Cardiovascular Disease Risk Factors and Related Preventive Health Practices Among Adults With and Without Diabetes -- Utah, 1988-1993

The risk for cardiovascular disease (CVD) among persons with diabetes is two to three times higher than among persons without diabetes, and CVD accounts for 48% of all deaths among persons with diabetes (1,2). To estimate the prevalence of CVD risk factors among and related preventive health practices of the adult population with diabetes in Utah, the Utah Diabetes Control Program (UDCP) previously had relied primarily on data from national surveys. To guide in planning and decision-making about future activities of the UDCP and to assess CVD-related behaviors and health practices among persons with diabetes, UDCP analyzed data from Utah's Behavioral Risk Factor Surveillance System (BRFSS) for 1988-1993. This report presents the findings of this analysis.

Data were available for 10,388 adults who participated in the Utah BRFSS during 1988-1993. The BRFSS is a state-specific, population-based, random-digit-dialed telephone survey of the civilian, noninstitutionalized population aged greater than or equal to 18 years. The analysis examined sociodemographic characteristics, CVD risk factors, and related preventive health practices of all BRFSS respondents. SUDAAN was used to weight the results to reflect the age and sex distributions of the Utah population aged greater than or equal to 18 years and to control for potential confounding by age and sex using logistic regression (3).

Of the 10,388 respondents, 405 (3.4% {95% confidence interval (CI)=3.0%-3.8%}) reported having been told by a physician they have diabetes. The unadjusted results indicated that persons with diabetes were more likely than persons without diabetes to be older and female, to have attained a lower level of education, to be retired, and to have lower annual incomes Table_1.

Among persons with diabetes, risk factors for CVD were highly prevalent Table_2: 50% reported having been told by a health-care professional they have high blood pressure, and 11% reported current smoking *. After controlling for potential confounding by age and sex, persons with diabetes were approximately 2.5 times more likely than persons without diabetes to report having high blood pressure (odds ratio {OR}=2.7; 95% CI=2.1-3.4) and to be obese ** (OR=2.5; 95% CI=2.0-3.2) and somewhat more likely to report a sedentary lifestyle *** (OR=1.3; 95% CI=1.0-1.7).

Persons with diabetes were more likely than persons without diabetes to report having engaged in health practices to prevent CVD Table_2, including having had a routine examination (86% versus 62%), having had their blood cholesterol checked during the preceding year (68% versus 39%), and trying to lose weight (41% versus 32%). However, of persons who reported trying to lose weight, those with diabetes were less likely to report using exercise, either alone or in conjunction with diet, than persons without diabetes (45% versus 71%). Differences in the prevalence of preventive health behaviors persisted after controlling for age and sex: routine examination (OR=2.6; 95% CI=1.8-3.8), blood cholesterol check (OR=2.0; 95% CI=1.5-2.5), trying to lose weight (OR=1.5; 95% CI=1.1-2.1).

Reported by: B Larsen, MPH, M Friedrichs, MS, Diabetes Control Program, R Giles, Bur of Health Promotion, Div of Community and Family Health Svcs; Bur of Surveillance and Analysis, Office of Public Health Data, Utah Dept of Health. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In Utah, characteristics of persons with and without diabetes are similar to national patterns: among persons with diabetes, higher proportions are older, have lower incomes, and are less educated (4). Based on these patterns, UDCP is collaborating with the state Medicare program to address the need for providers caring for patients with diabetes to receive reimbursement for outpatient education and nutrition counseling, and to ensure access to diabetes education and counseling for Medicaid recipients. In addition, UDCP is adapting current diabetes educational materials for selected groups, including persons who attained low education levels.

Although the prevalences of major CVD risk factors in the adult population of Utah were lower than national prevalences (5,6), the BRFSS findings documented substantially higher prevalences among persons with diabetes. Based on these findings, UDCP will initiate efforts to increase patient and community awareness about CVD risk factors by 1) educating community members through outreach activities; 2) training local health department staff to emphasize the importance of diabetes education and the reduction of CVD risk factors (e.g., smoking and sedentary lifestyle); and 3) implementing a statewide media campaign with the Utah Diabetes Awareness Partnership about CVD risk factors. The BRFSS findings also will be used to increase awareness and improve care practices among health-care providers through 1) professional education seminars for primary-care physicians in rural areas, geriatric nurses working in home health, and mid-level practitioners; 2) development of office reminder systems to improve the quality of care in the primary-care setting, and 3) collaboration with the state Medicaid program to develop statewide standards of care for persons with diabetes.

