.3% to 39.2%
45 to 64
34.2%
32.4% to 36.0%
65 and older
25.7%
24.0% to 27.5%
White, Non-Hispanic
29.2%
27.7% to 30.8%
African American, Non-Hispanic
39.2%
32.2% to 46.1%
Other/Multi-Race, Non-Hispanic
28.4%
22.5% to 34.4%
Hispanic
34.9%
28.6% to 41.1%
Below $15,000
36.0%
30.0% to 42.1%
$15,000 to $24,999
35.9%
31.6% to 40.2%
$25,000 to $34,999
34.6%
30.3% to 39.0%
$35,000 to $49,999
35.3%
31.5% to 39.1%
$50,000 or Higher
26.8%
24.9% to 28.7%
Did Not Graduate High School
34.1%
28.0% to 40.2%
High School Graduate
31.6%
28.9% to 34.4%
Some Technical Education or College
33.3%
30.6% to 36.0%
College or Technical Education Graduate
26.2%
24.2% to 28.1%
Living with a Disability
41.8%
39.1% to 44.5%
Not living with a Disability
26.7%
25.2% to 28.3%
Characteristic
Total
Gender
Age
Race and Ethnicity (age-adjusted)
Annual Household Income
Education
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated. Obesity is defined as Body Mass Index 30 or higher.
41
Table 5-3. Percentage of adults 18 years and older with diabetes by obesity status and selected
demographic and social factors, Kansas 2009-2010.
Obese (BMI 30 or Higher)
Selected Demographic
or Social Factor
Not Obese (BMI 29 or Lower)
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
16.1%
15.2% to 17.0%
5.4%
5.0% to 5.7%
Women
17.3%
16.1% to 18.6%
4.7%
4.3% to 5.1%
Men
15.0%
13.6% to 16.3%
6.1%
5.4% to 6.7%
Total
Gender
Age
18 to 44 Years
6.3%
5.0% to 7.6%
1.6%
1.1% to 2.1%
45 to 64 Years
20.9%
19.5% to 22.3%
5.9%
5.3% to 6.5%
65 Years and Older
32.5%
30.4% to 34.7%
14.4%
13.4% to 15.3%
White, non-Hispanic
14.4%
13.5% to 15.4%
4.6%
4.3% to 5.0%
African American, non-Hispanic
22.4%
17.6% to 27.1%
8.7%
6.8% to 10.6%
Other/Multiracial, non-Hispanic
20.8%
16.2% to 25.4%
7.2%
5.3% to 9.1%
Hispanic
17.6%
13.7% to 21.5%
10.6%
7.9% to 13.2%
Below $15,000
23.3%
19.4% to 27.2%
10.1%
6.9% to 13.3%
$15,000 to $24,999
20.7%
18.0% to 23.4%
10.4%
8.9% to 11.8%
$25,000 to $34,999
18.3%
15.7% to 20.9%
7.1%
5.9% to 8.3%
$35,000 to $49,999
14.1%
12.0% to 16.1%
5.6%
4.7% to 6.4%
$50,000 or higher
12.8%
11.6% to 14.1%
3.4%
3.0% to 3.8%
20.0%
16.1% to 24.0%
10.4%
8.0% to 12.8%
High School Graduate
16.9%
15.2% to 18.6%
6.4%
5.6% to 7.2%
Some Technical or College
16.3%
14.7% to 17.9%
5.4%
4.7% to 6.1%
College or Technical Graduate
14.2%
12.7% to 15.8%
3.8%
3.3% to 4.3%
Living with a Disability
27.5%
25.5% to 29.5%
11.2%
10.1% to 12.3%
Not Living with a Disability
11.3%
10.3% to 12.2%
4.1%
3.7% to 4.5%
Race, Ethnicity*
Annual Household Income
Education
Did Not Graduate High School
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
* Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
42
High Blood Pressure
Blood pressure is the force exerted on artery walls as blood is pumped by the heart through the
circulatory system. High blood pressure, also called hypertension, is a chronic health condition that requires
the heart to work harder causing the heart muscle to weaken over time. High blood pressure is both a
common complication of diabetes and a risk factor for developing diabetes.11 About 600,000 Kansas adults
18 years and older (28.7%; 95% confidence interval: 27.9% to 29.5%) have been diagnosed with high blood
pressure (Table 5-4).
The percentage of adults 18 years and older diagnosed with high blood pressure increases with age from
6.6% (95% confidence interval: 4.1% to 9.0%) among those aged 18 to 24 years to 59.1% (95% confidence
interval: 57.7% to 60.4%) among those ages 65 years and older. To assess the prevalence of high blood
pressure by race and ethnicity, prevalence estimates were age-adjusted to account for differences in the
underlying age distribution among different racial and ethnic population subgroups. In 2009, the ageadjusted percentage of high blood pressure among non-Hispanic African American adults 18 years and older
(42.7%; 95% confidence interval: 38.9% to 46.4%) was significantly higher than for non-Hispanic whites (27.1%;
95% confidence interval: 26.3% to 27.8%), non-Hispanic adults of other race or multiple race (28.8%; 95%
confidence interval: 25.3% to 32.4%) and Hispanics (27.0%; 95% confidence interval: 23.6% to 30.5%).
In 2009, the percentage of adults 18 years and older with high blood pressure was higher among those
with lower average annual household income. The prevalence of high blood pressure was significantly lower
among those with an annual household income of $50,000 or more (23.6%; 95% confidence interval: 22.4%
to 24.7%) as compared to all other income groups. The prevalence of high blood pressure was also higher
among Kansans 18 years and older with lower educational levels. The prevalence of high blood pressure was
significantly lower among college graduates (24.4%; 95% confidence interval: 23.2% to 25.6%) as compared to
all other levels of education. The percentage of adults 18 years and older with high blood pressure is higher
among those living with a disability (48.0%; 95% confidence interval: 46.1% to 49.9%) as compared to those
living without a disability (23.8%; 95% confidence interval: 22.9% to 24.6%).
Diabetes Prevalence by High Blood Pressure Status
The prevalence of diabetes is significantly higher among Kansas adults 18 years and older who have
high blood pressure (19.2%; 95% confidence interval: 18.2% to 20.2%) as compared to those who do not
have high blood pressure (4.2%; 95% confidence interval: 3.8% to 4.7%). Disparities in diabetes prevalence
are evident in Kansans adults 18 years and older regardless of high blood pressure status (Table 5-5). As with
obesity, the intersection between high blood pressure and other factors reveals large disparities in diabetes
prevalence. For example, the prevalence of diabetes among Kansas adults with high blood pressure who did
not graduate from high school is 27.3% (95% confidence interval: 22.9% to 31.8%) as compared to 3.3% (95%
confidence interval: 2.6% to 3.9%) among those without high blood pressure who graduated from college or
technical school. This comparison underscores the importance of targeted efforts to reduce diabetes burden
by addressing multiple risk factors in high-risk population subgroups.
43
Table 5-4. Percentage of adults 18 years and older diagnosed with high blood pressure by selected
demographic and social factors, Kansas 2009.
Percent of Adults 18 Years and
Older with High Blood Pressure
95% Confidence
Interval
28.7%
27.9% to 29.5%
Women
28.4%
27.4% to 29.3%
Men
29.0%
27.7% to 30.3%
18 to 24
6.6%
4.1% to 9.0%
25 to 34
11.3%
9.5% to 13.2%
34 to 44
17.7%
16.0% to 19.4%
45 to 64
36.3%
35.1% to 37.4%
65 and older
59.1%
57.7% to 60.4%
White, Non-Hispanic
27.1%
26.3% to 27.8%
African American, Non-Hispanic
42.7%
38.9% to 46.4%
Other/Multi-Race, Non-Hispanic
28.8%
25.3% to 32.4%
Hispanic
27.0%
23.6% to 30.5%
Below $15,000
34.7%
30.9% to 38.5%
$15,000 to $24,999
37.1%
34.8% to 39.5%
$25,000 to $34,999
36.3%
33.6% to 38.9%
$35,000 to $49,999
30.9%
28.9% to 33.0%
$50,000 or Higher
23.6%
22.4% to 24.7%
32.8%
29.2% to 36.4%
High School Graduate
31.9%
30.3% to 33.6%
Some Technical Education or College
29.6%
28.1% to 31.1%
College or Technical Education Graduate
24.4%
23.2% to 25.6%
Living with a Disability
48.0%
46.1% to 49.9%
Not Living with a Disability
23.8%
22.9% to 24.6%
Characteristic
Total
Gender
Age
Race and Ethnicity (age-adjusted)
Annual Household Income
Education
Did Not Graduate High School
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
44
Table 5-5. Percentage of adults 18 years and older with diabetes by high blood pressure status and
selected demographic and social factors, Kansas 2009.
High Blood Pressure
Not Diagnosed with
High Blood Pressure
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
19.2%
18.2% to 20.2%
4.2%
3.8% to 4.7%
Women
20.1%
18.8% to 21.4%
3.6%
3.1% to 4.1%
Men
18.3%
16.7% to 19.8%
4.9%
4.1% to 5.8%
18 to 44 Years
7.7%
5.5% to 9.9%
2.3%
1.6% to 3.0%
45 to 64 Years
20.3%
18.7% to 21.8%
5.5%
4.7% to 6.2%
65 Years and Older
24.5%
23.0% to 26.1%
12.2%
10.7% to 13.6%
White, non-Hispanic
13.0%
11.8% to 14.3%
4.6%
4.1% to 5.1%
African American, non-Hispanic
20.0%
15.5% to 24.6%
7.3%
3.7% to 10.9%
Other/Multiracial, non-Hispanic
19.0%
12.7% to 25.4%
7.8%
5.1% to 10.4%
Hispanic
24.1%
16.0% to 32.2%
9.9%
6.7% to 13.1%
Below $15,000
25.3%
21.4% to 29.1%
8.7%
4.3% to 13.1%
$15,000 to $24,999
25.3%
22.5% to 28.1%
6.8%
5.3% to 8.3%
$25,000 to $34,999
20.7%
17.9% to 23.4%
5.7%
4.1% to 7.3%
$35,000 to $49,999
18.1%
15.6% to 20.5%
3.3%
2.5% to 4.2%
$50,000 or higher
16.1%
14.3% to 17.8%
3.1%
2.6% to 3.6%
Selected Demographic or Social Factor
Total
Gender
Age
Race, Ethnicity*
Annual Household Income
Education
Did Not Graduate High School
27.3%
22.9% to 31.8%
6.7%
3.9% to 9.5%
High School Graduate
20.3%
18.4% to 22.2%
4.8%
3.8% to 5.8%
Some Technical or College
19.0%
17.2% to 20.8%
4.4%
3.5% to 5.3%
College or Technical Graduate
16.1%
14.4% to 17.9%
3.3%
2.6% to 3.9%
Living with a Disability
27.0%
25.1% to 29.0%
10.2%
8.7% to 11.8%
Not Living with a Disability
15.1%
14.0% to 16.3%
3.2%
2.7% to 3.7%
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
* Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
45
High Blood Cholesterol among Those Tested for Blood Cholesterol
Cholesterol is a waxy substance present throughout the body. In the blood, cholesterol is transported
predominantly in two forms: low density lipoproteins (LDL), also known as “bad cholesterol”, and high density
lipoproteins (HDL), also known as “good cholesterol”. Abnormal cholesterol is a risk factor for developing
diabetes (particularly HDL cholesterol below 35 mg/dL or triglycerides greater than 250 mg/dL) and can also
cause or exacerbate complications from diabetes.11 In Kansas, about one-third of adults 18 years and older
who were tested for cholesterol had high blood cholesterol. It is important to note that about 21.5% of the
adult population report never having been tested for cholesterol (data not shown).
