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Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations Due to Diabetes

Policy Date: 1/1/2000
Policy Number: 20002

The American Public Health Association,
Observing that epidemiological studies have shown that the prevalence of diagnosed diabetes has increased dramatically in the last 30 years;1-5 and
Noting that diabetes has reached epidemic proportions, with more than 20 million Americans of every age, gender, and race now afflicted;5,6 and
Recognizing that diabetes is a serious public health concern, with a prevalence in minority populations of African-Americans, Hispanic-Americans and Native-Americans that is two to three times that of non-Hispanic whites;7-9 and
Noting that type 2 diabetes is also emerging as a problem among minority children and adolescents;10-13,47,48 and
Realizing that the increasing prevalence of diabetes among all groups has lead to an increase in the microvascular and macrovascular complications, including blindness,14,15 lower extremity amputation,16-20 and destructive periodontitis and tooth loss;44-46 and
Understanding that the lower extremity, periodontal and visual complications of diabetes are generally a function of the duration of diabetes21-23 and the level of glycemic control;23-28 and
Recognizing that approximately 67,000 amputations occur among the diabetic population annually, an incidence of at least 15 times greater than non-diabetic populations;5,20 and
Noting that foot ulcers precede amputation in 85 percent of cases;16 and
Recognizing that the 5-year mortality rate of diabetic patients increases by 39 to 68 percent fol-lowing lower extremity amputation;16 and
Understanding that periodontal complications may lead directly to tooth loss and chronic infec-tion. This adversely affects glycemic contol;44-46 and
Recognizing that diabetic retinopathy is the new leading cause of blindness among working-age Americans, accounting for approximately 8% of all cases of legal blindness and 12% of all new cases of blindness in the United States each year;29 and
Knowing the health benefit and cost-effec-tiveness of well established strategies of preven-tion and treatment in diabetic foot and vision care;30,31,26,28,32 and
Knowing that much of the vision loss, peri-odontal disease, and lower extremity amputation in diabetes mellitus is preventable through early detec-tion and timely treatment;33,34,20,32,35-38 and
Recognizing that annual foot examinations by podiatrists and other foot care providers,39,26,28,40 vision examinations through a dilated pupil by opthalmologists and optometrists,39,26 and dental examinations by oral health providers are the accepted standards of care for all persons with diabetes; therefore,

The American Public Health Association urges health care professionals to
1. Promote awareness of the need for annual foot screening and examinations for individ-uals with diabetes and make appropriate referrals to podiatrists and other foot care providers;
2. Promote awareness of the need for annual dilated fundus exams for all individuals with diabetes and to make appropriate referrals to ophthalmologists and optometrists;
3. Promote awareness of the need for at least annual oral health examinations for all indi-viduals with diabetes and to make ap-propriate referrals to oral health providers; and
4. Encourages federal, state, and privately fund-ed health care organizations to target high-risk minority populations, including African-American, Hispanic-Americans, and Native-Americans, for annual foot and vision care.
5. Promote interdisciplinary diabetes manage-ment and appropriately timed referrals.

References

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  2. Trends in the prevalence and incidence of self-reported diabetes mellitus-United States, 1980-1994. MMWR Morb Mortal Wkly Rep. October 31, 1997; 46(43): 1014-1018.
  3. Vinicor F. Is diabetes a public health disor-der? Diabetes Care. 1994; 17: 22-27.
  4. National Center for Health Statistics. Healthy People 2000 Review, 1998-99. Hyatts-ville, MD: US Public Health Service, 1999.
  5. American Diabetes Association. Diabetes 1996 vital statistics. Alexandria, VA, 1996.
  6. Healthy People 2010: National Health Promotion and Disease Prevention Objectives. Washington, DC. US Department of Health and Human Services; 2000
  7. Carter JS, Pugh JA, Monterrosa A. Non-insulin- dependent diabetes mellitus in minorities in the United States: Ann Intern Med. August 1, 1996; 125(3): 221-232.
  8. Gavin JR 3rd. Diabetes in minorities: Reflections on the medical dilema and the health care crisis. Trans Am Clin Climatol Assoc. 1995; 107:213-223.
  9. Prevalence of diagnosed diabetes among American Indians/Alaskan Natives-United States, 1996.; Morb Mortal Wkly Rep. October 30, 1998; 47(42):901-904.
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  21. Taylor R. Diabetic eye disease: A natural history. Eye. 1997; 11(P4): 547-553.
  22. Krowleski A. Epidemiology of late dia-betic complications. A basis for the development and evaluation of preventive programs. Endo-crinol Metab North Am. June 1996; 25(2): 217- 242.
  23. Klein R. Diabetic retinopathy. Annu Rev Public Health. 1996; 17:137-158.
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  26. Centers for Disease Control Division of Diabetes Translation: The Prevention and Treatment of Complications of Diabetes Melli-tus. Atlanta, GA: January 1991;45: 30,47.
  27. The DCCT Research Group: Diabetes Control and Complications Trial, The effect of intensive treatment of diabetes on the develop-ment and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med. 1993; 329:977-986.
  28. Veterans Health Affairs, Clinical Guide-lines for Management of Patients with Diabetes Mellitus, March 31, 1997.
  29. Blindness caused by diabetes—Massa-chusetts, 1987-1994; MMWR Morbid Mortal Wkly Rep. Nov 1, 1996; 45(43): 937-941. 30. Daschbach et al. Cost effectiveness of strategies for detecting diabetic retinopathy. Med Care. 1991; 29: 20-39.
  30. Javitt et al. Preventive eye care is a cost saving to the federal government. Diabetes Care. 1994; 17: 909-917.
  31. Pecoraro RE, Reiber GE, Burgess EM. Casual pathways to amputation. Pathways top pre-vention; Diabetes Care. 1990; 13:513-521
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  38. Healthy People 2010: National Health Promotion and Disease Prevention Objective 5- 12. Washington, DC: US Department of Health and Human Services, HP 2010 Conference Edition, January 2000.
  39. Healthy People 2010: National Health Promotion and Disease Prevention Objective 5- 14, Washington, DC: US Department of Health and Human Services, HP 2010 Conference Edition, January 2000.
  40. Veterans Health Affairs Directive 10-96- 007; Preservation of Amputation Care and Treatment Program (PACT), Washington, DC: Department of Veterans Affairs, Veterans Health Administration, Washington, DC.
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  45. Taylor G. Periodontal treatment and its affects of glycemic control. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 87:311-316. 1999.
  46. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North Am-erican cjhildren and adolescents: an epidemiolog-ical review and a public health perspective. J Pediatr 2000; 136:664-672.
  47. American Diabetes Association. Type 2 diabetes in children: consensus conference. Dia-betes Care 2000; 23:381-398.

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