Beginning in 1994, CDC-funded cooperative agreements facilitated the restructuring of state diabetes-control programs to emphasize quality of care and monitoring of behavioral risk factors and preventive health practices (7). Based on the findings in this report, the Utah Department of Health will emphasize development of strategies to increase awareness about CVD risk factors and related preventive health behaviors and to improve medical care for persons with diabetes. In 1994, UDCP expanded surveillance efforts to include the use of the new BRFSS diabetes module recently developed by CDC to collect additional information from persons with diabetes about diabetes education, glycemic control, the frequency of screening for diabetic complications, and impaired visual acuity. These data are not available from other state-specific data sources and will enable the UDCP to evaluate the impact of efforts to improve the health status of persons with diabetes.

References

1. CDC. The prevention and treatment of complications of diabetes mellitus: a guide for primary care practitioners. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1991.

2. CDC. Diabetes surveillance, 1993. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1993.

3. Shah BV. SUDAAN. Professional software for survey data analysis for multistage sample designs. Research Triangle Park, North Carolina: Research Triangle Institute, 1992.

4. Cowie CC, Eberhardt MS. Sociodemographic characteristics of persons with diabetes. In: National Diabetes Data Group, National Institutes of Health. Diabetes in America. 2nd ed. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1995:85-116; DHHS publication no. (NIH)95-1468.

5. Siegel PZ, Brackbill RM, Frazier EL, et al. Behavioral risk factor surveillance, 1986-1990. In: CDC Surveillance Summaries (December). MMWR 1991;40(no. SS-4).

6. CDC. Prevalence of adults with no known major risk factors for coronary heart disease -- Behavioral Risk Factor Surveillance System, 1992. MMWR 1994;43:61-63,69.

7. CDC. State-based programs to reduce the burden of diabetes: guidelines for program design, implementation, and evaluation. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1994.

* Persons who smoked at least 100 cigarettes during their lifetime and who reported smoking at the time of the interview. 

** Body mass index (kg/m2) greater than or equal to 27.8 for men and greater than or equal to 27.3 for women. 

*** Fewer than three 20-minute sessions of leisure-time physical activity per week.

TABLE 1. Percentage distribution of selected characteristics among persons with and
without diabetes -- Behavioral Risk Factor Surveillance System, Utah, 1988-1993 *
==================================================================================================
                                  With diabetes                   Without diabetes
                         ----------------------------    ----------------------------
                          Sample                          Sample
                           size                            size
Characteristic &         (n=405)   %     (95% CI +)      (n=9983)   %      (95% CI)
-------------------------------------------------------------------------------------
Age group (yrs)
 18-24                      13     6.5  ( 2.8%-10.2%)      1415   24.1  (22.9%-25.3%)
 25-34                      34     9.1  ( 5.7%-12.5%)      2642   26.8  (25.8%-27.8%)
 35-44                      43     9.3  ( 6.1%-12.4%)      2206   15.6  (14.9%-16.3%)
 45-54                      54    14.8  (10.8%-18.7%)      1260   12.2  (11.5%-12.9%)
 55-64                      78    22.7  (17.9%-27.5%)       976   10.3  ( 9.6%-11.0%)
  >=65                     182    37.6  (32.4%-42.8%)      1466   11.0  (10.4%-11.6%)

Sex
 Men                       133    41.7  (36.0%-47.3%)      4281   49.0  (47.8%-50.1%)
 Women                     272    58.3  (52.7%-64.0%)      5702   51.0  (50.0%-52.2%)

Education
 Less than high
  school diploma            67    14.4  (10.7%-18.0%)       790    8.1  ( 7.5%- 8.7%)
 High school graduate      147    37.8  (32.4%-43.1%)      3183   32.4  (31.3%-33.5%)
 Some college              140    35.2  (29.8%-40.6%)      3634   37.6  (36.5%-38.7%)
 College                    49    12.7  ( 9.0%-16.3%)      2357   21.9  (21.0%-22.8%)

Employment
 Employed                  136    37.5  (31.9%-43.1%)      6221   63.3  (62.1%-64.5%)
 Unemployed                 20     5.5  ( 2.6%- 8.5%)       342    3.7  ( 3.2%- 4.1%)
 Homemaker                  47    11.5  ( 8.3%-15.2%)      1299   12.2  (11.6%-12.9%)
 Student                     8     3.0  ( 0.1%- 5.8%)       507    8.0  ( 7.1%- 8.9%)
 Retired                   193    42.2  (36.8%-47.6%)      1603   12.8  (12.1%-13.5%)