The percentage of adults 18 years and older diagnosed with high blood cholesterol among those
tested for blood cholesterol increases with age from 10.5% (95% confidence interval: 5.5% to 15.6%) among
those aged 18 to 24 years to 52.3% (95% confidence interval: 50.9% to 53.7%) among those ages 65 years
and older (Table 5-6). To assess the prevalence of high blood cholesterol by race and ethnicity, prevalence
estimates were age-adjusted to account for differences in the underlying age distribution among different
racial and ethnic population subgroups. In 2009, the age-adjusted percentage of high blood cholesterol
among those tested was lower among Hispanics (28.2%; 95% confidence interval: 24.2% to 32.3%) as
compared to non-Hispanic whites (35.0%; 95% confidence interval: 33.8% to 36.1%) and non-Hispanic adults
of other or multiple race (37.5%; 95% confidence interval: 32.6% to 42.4%).
In 2009, the percentage of adults 18 years and older with high blood cholesterol among those tested
was higher among those with lower average annual household income. The percentage of adults 18 years
and older tested and diagnosed with high blood cholesterol was significantly higher for those with an annual
household income below $35,000 (42.8% for incomes below $15,000, 95% confidence interval: 38.2% to
47.4%; 41.8% for incomes between $15,000 and $24,999, 95% confidence interval: 39.1% to 44.5%; 43.0%
for incomes between $25,000 and $34,999, 95% confidence interval: 40.0% to 46.0%) as compared to those
with an annual household income of $50,000 or more (36.7%; 95% confidence interval: 35.4% to 38.1%). The
percentage of adults 18 years and older tested and diagnosed with high blood cholesterol was lower for
those with higher levels of education. The percentage of adults 18 years and older tested and diagnosed
with high blood cholesterol was significantly higher among those without a high school diploma (43.0%;
95% confidence interval: 38.3% to 47.6%) and among high school graduates (42.4%; 95% confidence interval:
40.5% to 44.3%) as compared to college graduates (35.5%; 95% confidence interval: 34.1% to 36.9%). The
percentage of adults 18 years and older tested and diagnosed with high blood cholesterol was higher among
those living with a disability (50.8%; 95% confidence interval: 48.9% to 52.6%) as compared to those living
without a disability (36.0%; 95% confidence interval: 35.0% to 36.9%).
46
Diabetes Prevalence by High Blood Cholesterol Status (among those tested for blood cholesterol)
The prevalence of diabetes is significantly higher among Kansas adults 18 years and older who were
tested and diagnosed with high blood cholesterol (16.4%; 95% confidence interval: 15.5% to 17.4%) as
compared to those who were tested and do not have high blood cholesterol (6.7%; 95% confidence interval:
6.1% to 7.2%). Disparities in diabetes prevalence are evident in Kansans adults 18 years and older regardless of
high blood cholesterol status (Table 5-7). As with obesity and high blood pressure, the intersection between
high blood cholesterol and other factors reveals large disparities in diabetes prevalence. For example, the
prevalence of diabetes among Kansas adults tested and diagnosed with high blood cholesterol with an annual
household income below $15,000 is 28.3% (95% confidence interval: 23.6% to 33.0%) as compared to 4.4%
(95% confidence interval: 3.7% to 5.0%) among those without high blood cholesterol who have an annual
household income of $50,000 or more. This comparison underscores the importance of targeted efforts to
reduce diabetes burden by addressing multiple risk factors in high-risk population subgroups.
Table 5-6. Percentage of adults 18 years and older diagnosed with high blood cholesterol among those
tested for blood cholesterol by selected demographic and social factors, Kansas 2009.
Characteristic
Total
Gender
Women
Men
Age
18 to 24
25 to 34
34 to 44
45 to 64
65 and older
Race and Ethnicity (age-adjusted)
White, Non-Hispanic
African American, Non-Hispanic
Other/Multi-Race, Non-Hispanic
Hispanic
Annual Household Income
Below $15,000
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $49,999
$50,000 or Higher
Education
Did Not Graduate High School
High School Graduate
Some Technical Education or College
College or Technical Education Graduate
Disability Status
Living with a Disability
Living without a Disability
Percent of Adults 18 Years and Older
with High Blood Cholesterol
38.6%
95% Confidence Interval
37.6% to 39.5%
37.4%
39.8%
36.3% to 38.6%
38.3% to 41.3%
10.5%
21.6%
29.8%
44.8%
52.3%
5.5% to 15.6%
18.7% to 24.5%
27.6% to 32.0%
43.5% to 46.1%
50.9% to 53.7%
35.0%
32.0%
37.5%
28.2%
33.8% to 36.1%
27.3% to 36.8%
32.6% to 42.4%
24.2% to 32.3%
42.8%
41.8%
43.0%
38.6%
36.7%
38.2% to 47.4%
39.1% to 44.5%
40.0% to 46.0%
36.2% to 40.9%
35.4% to 38.1%
43.0%
42.4%
38.6%
35.5%
38.3% to 47.6%
40.5% to 44.3%
36.9% to 40.4%
34.1% to 36.9%
50.8%
35.1%
48.9% to 52.6%
34.1% to 36.2%
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
47
Table 5-7. Percentage of adults 18 years and older with diabetes by high cholesterol status and
selected demographic and social factors, Kansas 2009.
High Blood Cholesterol
(Among Those Tested)
Not Diagnosed with High
Cholesterol (Among Those Tested)
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
16.4%
15.5% to 17.4%
6.7%
6.1% to 7.2%
Women
17.2%
15.9% to 18.4%
5.6%
4.9% to 6.2%
Men
15.7%
14.2% to 17.2%
7.9%
6.9% to 8.9%
8.3%
6.2% to 10.5%
2.4%
1.6% to 3.3%
Selected Demographic or Social Factor
Total
Gender
Age
18 to 44 Years
45 to 64 Years
17.0%
15.6% to 18.4%
7.3%
6.4% to 8.1%
65 Years and Older
22.1%
20.4% to 23.8%
17.0%
15.5% to 18.6%
White, non-Hispanic
11.8%
10.6% to 12.9%
5.9%
5.3% to 6.4%
African American, non-Hispanic
22.2%
16.9% to 27.5%
12.7%
8.0% to 17.4%
Other/Multiracial, non-Hispanic
19.4%
12.8% to 26.0%
9.2%
6.2% to 12.2%
Hispanic
32.2%
22.0% to 42.6%
9.7%
6.5% to 12.8%
Race, Ethnicity*
Annual Household Income
Below $15,000
28.3%
23.6% to 33.0%
12.4%
7.3% to 17.6%
$15,000 to $24,999
27.2%
24.0% to 30.5%
13.4%
11.1% to 15.7%
$25,000 to $34,999
20.7%
17.6% to 23.8%
9.0%
7.0% to 11.1%
$35,000 to $49,999
15.4%
13.1% to 17.7%
6.8%
5.4% to 8.3%
$50,000 or higher
11.9%
10.5% to 13.3%
4.4%
3.7% to 5.0%
Did Not Graduate High School
31.2%
25.7% to 36.7%
12.3%
7.7% to 17.0%
High School Graduate
19.1%
17.1% to 21.0%
9.0%
7.7% to 10.2%
Some Technical or College
16.5%
14.8% to 18.2%
7.0%
5.9% to 8.1%
College or Technical Graduate
12.1%
10.6% to 13.6%
4.4%
3.7% to 5.1%
Living with a Disability
26.1%
24.0% to 28.1%
15.1%
13.3% to 16.8%
Not Living with a Disability
12.5%
11.5% to 13.6%
4.8%
4.3% to 5.4%
Education
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. *
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
48
Physical Inactivity
Physical activity is a key factor in successful diabetes prevention and management. There is a substantial
body of scientific evidence that regular exercise improves blood glucose control, reduces high blood
pressure and high cholesterol and plays a key role in weight loss.15 Physical activity guidelines for diabetes
management from the American Diabetes Association11 are consistent with the Physical Activity Guidelines for
Americans, published by the U.S. Department of Health and Human Services.16 Most adults, including those
with diabetes, should participate in at least 150 minutes per week of moderate aerobic physical activity or 75
minutes per week of vigorous aerobic physical activity (or an equivalent combination of both) in addition to
muscle-strengthening activities such as resistance training.11, 16
The Kansas Behavioral Risk Factor Surveillance System collects information on physical activity in two ways.
A. The prevalence of leisure time physical activity is based on participation in any physical activity or
exercise other than at a regular job such as running, calisthenics, golf, gardening, or walking for exercise
in the past 30 days.
B. The prevalence of participating in recommended moderate and/or vigorous physical activity is based
on participation in moderate physical activity (such as walking, gardening or vacuuming that involve
small increases in heart rate or breathing rate) or vigorous physical activity (such as running or aerobics
that involve large increases in heart rate or breathing rate).
A. Leisure time physical activity
In 2010, 1 in 5 adult Kansans 18 years and older did not participate in any leisure time physical activity.
During the period from 2001 to 2010, the percentage of Kansans 18 years and older reporting no leisure time
physical activity in the past 30 days declined modestly from 26.7% (95% confidence interval: 25.3% to 28.1%)
in 2001 to 24.0% (95% confidence interval: 22.8% to 25.2%) in 2010 (Figure 5-2). While this trend is positive,
efforts to further reduce the percentage of adults who do not participate in any leisure time physical activity
may help to counter the growing burden of diabetes, obesity, high blood pressure and high cholesterol.
The prevalence of no leisure time physical activity increased with age from 18.5% (95% confidence
interval: 13.0% to 24.0%) among persons ages 18 to 24 years to 31.0% (95% confidence interval: 29.2% to
32.9%) among persons ages 65 years and older. To assess the prevalence of no leisure time physical activity
by race and ethnicity, prevalence estimates were age-adjusted to account for differences in the underlying
age distribution among different racial and ethnic population subgroups. The age-adjusted prevalence of no
leisure physical activity among adults 18 years and older was higher among Hispanics (39.6%; 95% confidence
interval: 35.5% to 45.6%) as compared to all other groups. The prevalence of no leisure time physical activity increased with age from 18.5% (95% confidence
interval: 13.0% to 24.0%) among persons ages 18 to 24 years to 31.0% (95% confidence interval: 29.2% to
32.9%) among persons ages 65 years and older. To assess the prevalence of no leisure time physical activity
by race and ethnicity, prevalence estimates were age-adjusted to account for differences in the underlying
age distribution among different racial and ethnic population subgroups. The age-adjusted prevalence of no
leisure physical activity among adults 18 years and older was higher among Hispanics (39.6%; 95% confidence
interval: 35.5% to 45.6%) as compared to all other groups. 49
Prevalence of No LeisureTime Physical Activity (%)
Figure 5-2. Percentage of adults 18 years and older who reported no leisure time physical activity in the
past 30 days, Kansas 2001-2010.
50%
40%
30%
26.7%
22.5%
25.9%
23.2%
24.4%
22.6%
23.0%
2004
2005
2006
2007
25.5%
23.2%
24.0%
2009
2010
20%
10%
0%
2001
2002
2003
2008
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Leisure time physical activity is defined as participation in any physical activity or exercise, other than at a regular job, such as running, calisthenics, golf,
gardening or walking for exercise.
The prevalence of no leisure time physical activity increased with age from 18.5% (95% confidence
interval: 13.0% to 24.0%) among persons ages 18 to 24 years to 31.0% (95% confidence interval: 29.2% to
32.9%) among persons ages 65 years and older. To assess the prevalence of no leisure time physical activity
by race and ethnicity, prevalence estimates were age-adjusted to account for differences in the underlying
age distribution among different racial and ethnic population subgroups. The age-adjusted prevalence of no
leisure physical activity among adults 18 years and older was higher among Hispanics (39.6%; 95% confidence
interval: 35.5% to 45.6%) as compared to all other groups. The prevalence of no leisure physical activity was higher among adults 18 years and older with lower
annual household income; the prevalence was 42.8% (95% confidence interval: 36.6% to 49.0%) among those
with an income of $15,000 or less as compared to 16.5% (95% confidence interval: 15.0% to 18.1%) among
those with an income of $50,000 or higher. Similarly, the prevalence of no leisure physical activity was higher
among adults 18 years and older with lower education; the prevalence was 44.8% (95% confidence interval:
38.9% to 50.7%) among those without a high school diploma as compared to 15.8% (95% confidence interval:
14.1% to 17.4%) among college graduates. The prevalence of no leisure physical activity was higher among
persons living with a disability (37.4%; 95% confidence interval: 34.9% to 39.9%) as compared to those living
without a disability (20.1%; 95% confidence interval: 18.7% to 21.4%).
50
Diabetes Prevalence by Participation in Leisure Time Physical Activity
The prevalence of diabetes is significantly higher among Kansas adults 18 years and older who do not
participate in leisure time physical activity (13.2%; 95% confidence interval: 12.3% to 14.1%) as compared to
those who do (7.1%; 95% confidence interval: 6.7% to 7.5%). Disparities in diabetes prevalence are evident
regardless of whether they participate in leisure time physical activity (Table 5-9). As with the risk factors
described previously, the intersection between leisure time physical activity and other factors reveals large
disparities in diabetes prevalence.
Table 5-8. Percentage of adults 18 years and older who reported no leisure time physical activity in the
past 30 days by selected demographic and social factors, Kansas 2010.
Percent of Adults 18 Years and Older
Reporting No Physical Activity
95% Confidence Interval
24.0%
22.8% to 25.2%
Women
25.4%
23.8% to 26.9%
Men
22.5%
20.7% to 24.4%
18 to 24
18.5%
13.0% to 24.0%
25 to 34
17.7%
14.4% to 21.0%
34 to 44
21.7%
18.8% to 24.6%
45 to 64
26.8%
25.1% to 28.4%
65 and older
31.0%
29.2% to 32.9%
Characteristic
Total
Gender
Age
Race and Ethnicity (age-adjusted)
White, Non-Hispanic
22.6%
21.3% to 24.0%
African American, Non-Hispanic
23.8%
18.4% to 29.1%
Other/Multi-Race, Non-Hispanic
24.0%
18.6% to 29.5%
Hispanic
39.6%
33.5% to 45.6%
Below $15,000
42.8%
36.6% to 49.0%
$15,000 to $24,999
33.7%
29.7% to 37.6%
$25,000 to $34,999
26.0%
22.2% to 29.8%
$35,000 to $49,999
24.6%
21.5% to 27.6%
$50,000 or Higher
16.5%
15.0% to 18.1%
Did Not Graduate High School
44.8%
38.9% to 50.7%
High School Graduate
31.8%
29.2% to 34.3%
Some Technical Education or College
22.6%
20.4% to 24.9%
College or Technical Education Graduate
15.8%
14.1% to 17.4%
Living with a Disability
37.4%
34.9% to 39.9%
Living without a Disability
20.1%
18.7% to 21.4%
Annual Household Income
Education
Disability Status
Source: 2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated. Leisure time physical activity is defined as participation in any physical activity or exercise, other than at a
regular job, such as running, calisthenics, golf, gardening or walking for exercise. 51
Table 5-9. Percentage of adults 18 years and older with diabetes by participation in leisure time
physical activity and selected demographic and social factors, Kansas 2009-2010.
Does Not Participate in Leisure
Time Physical Activity
Participates in Leisure Time
Physical Activity
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
13.2%
12.3% to 14.1%
7.1%
6.7% to 7.5%
Women
13.6%
12.5% to 14.6%
6.5%
6.0% to 7.0%
Men
12.8%
11.3% to 14.2%
7.6%
7.0% to 8.3%
4.0%
2.7% to 5.2%
2.6%
2.0% to 3.1%
45 to 64 Years
15.4%
14.0% to 16.8%
9.5%
8.8% to 10.2%
65 Years and Older
24.8%
23.1% to 26.6%
16.5%
15.4% to 17.5%
White, non-Hispanic
10.1%
9.2% to 10.9%
6.6%
6.2% to 7.0%
African American, non-Hispanic
18.3%
14.7% to 21.9%
11.8%
9.2% to 14.4%
Other/Multiracial, non-Hispanic
14.1%
10.0% to 18.1%
9.7%
7.6% to 11.7%
Hispanic
15.9%
11.9% to 19.9%
11.5%
9.0% to 13.9%
Selected Demographic or Social Factor
Total
Gender
Age
18 to 44 Years
Race, Ethnicity*
Annual Household Income
Below $15,000
17.5%
14.4% to 20.6%
12.3%
8.9% to 15.6%
$15,000 to $24,999
17.8%
15.5% to 20.0%
11.3%
9.7% to 12.8%
$25,000 to $34,999
13.1%
10.8% to 15.4%
9.8%
8.5% to 11.2%
$35,000 to $49,999
13.5%
11.3% to 15.7%
6.9%
6.0% to 7.7%
$50,000 or higher
9.4%
8.0% to 10.9%
5.3%
4.8% to 5.7%
Did Not Graduate High School
17.4%
14.3% to 20.5%
9.9%
7.5% to 12.4%
High School Graduate
13.6%
12.2% to 15.0%
7.7%
6.9% to 8.6%
Some Technical or College
12.7%
11.1% to 14.3%
7.8%
7.0% to 8.6%
College or Technical Graduate
10.7%
9.1% to 12.3%
5.7%
5.2% to 6.3%
Living with a Disability
22.5%
20.7% to 24.3%
15.1%
13.9% to 16.4%
Not Living with a Disability
8.5%
7.6% to 9.4%
5.4%
5.0% to 5.8%
Education
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
* Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated.
52
B. Recommended Moderate and/or Vigorous Physical Activity
To assess participation in physical activity as recommended in national guidelines, respondents to the
2009 Kansas BRFSS were asked about how many days per week they participate in moderate physical activity
such as walking, gardening or vacuuming that involve small increases in heart rate or breathing rate and how
many days per week they participate in vigorous physical activity such as running or aerobics that involve
large increases in heart rate or breathing rate. They were then asked about the average number of minutes
they spent in moderate and/or vigorous physical activity on the days they participated in those activities. The
total minutes of physical activity was computed as the product of the average number of days of each kind of
activity and the average number of minutes doing moderate and/or vigorous physical activity. To combine
minutes of moderate and vigorous physical activity into one measure, each minute of moderate physical
activity counted as 1 minute toward the recommended 150 minutes per week of physical activity and each
minute of vigorous physical activity counted as 2 minutes toward the recommended 150 minutes per week of
physical activity.
Based on this methodology, about 2 in 3 (64.1%; 95% confidence interval: 63.1% to 65.1%) Kansas
adults 18 years and older met the physical activity recommendation of 150 minutes or more of moderate
and/or vigorous physical activity in an average week during 2009 (Table 5-10). The prevalence of meeting
the physical activity recommendation (150 minutes/week) was higher among men (69.2%; 95% confidence
interval: 67.7% to 70.6%) than among women (59.3%; 95% confidence interval: 58.1% to 60.5%) and decreased
with age from 75.4% (95% confidence interval: 71.2% to 79.7%) among persons ages 18 to 24 years to 50.8%
(95% confidence interval: 54.7% to 63.0%) among persons ages 65 years and older. To assess the prevalence
of meeting the physical activity recommendation (150 minutes/week) by race and ethnicity, prevalence
estimates were age-adjusted to account for differences in the underlying age distribution among different
racial and ethnic population subgroups. The age-adjusted prevalence of meeting the physical activity
recommendation (150 minutes/week) among adults 18 years and older was lower among non-Hispanic
African Americans (55.9%; 95% confidence interval: 51.0% to 60.7%) and among Hispanics (58.8%; 95%
confidence interval: 54.7% to 63.0%) as compared to non-Hispanic whites (65.3; 95% confidence interval:
64.3% to 66.3%). The prevalence of meeting the physical activity recommendation (150 minutes/week) was lower
among adults 18 years and older with lower annual household income; the prevalence was 50.4% (95%
confidence interval: 45.6% to 55.2%) among those with an income of $15,000 or less as compared to 70.6%
(95% confidence interval: 69.3% to 71.9%) among those with an income of $50,000 or higher. Similarly, the
prevalence of meeting the physical activity recommendation (150 minutes/week) was lower among adults 18
years and older with lower education; the prevalence was 49.0% (95% confidence interval: 44.4% to 53.5%)
among those without a high school diploma as compared to 69.4% (95% confidence interval: 68.1% to
70.8%) among college graduates. The prevalence of meeting the physical activity recommendation (150 min/
week) was lower among persons living with a disability (46.9%; 95% confidence interval: 44.9% to 48.9%) as
compared to those living without a disability (68.6%; 95% confidence interval: 67.5% to 69.7%).