Annual
 household income
         <$20,000          206    52.6  (46.7%-58.6%)      3161   35.7  (34.5%-36.9%)
  $20,000-$34,999           79    25.7  (20.4%-30.9%)      3043   35.1  (33.9%-36.3%)
        >=$35,000           72    21.7  (16.8%-26.6%)      2430   29.2  (28.0%-30.3%)
-------------------------------------------------------------------------------------
* Weighted data. Unweighted sample size=10,388.
& In this analysis, data for each characteristic are included only for persons for whom the data
  were available; excluded data were either unknown or refused.
+ Confidence interval.
==================================================================================================

TABLE 2. Prevalence of cardiovascular disease (CVD) risk factors and related preventive
health practices among persons with and without diabetes -- Behavioral Risk Factor
Surveillance System, Utah, 1988-1993 *
===============================================================================================
                                     With diabetes                    Without diabetes
                            -------------------------------  --------------------------------
                            Sample size                      Sample size
Category +                    (n=405)     %    (95% CI &)     (n=9983)     %      (95% CI)
---------------------------------------------------------------------------------------------
CVD RISK FACTORS
 Hypertension @                 212      50.4 (44.9%-56.0%)      1996     17.6  (16.8%-18.4%)
 Cigarette smoking
  Current smoker **              42      11.3 ( 7.6%-15.0%)      1591     15.6  (14.7%-16.4%)
  Former smoker ++              108      27.7 (22.6%-32.8%)      1658     15.7  (15.0%-16.5%)
  Nonsmoker                     254      60.9 (55.5%-66.4%)      6684     68.5  (67.4%-69.6%)

 Obesity &&
  Men                            51      38.5 (29.1%-47.9%)       858     19.2  (17.9%-20.4%)
  Women                         109      42.7 (35.9%-49.4%)      1039     17.5  (16.3%-18.6%)

 Sedentary lifestyle @@
  Men                            35      26.6 (17.1%-34.0%)       733     20.0  (18.5%-21.4%)
  Women                          79      35.0 (28.1%-41.8%)      1095     22.7  (21.4%-24.1%)

PREVENTIVE HEALTH PRACTICES
 Weight control
  Not trying to lose weight     159      59.1 (58.5%-68.4%)      4341     66.9  (65.6%-68.2%)
  Yes, trying to lose weight    102      41.5 (34.6%-48.4%)      2045     33.1  (32.4%-34.4%)
   Diet only                     56      54.9 (50.2%-62.9%)       602     29.4  (24.3%-25.1%)
   Exercise only                  5       4.9 ( 2.9%- 6.9%)       315     15.4  (13.2%-17.1%)
   Diet and exercise             41      40.2 (36.4%-42.3%)      1128     55.2  (53.8%-57.9%)

 Routine examination
  During preceding year         361      85.5 (80.9%-90.1%)      6320     62.3  (61.2%-63.4%)
  1-5 years ago                  32      10.0 ( 6.2%-13.9%)      2397     15.4  (13.2%-17.1%)
  >5 years ago                    9       3.6 ( 1.0%- 6.2%)      1027     10.3  ( 9.0%-10.4%)
  Never                           3       0.9 (   0 - 1.8%)       198      2.3  ( 1.8%- 2.6%)

 Cholesterol checked ***
  During preceding year         282      68.1 (62.5%-73.6%)      4138     39.0  (37.8%-40.1%)
  >1 year ago                    46      11.8 ( 8.3%-15.3%)      1558     14.9  (14.2%-15.7%)
  Not checked                    71      20.2 (15.0%-25.3%)      4083     46.1  (44.9%-47.3%)
---------------------------------------------------------------------------------------------
  * Weighted data. Unweighted sample size=10,388.
  + In this analysis, data for each characteristic age included only for persons for whom the
    data were available; excluded data were either unknown or refused.
  & Confidence interval.
  @ Among persons ever told by a health-care professional that they have high blood pressure.
 ** Persons who smoked at least 100 cigarettes during their lifetime and who reported smoking
    at the time of the interview.
 ++ Persons who smoked at least 100 cigarettes during their lifetime and who reported not
    smoking at the time of the interview.
 && Body mass index (kg/m2) >=27.8 for men and >=27.3 for women.
 @@ Fewer than three 20-minute sessions of leisure-time physical activity per week.
*** Not asked in 1993.
===============================================================================================

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