53
Table 5-10. Percentage of adults 18 years and older who participate in 150 minutes per week or more
of moderate and/or vigorous physical activity, or an equivalent combination of both, by selected
demographic and social factors, Kansas 2009.
Percent of Adults 18 Years and
Older Meeting Physical Activity
Recommendation (150 min/week)
95% Confidence
Interval
64.1%
63.2% to 65.1%
Women
59.3%
58.1% to 60.5%
Men
69.2%
67.7% to 70.6%
18 to 24
75.4%
71.2% to 79.7%
25 to 34
71.1%
68.6% to 73.6%
34 to 44
67.3%
65.3% to 69.4%
45 to 64
61.3%
60.1% to 62.5%
65 and older
50.8%
49.4% to 52.2%
Characteristic
Total
Gender
Age
Race and Ethnicity (age-adjusted)
White, Non-Hispanic
65.3%
64.3% to 66.3%
African American, Non-Hispanic
55.9%
51.0% to 60.7%
Other/Multi-Race, Non-Hispanic
61.9%
57.3% to 66.4%
Hispanic
58.8%
54.7% to 63.0%
Below $15,000
50.4%
45.6% to 55.2%
$15,000 to $24,999
54.0%
51.2% to 56.7%
$25,000 to $34,999
60.9%
57.9% to 63.9%
$35,000 to $49,999
64.6%
62.3% to 66.9%
$50,000 or Higher
70.6%
69.3% to 71.9%
Did Not Graduate High School
49.0%
44.4% to 53.5%
High School Graduate
60.8%
58.9% to 62.7%
Some Technical Education or College
64.2%
62.3% to 66.0%
College or Technical Education Graduate
69.4%
68.1% to 70.8%
Living with a Disability
46.9%
44.9% to 48.9%
Living without a Disability
68.6%
67.5% to 69.7%
Annual Household Income
Education
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated. See text for details on methodology for computing minutes per week of moderate and or vigorous physical
activity per week.
54
Table 5-11. Percentage of adults 18 years and older with diabetes by level of participation in moderate
and/or vigorous physical activity and selected demographic and social factors, Kansas 2009.
Meets recommendation (150
Minutes/Week) of Moderate and/
or Vigorous Physical Activity
Less than 150 Minutes/Week or No
Moderate and/or Vigorous Physical
Activity
Prevalence of
Diabetes (%)
95% Confidence
Interval
Prevalence of
Diabetes (%)
95% Confidence
Interval
6.3%
5.7% to 6.8%
12.6%
11.8% to 13.5%
Women
5.6%
5.1% to 6.2%
12.1%
11.1% to 13.1%
Men
6.9%
6.0% to 7.8%
13.4%
12.0% to 14.8%
18 to 44 Years
2.7%
1.9% to 3.5%
3.7%
2.5% to 4.8%
45 to 64 Years
8.4%
7.5% to 9.3%
14.9%
13.5% to 16.3%
65 Years and Older
15.4%
13.9% to 16.8%
24.1%
22.4% to 25.9%
Selected Demographic or Social Factor
Total
Gender
Age
Race, Ethnicity*
White, non-Hispanic
6.1%
5.5% to 6.7%
9.8
8.9% to 10.7%
African American, non-Hispanic
12.2%
8.3% to 16.1%
17.6
13.5% to 21.8%
Other/Multiracial, non-Hispanic
9.0%
6.1% to 11.8%
15.2
11.2% to 19.3%
Hispanic
11.4%
8.1% to 14.7%
15.8
11.7% to 19.8%
Below $15,000
10.6%
5.0% to 16.1%
18.8%
15.1% to 22.6%
$15,000 to $24,999
8.8%
7.2% to 10.4%
19.5%
16.9% to 22.0%
$25,000 to $34,999
8.5%
6.7% to 10.3%
15.4%
12.8% to 18.0%
Annual Household Income
$35,000 to $49,999
5.9%
4.8% to 7.0%
11.8%
9.7% to 13.8%
$50,000 or higher
5.3%
4.6% to 5.9%
8.5%
7.4% to 9.7%
Did Not Graduate High School
7.9%
4.4% to 11.4%
19.4%
15.7% to 23.1%
High School Graduate
7.1%
5.9% to 8.2%
14.4%
12.8% to 16.1%
Some Technical or College
7.0%
5.8% to 8.1%
12.0%
10.5% to 13.4%
College or Technical Graduate
5.0%
4.3% to 5.8%
9.5%
8.1% to 10.8%
Living with a Disability
12.9%
11.2% to 14.6%
23.2%
21.3% to 25.1%
Not Living with a Disability
5.1%
4.6% to 5.7%
8.1%
7.2% to 8.9%
Education
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for race and ethnicity were age-adjusted to the U.S. 2000 standard population. See Technical Appendix for details on how
prevalence estimates were calculated. See text for details on methodology for computing minutes per week of moderate and or vigorous physical
activity per week.
55
Diabetes Prevalence by Physical Activity Recommendation (150 Minutes/Week) Status
The prevalence of diabetes is significantly lower among Kansas adults 18 years and older who met
the recommendation for 150 minutes per week of moderate and/or vigorous physical activity (6.3%; 95%
confidence interval: 5.7% to 6.8%) as compared to those who participated in less than 150 minutes per week
or did not participate in any moderate or vigorous physical activity (12.6%; 95% confidence interval: 11.8% to
13.5%). Disparities in diabetes prevalence are evident regardless of whether they meet the physical activity
recommendation (Table 5-11). As with the risk factors described previously, the intersection between meeting
the physical activity recommendation and other factors reveals large disparities in diabetes prevalence.
High-Risk for Diabetes (Diabetes Risk Test Score)
The paper-and-pencil Diabetes Risk Test (DRT) questionnaire17 developed by the American Diabetes
Association is a tool for identifying individuals at risk for developing diabetes based on the following risk
factors: age, sex, history of delivery of a macrosomic infant (a baby weighting more than 9 pounds), obesity,
sedentary lifestyle and family history of diabetes.18 Although the DRT was not originally intended for use as
a population-based survey, the Kansas BRFSS collects information on each of these risk factors. In the DRT
scoring system, points are assigned for each reported risk factor (Table 5-12). A cumulative point total of 10 or
above is categorized as “High Risk”.
Table 5-12. Diabetes Risk Test (DRT) scoring system.
Item
Points
Woman who delivered a macrosomic (≥9 pounds) infant
1
At least one sibling with diabetes
1
At least one parent with diabetes
1
BMI 27 or higher
5
Younger than 65 and little or no exercise in the past month
5
Age 45-65
5
Age 65 and older
9
Using this DRT scoring system methodology, more than 1 in 3 (36.0%; 95% confidence interval: 35.0% to
37.1%) Kansas adults 18 years and older without diabetes are at high risk for developing diabetes (Table 5-13). The prevalence of high risk for developing diabetes was significantly lower among Kansas adults 18 years and
older with an annual household income of $50,000 or more (30.6%; 95% confidence interval: 29.1% to 32.0%)
as compared to all other household income groups. Similarly, the prevalence of high risk for developing
diabetes among adults with a college or technical degree at (29.7%; 95% confidence interval: 28.1% to 31.2%)
was significantly lower than among all other education groups. The prevalence of high risk for developing
diabetes was higher among those living with a disability (51.8%; 95% confidence interval: 49.4% to 54.3%) as
compared to those not living with a disability (32.3%; 95% confidence interval: 31.1% to 33.4%). No significant
differences were seen in the prevalence of high risk for developing diabetes among non-Hispanic whites
(36.7%; 95% confidence interval: 35.6% to 37.9%), non-Hispanic African Americans (37.7%; 95% confidence
interval: 31.5% to 44.0%) or Hispanics (32.7%; 27.3% to 38.1%), although the prevalence was lower among
non-Hispanic individuals of other or multiple race (24.0%; 95% confidence interval: 19.5% to 28.5%). The
prevalence estimates are not age adjusted because age is a prominent component in the scoring algorithm.
56
Table 5-13. Percentage of adults 18 years without diabetes at high risk for developing diabetes
(based on their score on the Diabetes Risk Test tool) by selected demographic and social factors,
Kansas 2009-2010.
Percent of Adults 18 Years and Older at
High Risk for Developing Diabetes (%)
95% Confidence
Interval
36.0%
35.0% to 37.1%
Women
35.0%
33.7% to 36.3%
Men
37.1%
35.4% to 38.7%
White, Non-Hispanic
36.7%
35.6% to 37.9%
African American, Non-Hispanic
37.7%
31.5% to 44.0%
Other/Multi-Race, Non-Hispanic
24.0%
19.5% to 28.5%
Hispanic
32.7%
27.3% to 38.1%
Characteristic
Total
Gender
Race and Ethnicity (age-adjusted)
Annual Household Income
Below $15,000
42.5%
37.2% to 47.8%
$15,000 to $24,999
43.6%
40.2% to 47.0%
$25,000 to $34,999
43.1%
39.6% to 46.6%
$35,000 to $49,999
40.8%
38.1% to 43.5%
$50,000 or Higher
30.6%
29.1% to 32.0%
Did Not Graduate High School
42.9%
37.7% to 48.2%
High School Graduate
43.6%
41.4% to 45.8%
Education
Some Technical Education or College
36.1%
34.1% to 38.1%
College or Technical Education Graduate
29.7%
28.1% to 31.2%
Living with a Disability
51.8%
49.4% to 54.3%
Living without a Disability
32.3%
31.1% to 33.4%
Disability Status
Source: 2009 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment. High risk
for developing diabetes was defined as a score of 10 or higher on the Diabetes Risk Test tool. See text for details on the methodology for adapting the
diabetes risk test tool for use in the Kansas BRFSS.
57
58
Chapter 6
Preventive Care Practices/
Quality of Care Indicators
In addition to controlling risk factors by eating a healthy diet, participating in regular physical activity
and quitting smoking, people with diabetes must engage in a number of preventive care practices to control
diabetes and reduce morbidity and mortality from diabetes and its complications. This chapter provides
data on preventive care indicators assessed in adults with diabetes through the Kansas Behavioral Risk Factor
Surveillance System.
• Annual dilated eye exam
• Daily self monitoring of blood glucose
• Foot exam by a health professional at least once
per year
• Visit to a health professional for diabetes care at
least once per year
• Daily self-exam of feet
• At least two tests of hemoglobin A1c each year
• Taking a class in diabetes self-management
• Annual influenza vaccination
• Pneumonia vaccination
• Smoking Cessation
Annual dilated eye exam
Annual dilated eye exams are important for detecting diabetic retinopathy, an eye condition associated
with leakage or blockage of the blood vessels of the retina, which can lead to visual impairment and blindness.
According to the 2009-2010 Kansas BRFSS, about 73.3% of adults 18 years and older with diabetes had a
dilated eye exam in the past 12 months (Table 6-1). The percentage receiving a dilated eye exam in the past
12 months among those ages 18 to 44 years (57.7%; 95% confidence interval: 39% to 65.3%) was significantly
lower than among those aged 65 years and older (83.8%; 95% confidence interval: 81.0% to 86.5%). The
percentage of persons with diabetes receiving a dilated eye exam in the past 12 months did not vary for
gender groups or by disability status.
59
Table 6-1. Percentage of adults 18 years and older with diabetes receiving a dilated eye exam in the
past 12 months by gender, age and disability status, Kansas 2009-2010.
Retinal Exam in the Past 12 Months (%)
95% Confidence
Interval
73.3%
70.6% to 76.1%
Women
71.3%
67.8% to 74.8%
Men
75.3%
71.0% to 79.5%
18 to 44 Years
57.7%
47.2% to 68.1%
45 to 64 Years
70.0%
66.2% to 73.8%
65 Years and Older
83.8%
81.0% to 86.5%
Living with a Disability
73.9%
70.1% to 77.7%
Not Living with a Disability
72.8%
68.8% to 76.7%
Selected Factor
Total*
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 1.
In Kansas, the age-adjusted percentage of adults 18 years and older with diabetes receiving a dilated eye
exam in the past 12 months did not change significantly during the period from 2001 through 2010, similar
to the national trend (Figure 6-1). The Healthy People 2010 target for this indicator was 76%.19 For Healthy
people 2020, the target is 58.7%, based on a baseline of 53.4% from the National Health Interview Survey in
2008.20 Though Kansas has achieved the Healthy People 2020 target for this indicator, efforts can be made by
health professionals to achieve further improvement in this statewide estimate.
Figure 6-1. Age-adjusted percentage of adults 18 years and older with diabetes receiving a dilated eye
exam in the past 12 months, Kansas and United States 2001-2010.
100%
Age-Adjusted Prevalence of
Annual Eye Exam (%)
90%
80%
70%
60%
50%
40%
30%
Kansas
20%
United States
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
66.0%
68.1%
72.2%
76.2%
71.0%
65.5%
72.3%
70.2%
70.8%
66.4%
United States
66.5%
64.2%
61.3%
61.9%
60.6%
64.4%
66.0%
63.2%
62.7%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
60
Daily self monitoring of blood glucose
Daily self-monitoring of blood glucose is an important practice for managing diabetes. In Kansas, about
2 in 3 (64.3%; 95% confidence interval: 61.5% to 67.1%) adults 18 years and older with diabetes monitor blood
glucose 1 or more times per day (Table 6-2). During 2009-2010, the percentage of persons with diabetes
engaging in daily self-monitoring of blood glucose did not vary among gender, age or disability status
subgroups.
In Kansas, the age-adjusted percentage of adults 18 years and older with diabetes that monitor blood
glucose 1 or more times per day did not change significantly from 2001 (49.6%; 95% confidence interval:
42.1% to 57.0%) to 2010 (57.1%; 95% confidence interval: 51.0%% to 63.2%). However, in 2009, the ageadjusted prevalence of daily blood glucose monitoring was 67.1% (95% confidence interval: 63.2% to 71.1%),
significantly higher than the 2010 estimate (Figure 6-2). Continued efforts to improve daily self monitoring
of blood glucose will be important for achieving national targets. The Healthy People 2010 target for this
indicator was 61%.19 The Healthy people 2020 national target is 70.4%, based on a baseline of 64.0% from
Behavioral Risk Factor Surveillance System data from all states.20
Table 6-2. Percentage of adults 18 years and older with diabetes that self-monitor blood glucose at
least once per day by gender, age and disability status, Kansas 2009-2010.
Monitors Blood Glucose 1 or More
Times per Day (%)
95% Confidence
Interval
64.3%
61.5% to 67.1%
Women
65.8%
62.2% to 69.4%
Men
62.9%
58.6% to 67.2%
18 to 44 Years
70.3%
61.0% to 79.6%
45 to 64 Years
60.8%
56.7% to 64.8%
65 Years and Older
65.5%
61.9% to 69.1%
Living with a Disability
68.6%
64.7% to 72.5%
Not Living with a Disability
61.0%
57.0% to 65.0%
Selected Factor
Total *
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 2.
61
Age-Adjusted Prevalence of Daily
Blood Glucose Self-Monitoring (%)
Figure 6-2. Age-adjusted percentage of adults 18 years and older with diabetes that self-monitor of
blood glucose at least once per day, Kansas and United States 2001-2010.
100%
90%
80%
70%
60%
50%
40%
30%
United States
Kansas
20%
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
49.6%
49.9%
57.5%
68.8%
67.8%
59.1%
67.7%
65.0%
67.1%
57.1%
United States
55.9%
56.5%
58.3%
60.4%
61.5%
64.6%
63.7%
63.2%
61.5%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
62
Foot exam by a health professional at least once per year
Persons with diabetes should have annual examination of their feet by a health professional including
assessment of sensation, structure and movement, circulation and skin integrity in the feet. In Kansas, about
69.3% (95% confidence interval: 66.4% to 72.1%) of adults 18 years and older with diabetes received a foot
exam by a health professional in the past 12 months (Table 6-3). During 2009-2010, the percentage of persons
with diabetes that received a foot exam in the past 12 months did not vary among gender, age or disability
status subgroups.
Table 6-3. Percentage of adults 18 years and older with diabetes receiving a foot exam by a health
professional the past 12 months by gender, age and disability status, Kansas 2009-2010.
Foot Exam by a Health Care Provider
in the Past 12 Months (%)
95% Confidence
Interval
69.3%
66.4% to 72.1%
Women
67.4%
63.8% to 71.1%
Men
71.0%
66.7% to 75.4%
18 to 44 Years
58.7%
48.3% to 69.1%
45 to 64 Years
72.0%
68.2% to 75.7%
65 Years and Older
71.1%
67.6% to 74.5%
Living with a Disability
71.9%
67.9% to 75.9%
Not Living with a Disability
66.9%
62.9% to 70.9%
Selected Factor
Total *
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes and respondents with no feet are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 3.
63
In Kansas, the age-adjusted percentage of adults 18 years and older with diabetes receiving a foot
exam by a health professional in the past 12 months did not change significantly during the period from
2001 through 2010, similar to the national trend (Figure 6-3). Continued efforts to increase the proportion of
persons with diabetes who receive an annual foot exam will be important for achieving national targets. The
Healthy People 2010 target for this indicator was 91%.19 For Healthy people 2020, the target is 74.8%, based on
a baseline of 68.0% from Behavioral Risk Factor Surveillance System data from all states.20
Age-Adjusted Prevalence of Receiving a
Foot Exam in Past 12 Months (%)
Figure 6-3. Age-adjusted percentage of adults 18 years and older with diabetes receiving a foot exam
by a health professional in the past 12 months, Kansas and United States 2001-2010.
100%
90%
80%
70%
60%
50%
40%
30%
Kansas
20%
United States
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
65.3%
67.1%
69.5%
77.7%
75.0%
62.5%
72.5%
71.6%
67.9%
69.9%
United States
64.1%
66.6%
67.4%
66.6%
66.0%
67.9%
69.4%
66.8%
67.3%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
64
Visit to a health professional for diabetes care at least once per year
In Kansas, about 87.8% (95% confidence interval: 85.5% to 90.0%) of adults 18 years and older with
diabetes who have visited a health professional at least once in the past 12 months (Table 6-4). The
percentage of persons with diabetes who have visited a health professional at least once in the past 12
months was lower among those ages 18-44 years (77.2%; 95% confidence interval: 67.6% to 86.7%) as
compared with those aged 45 to 64 years (91.3%; 95% confidence interval: 89.0% to 93.6%). During 20092010, the percentage of persons with diabetes who have visited a health professional at least once in the past
12 months was not significantly different among gender or disability status subgroups. The age-adjusted
percentage of adults 18 years and older with diabetes who have visited a health professional at least once for
diabetes care in the past 12 months did not change significantly during the period from 2001 through 2010,
similar to the national trend (Figure 6-4).
Table 6-4. Percentage of adults 18 years and older with diabetes visiting a doctor, nurse or other health
professional at least once in the past 12 months by gender, age and disability status, Kansas 2009-2010.
One or More Visits in the Past
12 Months (%)
95% Confidence
Interval
87.8%
85.5% to 90.0%
Women
87.4%
84.7% to 90.2%
Men
88.1%
84.5% to 91.7%
18 to 44 Years
77.2%
67.6% to 86.8%
45 to 64 Years
91.3%
89.0% to 93.6%
65 Years and Older
88.8%
86.3% to 91.2%
Living with a Disability
87.0%
83.7% to 90.3%
Not Living with a Disability
88.3%
85.2% to 91.4%
Selected Factor
Total *
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 4.
65
Figure 6-4. Age-Adjusted percentage of adults 18 years and older with diabetes visiting a doctor, nurse
or other health professional at least once in the past 12 months, Kansas 2001-2010.
Age-Adjusted Prevalence of at Least
One Doctor Visit in Past 12 Months (%)
100%
90%
80%
70%
60%
50%
40%
30%
Kansas
20%
United States
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
84.9%
89.8%
93.1%
90.0%
89.5%
87.3%
88.4%
92.1%
88.5%
85.2%
United States
88.0%
89.6%
88.3%
88.8%
87.7%
88.1%
85.9%
86.4%
85.1%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
66
Daily self-exam of feet
In addition to annual examination by a health professional, persons with diabetes should perform daily
self-exams of their feet to detect any loss of sensation, sores, irritations or injuries. In Kansas, about 69.9%
(95% confidence interval: 67.1% to 72.6%) of adults 18 years and older with diabetes checked their feet at least
once per day (Table 6-5). During 2009-2010, the percentage of people with diabetes who performed daily
foot self exam was not significantly different among gender, age or disability status subgroups. In Kansas, the
age-adjusted percentage of adults 18 years and older with diabetes who perform daily foot self exam did not
change significantly during the period from 2001 through 2010, similar to the national trend (Figure 6-5).
Table 6-5. Percentage of adults 18 years and older with diabetes performing self-exam of feet at least
once per day by gender, age and disability status, Kansas 2009-2010.
Self-Exam of Feet 1 or More
Times per Day (%)
95% Confidence
Interval
69.9%
67.1% to 72.6%
Women
71.8%
68.4% to 75.2%
Men
68.0%
63.6% to 72.3%
18 to 44 Years
65.1%
55.2% to 75.1%
45 to 64 Years
72.4%
68.6% to 76.2%
65 Years and Older
69.1%
65.6% to 72.6%
Living with a Disability
70.0%
65.9% to 74.0%
Not Living with a Disability
69.6%
65.7% to 73.4%
Selected Factor
Total *
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes and respondents with no feet are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 5.
67
Figure 6-5. Age-adjusted Percentage of adults 18 years and older with diabetes performing self-exam
of feet at least once per day, Kansas and United States 2001-2010.
Age-Adjusted Prevalence of Performing
Daily Self-Exam of Feet (%)
100%
90%
80%
70%
60%
50%
40%
Kansas
30%
United States
20%
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
72.4%
66.6%
75.7%
72.6%
66.9%
68.6%
74.2%
70.7%
72.8%
64.7%
United States
64.8%
67.3%
67.4%
63.7%
64.6%
66.3%
64.4%
62.7%
61.4%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
68
At least two tests of hemoglobin A1c each year
A test for hemoglobin A1c, a component of the blood, is an important laboratory test for persons with
diabetes. Levels of hemoglobin A1c indicate the average amount of glucose in the blood over the previous
2 to 3 months. Persistent high levels of hemoglobin A1c indicate poor diabetes control and increased risk for
complications. Persons with diabetes are recommended to receive at least 2 tests per year. In Kansas, about
73.0% (95% confidence interval: 70.0% to 76.1%) of adults 18 years and older with diabetes had 2 or more
Hemoglobin A1c tests in the previous 12 months (Table 6-6). The percentage of adults with diabetes meeting
this recommendation among those ages 18 to 44 years (49.3%; 95% confidence interval: 38.5% to 60.1%) was
significantly lower than among those in all other age groups. The percentage of adults with diabetes who had
at least 2 tests in the past 12 months did not vary among gender or disability status subgroups.
In Kansas, the age-adjusted percentage of adults 18 years and older with diabetes with at least 2 tests
in the past 12 months did not change significantly during the period from 2001 through 2010, similar to the
national trend (Figure 6-6). The age-adjusted percentage of adults with diabetes receiving at least two A1c
tests per year exceeds the Healthy People 2010 target of 65% (the Healthy People 2010 Target is defined as
at least 1 A1c test per year).19 Continued efforts to improve this percentage will be important to achieve the
Healthy People 2020 target. The Healthy people 2020 target is 71.1%, based on a baseline of 64.6% from
Behavioral Risk Factor Surveillance System data from all states (the Healthy People 2020 Target is defined as at
least 2 A1c tests per year).20
Table 6-6. Percentage of adults 18 years and older with diabetes having 2 or more Hemoglobin A1c
tests in the past 12 months by gender, age and disability status, Kansas 2009-2010.
At least 2 Hemoglobin A1c Tests
in Past 12 Months (%)
95% Confidence
Interval
73.0%
70.0% to 76.1%
Women
71.7%
67.9% to 75.4%
Men
74.4%
69.6% to 79.2%
18 to 44 Years
49.3%
38.5% to 60.1%
45 to 64 Years
75.5%
71.8% to 79.2%
65 Years and Older
81.3%
78.2% to 84.4%
Living with a Disability
74.8%
70.4% to 79.1%
Not Living with a Disability
71.6%
67.3% to 75.9%
Selected Factor
Total *
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes and respondents who have never heard of a
Hemoglobin A1c tests are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 6.
69
Age-Adjusted Prevalence of 2 or more
Hemoglobin A1c Tests in Past 12 Months (%)
Figure 6-6. Age-adjusted percentage of adults 18 years and older with diabetes having 2 or more
Hemoglobin A1c tests in the past 12 months, Kansas and United States 2001-2010.
100%
90%
80%
70%
60%
50%
40%
Kansas
30%
United States
20%
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
68.8%
71.3%
74.8%
77.9%
75.1%
64.4%
71.6%
69.3%
69.3%
72.1%
United States
64.5%
68.1%
65.9%
68.8%
64.3%
68.1%
69.8%
69.1%
69.2%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
70
Taking a class in diabetes self-management
Diabetes self-management education is a crucial part of diabetes care. Self-management classes help
persons with diabetes to understand the disease and how to control it. In Kansas, about 59.8% of adults
18 years and older with diabetes have ever attended a diabetes self management class (Table 6-7). The
percentage of persons with diabetes that have ever attended a class did not vary significantly among gender,
age or disability status subgroups.
In Kansas, the age-adjusted percentage of adults 18 years and older with diabetes that have ever
attended a self-management class did not change significantly during the period from 2001 through 2010,
similar to the national trend (Figure 6-7). Continued efforts to increase the proportion of adults with diabetes
who have attended a self-management class will be important for achieving National targets. The Healthy
People 2010 target for this indicator was 60%.19 For Healthy people 2020, the target is 62.5%, based on a
baseline of 56.8% from Behavioral Risk Factor Surveillance System data from all states.20
Table 6-7. Percentage of adults 18 years and older with diabetes who have ever attended a diabetes
self-management class by gender, age and disability status, Kansas 2009-2010.
Ever Attended a Diabetes SelfManagement Class (%)
95% Confidence
Interval
59.8%
57.0% to 62.7%
Women
61.3%
57.6% to 64.9%
Men
58.4%
53.9% to 62.9%
18 to 44 Years
64.8%
54.8% to 74.7%
45 to 64 Years
61.3%
57.3% to 65.4%
65 Years and Older
55.7%
52.0% to 59.4%
Selected Factor
Total *
Gender
Age
Disability Status
Living with a Disability
61.1%
57.0% to 65.2%
Not Living with a Disability
58.9%
54.9% to 63.0%
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 7.
71
Figure 6-7. Age-adjusted percentage of adults 18 years and older with diabetes who have ever
attended a diabetes self-management class, Kansas and United States 2001-2010.
Age-Adjusted Prevalence of Ever
Taking Self-Management Class (%)
100%
90%
80%
70%
60%
50%
40%
30%
Kansas
20%
United States
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
57.4%
53.9%
59.1%
61.3%
60.0%
55.6%
60.2%
60.1%
63.6%
56.3%
United States
52.3%
55.7%
54.2%
56.6%
54.3%
54.9%
56.5%
55.2%
55.7%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
72
Annual influenza vaccination
Persons with diabetes are at increased risk for influenza. In Kansas, about 61.2% (95% confidence
interval: 59.0% to 63.5%) of adults 18 years and older with diabetes received an influenza shot in the past 12
months (Table 6-8). The percentage receiving an influenza shot in past 12 months among those ages 18 to
44 years (29.1%; 95% confidence interval: 21.2% to 36.9%) was significantly lower than among all other age
groups. The percentage of persons with diabetes receiving an influenza shot in the past 12 months was not
significantly different among gender or disability status subgroups. In Kansas, the age-adjusted percentage
of adults 18 years and older with diabetes did not change significantly during the period from 2001 through
2010, similar to the national trend (Figure 6-8).
Table 6-8. Percentage of adults 18 years and older with diabetes receiving an influenza shot in the past
12 months by gender, age and disability status, Kansas 2009-2010.
Influenza Vaccination in the
Past 12 Months (%)
95% Confidence
Interval
61.2%
59.0% to 63.5%
Women
62.0%
59.2% to 64.8%
Men
60.5%
56.9% to 64.0%
Selected Factor
Total *
Gender
Age
18 to 44 Years
29.1%
21.2% to 36.9%
45 to 64 Years
60.1%
57.2% to 63.1%
65 Years and Older
75.4%
73.2% to 77.6%
Living with a Disability
63.9%
60.7% to 67.1%
Not Living with a Disability
59.1%
55.9% to 62.3%
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 8. 73
Figure 6-8. Age-adjusted percentage of adults 18 years and older with diabetes receiving an influenza
shot in the past 12 months, Kansas and United States 2001-2010.
Age-Adjusted Prevalence of Influenza
Vaccination in the Past 12 Months (%)
100%
90%
80%
70%
60%
50%
40%
30%
Kansas
20%
United States
10%
0%
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Kansas
52.1%
56.3%
54.2%
56.0%
51.9%
52.3%
56.2%
56.3%
56.2%
55.0%
United States
42.8%
45.5%
44.5%
45.9%
39.4%
45.4%
51.5%
49.8%
49.5%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
74
Pneumonia Vaccination
Persons with diabetes are at increased risk for pneumococcal disease. In Kansas, about 57.9% (95%
confidence interval: 55.6% to 60.2%) of adults 18 years and older with diabetes have received a pneumococcal
vaccination (ever received; Table 6-9). The percentage of adults with diabetes ever receiving a pneumococcal
vaccination among those ages 18 to 44 years (30.9%%; 95% confidence interval: 22.4% to 39.4%) was
significantly lower than the percentage in all other age groups. The receiving a pneumococcal vaccination
among those ages 45 to 64 years (50.5%; 95% confidence interval: 47.4% to 53.5%) was significantly lower
than among those ages 65 years and older (76.4%; 95% confidence interval: 74.2% to 78.6%). The percentage
of persons with diabetes with a disability were more likely to have had a pneumococcal vaccination (66.0%;
95% confidence interval: 62.8% to 69.2%) than those not living with a disability (51.4%; 48.2% to 54.6%). The
percentage of adults with diabetes who received a pneumococcal vaccination was not significantly different
between women and men. During the period from 2001 to 2010, the age-adjusted percentage of adults 18
years and older with diabetes who received a pneumococcal vaccination increased significantly from 34.6%
(95% confidence interval: 28.5% to 40.8%) in 2001 to 50.9% (95% confidence interval: 46.4% to 55.5%) in 2010
(Figure 6-9). A similar improvement is evident in the National trend.
Table 6-9. Percentage of adults 18 years and older with diabetes ever receiving a pneumococcal
vaccination in the past 12 months by gender, age and disability status, Kansas 2009-2010.
Ever Received Pneumococcal
Vaccination (%)
95% Confidence
Interval
57.9%
55.6% to 60.2%
Women
60.6%
57.7% to 63.4%
Men
55.3%
51.7% to 58.9%
18 to 44 Years
30.9%
22.4% to 39.4%
45 to 64 Years
50.5%
47.4% to 53.5%
65 Years and Older
76.4%
74.2% to 78.6%
Selected Factor
Total *
Gender
Age
Disability Status
Living with a Disability
66.0%
62.8% to 69.2%
Not Living with a Disability
51.4%
48.2% to 54.6%
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
* Unadjusted prevalence may differ from the age-adjusted prevalence in Figure 9.
75
Age-Adjusted Prevalence
of Ever Receiving
Pneumococcal Vaccination (%)
Figure 6-9. Age-adjusted percentage of adults 18 years and older with diabetes receiving an influenza
vaccination in the past 12 months, Kansas and United States 2001-2010.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Kansas
United States
2001
2002
2003
2004
2005
2006
2007
2008
2009
Kansas
34.6%
40.9%
39.8%
41.7%
48.0%
42.9%
50.7%
48.9%
50.5%
United States
34.6%
35.2%
36.6%
38.8%
37.4%
38.2%
39.3%
40.5%
43.0%
Year
Source: 2001-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Prevalence estimates for the United States are available from the CDC (http://www.cdc.gov/diabetes/statistics/; accessed August, 2011). Women told
only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded. Prevalence estimates were age-adjusted to the
2000 U.S. standard population using two age groups: 18 to 64 years and 65 years and older. See Technical Appendix for details on how prevalence
estimates were calculated.
76
77
Smoking Cessation
Cessation of tobacco use is an important goal in diabetes management because tobacco use exacerbates
risk for heart disease, stroke and other complications of diabetes.11 Among adult Kansans with diabetes who
currently smoke, about 60.4% (95% confidence interval: 54.4% to 66.4%) tried to quit smoking in the past 12
months. The percentage of current smokers with diabetes attempting to quit smoking was higher among
those ages 18 to 44 years (77.0%; 95% confidence interval: 65.0% to 89.0%) as compared to those ages 45 to
64 years (51.8%; 95% confidence interval: 44.4% to 59.1%). The percentage of current smokers with diabetes
who attempted to quit smoking in the past 12 months did not vary significantly among gender, disability
status subgroups.
Table 6-10. Percentage of current smoker 18 years and older with diabetes who stopped smoking 1 day
or longer during the past 12 months because they were trying to quit smoking, Kansas 2009-2010.
Tried to Quit Smoking in Past 12 Months
Among Current Smokers with Diabetes (%)
95% Confidence
Interval
60.4%
54.4% to 66.4%
Women
65.0%
57.4% to 72.6%
Men
55.6%
46.3% to 65.0%
18 to 44 Years
77.0%
65.0% to 89.0%
45 to 64 Years
51.8%
44.4% to 59.1%
65 Years and Older
57.5%
47.6% to 67.4%
Living with a Disability
53.4%
44.0% to 62.8%
Not Living with a Disability
66.6%
59.2% to 74.1%
Selected Factor
Total
Gender
Age
Disability Status
Source: 2009-2010 Kansas Behavioral Risk Factor Surveillance System, Bureau of Health Promotion, Kansas Department of Health and Environment.
Women told only during pregnancy that they had diabetes and pre-diabetes or borderline diabetes are excluded.
78
Chapter 7
Health Disparities and Social
Determinants of Diabetes
Burden
Differences in mortality and morbidity between subgroups within a population are referred to as
health disparities. Health disparities usually occur between population subgroups that differ on the basis
of socioeconomic status, gender, race, ethnicity, sexual orientation, disability, geographic location or some
combination of these characteristics. Individuals in these groups may have less access to healthy food,
good housing, quality education, safe neighborhoods, and may be affected by racism or another form of
discrimination. Together these factors are called social determinants of health.21
This chapter includes a listing of findings from previous chapters related to health disparities and social
determinants of diabetes burden.
Mortality from Diabetes
• The age-adjusted diabetes mortality rate for men was higher than the rate for women.
• Age-adjusted diabetes mortality rates were higher among non-Hispanic African Americans, non-Hispanic
American Indians/Alaska Natives and Hispanics and Hispanics as compared to non-Hispanic whites.
• The age-adjusted diabetes mortality rate in urban counties was lower than the rate in rural and denselysettled rural counties.
Prevalence of Diabetes
• The age-adjusted diabetes prevalence among non-Hispanic African Americans, non-Hispanic American
Indians/Alaska Natives, non-Hispanic adults of other race or multiple race and Hispanic adults were all
significantly higher than for non-Hispanic whites.
• Diabetes prevalence was higher among persons with lower annual household income. This was true for all
age groups.
• Diabetes prevalence was higher among persons with lower levels of education. This was true for all age
groups.
• The prevalence of diabetes was significantly higher among adults 18 years and older living with a disability
as compared to those not living with a disability. This disparity is present regardless of gender, age, race,
ethnicity, annual household income or education.
Impact: Hospitalizations, complications and cost
• Age-adjusted hospital discharge rates for diabetes (listed as any primary or secondary diagnosis) were
higher in non-Hispanic African Americans than in any other racial or ethnic group in 2008.
• The percentage of Kansas adults with diabetes who have retinopathy was higher among those living with a
disability as compared to those not living with a disability.
79
80
Undiagnosed Diabetes, Pre-diabetes and Gestational Diabetes
• The percentage of adults without diabetes that received a diabetes test in the past 3 years was lower
among those with an annual household income below $15,000 as compared to all other household income
levels.
• The percentage of adults without diabetes that received a diabetes test in the past 3 years was lower
among those with less education.
• The prevalence of pre-diabetes was higher among adults living with a disability as compared to those not
living with a disability.
• On average, the percentage of pregnancies with gestational diabetes among those receiving services from
the Kansas Women, Infants and Children Program was slightly higher than the percentage pregnancies
with gestational diabetes among all Kansas births.
Diabetes Risk Factors
• The percentage of men who are obese was higher than the percentage among women.
• The age-adjusted prevalence of obesity was higher among non-Hispanic African Americans as compared
to non-Hispanic whites.
• The prevalence of obesity was lower among adult Kansans with an annual income of $50,000 or more as
compared to all other income categories.
• The prevalence of obesity was lower among Kansans with higher levels of education.
• The percentage of obese adults was higher among persons living with a disability as compared to those
living without a disability.
• The age-adjusted prevalence of high blood pressure among non-Hispanic African American adults was
significantly higher than for non-Hispanic whites, non-Hispanic adults of other race or multiple race and
Hispanics.
• The prevalence of high blood pressure was lower among those with an annual household income of
$50,000 or more as compared to all other income groups.
• The prevalence of high blood pressure was higher among Kansans with lower educational levels.
• The percentage of adults with high blood pressure was higher among those living with a disability as
compared to those living without a disability.
• The percentage of adults tested and diagnosed with high blood cholesterol was higher for those with
annual household income below $35,000 as compared to those with an annual household income of
$50,000 or more. • The percentage of adults tested and diagnosed with high blood cholesterol was higher among those
without a high school diploma and among high school graduates as compared to college graduates.
• The percentage of adults tested and diagnosed with high blood cholesterol was higher among those living
with a disability as compared to those living without a disability.
• The age-adjusted prevalence of meeting the physical activity recommendation (150 minutes/week) was
lower among non-Hispanic African Americans and Hispanics as compared to non-Hispanic whites.
• The percentage of adults meeting the physical activity recommendation (150 minutes/week) was lower
among adults with lower annual household income.
• The percentage of adults meeting the physical activity recommendation (150 minutes/week) was lower
among adults with lower levels of education.
• The percentage of adults meeting the physical activity recommendation (150 minutes/week) was lower
among persons living with a disability as compared to those living without a disability.
81
• The prevalence of diabetes is significantly higher among Kansans who are obese, have high blood pressure,
have been tested and diagnosed with high blood cholesterol and who engage in insufficient physical
activity. Disparities in diabetes prevalence with regard to race, annual household income, education and
disability were persistent regardless of risk factor status.
Preventive Care Practices / Quality of Care Indicators
• The percentage of adults with diabetes receiving a dilated eye exam in the past 12 months among those
ages 18 to 44 years was lower than among those aged 65 years and older.
• The percentage of adults with diabetes who have visited a health professional at least once in the past 12
months was lower among those ages 18 to 44 years as compared to those aged 45 to 64 years.
• The percentage of adults with diabetes who received at least 2 tests for hemoglobin A1c in the past year
was lower among those ages 18 to 44 years as compared to those in all other age groups.
• The percentage of adults with diabetes receiving an influenza vaccination in the past 12 months was lower
among those ages 18 to 44 years as compared to those in all other age groups.
• The percentage of adults with diabetes who have ever received a pneumonia vaccination was lower
among those ages 18-44 years as compared to those in all other age groups.
82
Technical Notes
• Description of Data Sources
- Vital Statistics
- Kansas Hospital Association Inpatient Database
- Behavioral Risk Factor Surveillance System
• Statistical Methods
- Population based rates
- Age adjusted rates
- Confidence intervals
• County Population Density Peer Groups
• Selected Category Crosswalks
• Kansas Women, Infants and Children Program Income Eligibility Chart
Description of Data Sources
Vital Statistics
All vital events in Kansas are reported to the Kansas Department of Health and Environment’s Center
for Health and Environmental Statistics (CHES). Certificates of death are completed and registered through
the efforts of physicians, hospital personnel, funeral directors, attorneys and local courts. Underlying cause
of death is defined as the disease or injury that initiated the chain of events leading directly to death. It is
established by a physician and classified according to the International Classification of Diseases, 10th Revision
(ICD-10).
Because vital events are reportable by law, the quality of mortality data is high. Nevertheless, there are
several important considerations for mortality data:
• To be consistent with existing vital statistics publications, analyses presented in this report include only
deaths of Kansas residents registered in the annual research summary files, provided to the Bureau of
Health Promotion by CHES. The number of deaths in Kansas reported here may differ slightly from those
available through the National Center for Health Statistics or other sources due to differences in time
frames and procedures for collecting mortality data.
• Mortality rates reported by CHES in the Annual Summary of Vital Statistics include only deaths that are
fully registered by June 1 of the year after the year the death occurred. Mortality rates reported in this
document include deaths that may have been registered at later dates. For this reason, mortality rates
reported here may not match those reported previously by CHES or in previous reports from the Kansas
Heart Disease and Stroke Prevention Program. However, for 2000-2008, this was a very small number of
deaths, so mortality rates from the two sources should be very close.
• Deaths of Kansas residents occurring in other states or abroad may be less likely to be included than
records from deaths occurring in Kansas.
• In 2005, the Kansas death certificate was revised. Race and ethnicity items were revised to allow reporting
of multiple races and collecting race separately from ethnicity. Although collection of race and ethnicity
data changed, the categories used in this report were the same for 2000-2004 and 2005-2009.
83
Kansas Hospital Association Inpatient Database
Hospital discharge data are collected by the Kansas Hospital Association and made available to the
Kansas Department of Health and Environment’s Office of Health Assessment. The complete dataset contains
nearly all inpatient discharges from non-federal, short stay community and general hospitals in Kansas.
Analyses in this report are limited to Kansas residents. Principal diagnosis is determined from information
in the medical record and is classified according to the International Classification of Disease, 9th Revision,
Clinical Modification (ICD-9-CM). Length of stay and age are determined from admission date, discharge date
and birth date. Selected medical procedures reported in this report are identified by scanning through all
listed ICD-9-CM procedure codes.
Several considerations should be taken into account when interpreting hospital discharge rates:
• Analyses are limited to data and classification codes listed in the inpatient database. Bias may be
introduced by inaccurate coding or incomplete records.
• It is not possible, using the inpatient database provided to KDHE, to verify that all short-stay community or
general hospitals in Kansas reported to the inpatient registry each year, or to verify that all discharges are
reported by a given hospital.
• Some Kansas Hospitals that treat heart disease and stroke, particularly specialty hospitals that are not
open to the public, do not submit data to the Kansas Hospital Association. This is likely to cause some bias,
especially for geographic regions served by those hospitals. The extent of this bias has not been assessed.
• It is often impossible to perform subpopulation analyses with hospital discharge data due to insufficient
discharges. Hospital discharge rates are only reported if at least 20 records are available.
• At the time the document was created, hospital discharge data were considered provisional for discharges
occurring between October and December (4th quarter) 2009.
Behavioral Risk Factor Surveillance System (BRFSS)
The BRFSS is an ongoing, population-based, random-digit-dialed telephone survey of noninstitutionalized civilian adults 18 years and older. The survey is coordinated by the Centers for Disease
Control and Prevention (CDC) and is conducted annually by all 50 states, the District of Colombia and several
U.S. Territories. This report includes data collected by the Kansas Department of Health and Environment
during 2001-2010.
The Kansas BRFSS employs a disproportionate stratified sampling method. During data analysis,
sampling weights are applied to account for unequal selection probability and response bias. The complex
survey methodology and analytical procedures for BRFSS are designed to produce valid statewide estimates
of prevalence. County- and region-level estimates were adjusted to reflect the age and gender distribution
within the county using a sample weight post-stratification methodology. A more detailed explanation of
the weighting methodology used for the Kansas BRFSS is available from the following website: http://www.
kdheks.gov/brfss/technotes.html (accessed September, 2011).
Several considerations should be taken into account when interpreting BRFSS estimates:
• BRFSS estimates do not apply to individuals without telephone service, those on military bases or living
within institutions and do not include answers from individuals who are unable to complete a telephone
survey.
84
• For the years of data included in the current report, the BRFSS only sampled individuals with a landline
phone. Future surveys will include a cell-phone sample as well.
• BRFSS prevalence estimates are self-reported. Some prevalence estimates may be higher or lower
than the true prevalence due to inaccuracies in self-reported data (for example, inability to remember,
exaggeration, refusal to respond to a particular question, etc…).
• It is often difficult to obtain subpopulation estimates because of an insufficient number of respondents. In order to report a prevalence estimate, the sample for the population subgroup must have at least 50
denominator respondents and 6 numerator respondents.
Statistical Methods
Population based rates
Rates presented in this report for mortality and hospital discharges are computed as the number of
events divided by the total population of Kansas or for the Kansas subpopulation of interest. Population
denominators are taken from estimates produced by the U.S. Census Bureau. The Census population
estimates used in this report for computing unadjusted (crude) rates and age-specific rates are midyear (July
1) bridged race post-censal estimates. To be consistent with other KDHE publications, 2002-2009 midyear
population estimates produced for each year are used, rather than using the most recent estimate. For
example, a 2005 rate will be based on the Kansas population estimate published in 2005 (2005 Vintage), rather
than using the most recent 2005 population estimate (2009 Vintage). For 2001, the vintage 2002 population
estimates were used. For 2000, census 2000 populations were used. Details on population datasets are
available from the Census website: http://www.census.gov.
Age adjusted rates
Age adjustment is a statistical method for standardizing rates to rates for groups that have different
underlying age distributions more comparable. Age-adjusted rates should be used to compare Kansas with
the United States as a whole, or for comparing two groups, or the same group over time, if the underlying
population distribution is different or changes (for example, comparing rates for men and women). Ageadjusted rates should be understood as relative indices, not as actual measures of burden, and should not be
compared to unadjusted rates.
All age-adjusted rates in this report are computed using the direct method.22 Briefly, rates are first
computed within each age group stratum. The products of each age-specific rate multiplied by the proportion
of the 2000 U.S. Standard Population in that age category are summed across the age group strata. For vital
statistics and hospital discharges, age-specific rates are based on 10 age groups: 0 to 4, 5 to 14, 15 to 24, 25 to
34, 35 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84 and 85 years and older. For BRFSS age-adjusted prevalence
estimates, age-specific rates are based on the 5 age groups recommended by the Council of State and
Territorial Epidemiologists: 18 to 24, 25 to 34, 35 to 44, 45 to 64, 65 years and older unless indicated otherwise
in the source note provided under each table or chart. If the sample was insufficient for the 18 to 24 year
group, the youngest two groups were combined (18 to 34 years) for that analysis. Alternative age grouping
were used if the sample was too small for a particular age group or to be consistent with the age-adjustment
methodology used for a comparison with national data. Age-adjusted prevalence estimates for diabetes
quality of care measures are based on two age groups: 18 to 64 years and 65 years and older following the
methods used by the CDC Division of Diabetes Translation and may differ slightly from those produced using
the Healthy People 2020 methodology.
85
Confidence intervals
All rates, proportions and prevalence estimates presented in this report can be thought of as estimates
of a theoretical true value, or population parameter. These estimates are subject to random variation. To
characterize this variability, some of the statistics presented in this report include 95% confidence intervals. This can be thought of as a range of values that will contain the population parameter (theoretical true
value) 95% of the time. Confidence intervals presented in this report for age-adjusted mortality and hospital
discharge rates were computed using a methodology based on the gamma distribution.23 Confidence
intervals for age-specific rates were computed using a methodology based on the Poisson distribution. For
proportions, exact confidence limits were computed from the binomial distribution. For BRFSS, the complex
survey design is taken into account for variance estimation and 95% confidence intervals are constructed
using a normal approximation.
All statistical data analyses presented in this report were accomplished using SAS, Version 9.2.
County Population Density Peer Groups
County population density peer groups were established by the Kansas Department of Health and
Environment’s Office of Local and Rural Health. Population density was computed based on the population
for each county in the 2000 Census.
Table T-1. County Population Density Peer Groups.
Category
Population Density
Kansas Counties
Frontier
Fewer than 6 persons
per square mile
Barber, Chase, Cheyenne, Clark, Comanche, Decatur, Edwards, Elk, Gove,
Graham, Greeley, Hamilton, Hodgeman, Jewell, Kearny, Kiowa, Lane,
Lincoln, Logan, Meade, Morton, Ness, Osborne, Rawlins, Rush, Sheridan,
Smith, Stanton, Trego, Wallace, Wichita
Rural
6 to 19.9 persons per
square mile
Anderson, Brown, Chautauqua, Clay, Cloud, Coffey, Ellsworth, Grant,
Gray, Greenwood, Harper, Haskell, Jackson, Kingman, Linn, Marion,
Marshall, Mitchell, Morris, Nemaha, Norton, Ottawa, Pawnee, Phillips,
Pratt, Republic, Rice, Rooks, Russell, Scott, Stafford, Stevens, Thomas,
Wabaunsee, Wilson, Woodson
Densely
Settled Rural
20 to 39.9 persons
per square mile
Allen, Atchison, Barton, Bourbon, Cherokee, Cowley, Dickinson, Doniphan,
Ellis, Finney, Ford, Jefferson, Labette, McPherson, Neosho, Osage,
Pottawatomie, Seward, Sumner,
Semi-urban
40 to 149.9 persons
per square mile
Butler, Crawford, Franklin, Geary, Harvey, Leavenworth, Lyon, Miami,
Montgomery, Reno, Riley, Saline
Urban
150 or more persons
per square mile
Douglas, Johnson, Sedgwick, Shawnee, Wyandotte
86
Selected Category Crosswalks
Table T-2. Crosswalk for primary payer source categories used in this report, Kansas Hospital
Association Inpatient Database.
87
KHA Inpatient Database Category
Burden Document Category
Medicaid
Medicaid
Blue Cross/Blue Shield
Commercial/Private Insurance
Workers Comp
Other
Self Pay
Self Pay
Commercial/Private Insurance
Commercial/Private Insurance
Charity/No charge
Other
Other Government (not Champus)
Other
Champus
Other
Other
Other
Medicare Managed Care
Medicare
Medicaid Managed Care
Medicaid
HealthWave/Health Connect Managed Care
HealthWave/Health Connect Managed Care
Blue Cross/Blue Shield Managed Care
Commercial/Private Insurance
Workers Comp Managed Care
Other
All Commercial Payers Managed Care
Commercial/Private Insurance
Other Government Managed Care
(not Champus)
Other
Champus Managed Care
Other
Other Managed Care
Other
Kansas Women, Infants and Children (WIC) Program Income Eligibility Chart
Table T-3. Kansas WIC Program Income Eligibility Chart.13
To be eligible for services provided through the Kansas WIC program, household income cannot exceed 185%
of the Federal Poverty Guidelines. Effective Date: May 1, 2011.
Economic
Unit
Income
Income
Income
Income
Income
Annual
Monthly
Twice-Monthly
Bi-Weekly
Weekly
1
$20,147
$1,679
$840
$775
$388
2
$27,214
$2,268
$1,134
$1,047
$524
3
$34,281
$2,857
$1,429
$1,319
$660
4
$41,348
$3,446
$1,723
$1,591
$796
5
$48,415
$4,035
$2,018
$1,863
$932
6
$55,482
$4,624
$2,312
$2,134
$1,067
7
$62,549
$5,213
$2,607
$2,406
$1,203
8
$69,616
$5,802
$2,901
$2,678
$1,339
9
$76,683
$6,391
$3,196
$2,950
$1,475
10
$83,750
$6,980
$3,490
$3,222
$1,611
11
$90,817
$7,569
$3,785
$3,493
$1,747
12
$97,884
$8,157
$4,079
$3,765
$1,883
13
$104,951
$8,746
$4,373
$4,037
$2,019
14
$112,018
$9,335
$4,668
$4,309
$2,155
15
$119,085
$9,924
$4,962
$4,581
$2,291
16
$126,152
$10,513
$5,257
$4,852
$2,426
$7,067
$589
$295
$272
$136
For each
additional
Person add:
88
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