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Scientific Data Documentation
Diabetes Supplement, 1991
ABSTRACT

 General Information

                     Diabetes Surveillance, 1991
                 The Division of Diabetes Translation
 National Center for Chronic Disease Prevention and Health Promotion

 Acknowledgments

 Editor:
 Linda S. Geiss

 Contributors:
 Frank DeStefano, Barbara L. Dougherty, Mark S. Eberhardt, Earl S. Ford,
 Robert R. German, William H. Herman, Merilyn G. Goldschmid,, Jeffrey M.
 Newman, David R. Olson, Todd W. Pierce, Stephen J. Sepe, John M. Stevenson,
 Frank Vinicor, Scott F. Wetterhall, Julie C. Will

 Secretarial support:
 Myra A. Montalbano

 Description

      Public health surveillance is the ongoing and systematic collection,
 analysis, and dissemination of health data for public health action.
 Surveillance data are important for formulating policy, identifying high-risk
 groups, targeting interventions, and evaluating progress in disease prevention
 and control.  Diabetes mellitus is a major cause of morbidity and premature
 mortality in the United States, and surveillance is essential for developing
 and evaluating public health strategies to reduce the burden associated with
 diabetes and for monitoring progress toward the national health objectives for
 the year 2000.
      In 1990, the Division of Diabetes Translation (DDT), National Center for
 Chronic Disease Prevention and Health Promotion, Centers for Disease Control,
 established a framework for an ongoing surveillance system to compile national
 data on diabetes and its complications.  In establishing this framework, DDT
 identified and evaluated data sources providing periodic and representative
 data on the disease burden associated with diabetes and its complications in
 the United States.  These data sources, which included vital statistics, the
 National Health Interview Survey, the National Hospital Discharge Survey, and
 Medicare claims data for end-stage renal disease, were analyzed to estimate
 diabetes prevalence and incidence, mortality, hospitalization, cardiovascular
 disease, lower extremity amputation, diabetic ketoacidosis, and end-stage
 renal disease.  The results of these analyses were reported in Chapters 2
 through 8 of DDT's first surveillance report, Diabetes Surveillance,
 1980-1987.
      The current report reprints Chapters 2 through 8 from the first report.
 These chapters describe methods and operational definitions and discuss the
 implications of the findings.  The update sections of each chapter briefly
 highlights and, in some cases, slightly modifies these findings in light of
 one additional year of hospitalization data, two additional years of
 mortality, prevalence, and incidence data, and three additional years of
 Medicare data on end-stage renal disease.  In addition, Medicare data on end-
 stage renal disease for years 1980-1986 have been updated.  The 1991 report
 also contains a new chapter,"Disability," which addresses that important
 aspect of the disease burden of diabetes.
      We evaluated temporal trends by age, sex, and race.  For most topics, we
 could only evaluate race-specific results for whites and blacks because racial
 designation for other groups was not adequate or because the number of persons
 in the sample was not sufficient to calculate stable estimates.  Where
 possible, we provide data by region of the country or state.  Regional
 estimates are classified according to the four major Bureau of the Census
 regions (Figure 1.1).  State-specific data could only be obtained for
 mortality and end-stage renal disease.  Since we generally limit the
 presentation of detailed results to specific subgroups for which we are able
 to obtain relatively stable estimates, the extent of subgroup information
 varies by data source.
      This report contains a section of detailed data tables upon which we
 base discussions of the disease burden of diabetes.  In these detailed tables,
 totals may not equal the sum of the individual cell counts because of
 unknowns, rounding, or the presentation of race-specific results for whites
 and blacks only.
      In most instances, we calculated rates based on two different
 denominators.  First, rates were calculated using the resident population of
 the United States as the denominator.  These general population rates indicate
 the disease burden of diabetes in the U.S. population and are useful for
 comparison with the disease burden of other diseases and conditions.  The
 general population rates are also useful for assessing the prevalence of
 diabetes and its complications and for estimating health care needs.  Second,
 we calculated rates using estimates of the number of persons known to have
 diabetes in the United States as the denominator.  These diabetic population
 rates are affected by differences in diabetes prevalence among different age,
 sex, or race groups and indicate the risk of various complications among
 persons with diabetes.  They are useful for comparing complication rates among
 subgroups of people with diabetes.
      In several analyses, we standardized the results.  For rates based on
 the general population denominators, we standardized the rates to the 1980
 resident population of the United States (Tables 1.1-1.7).  For rates based on
 diabetic population denominators, we standardized rates to estimates of the
 1980 population of persons with diabetes in the United States (Table 2.1).
      We were not able to distinguish persons with insulin-dependent diabetes
 mellitus (IDDM, or Type I diabetes) from those with non-insulin-dependent
 diabetes mellitus (NIDDM, or Type II diabetes) in any of the analyses.
 Because NIDDM is much more common after 45 years of age and because it
 accounts for 90% or more of patients with diabetes in the United States, the
 results presented for persons aged 45 and older pertain mostly to NIDDM.
      We are aware that each of the data sources used has limitations.  These
 limitations are discussed within each chapter.  The analysis of surveillance
 data can indicate general trends and differences between groups, but usually
 the information available is not sufficient to provide reasons for observed
 differences and trends.  Identifying differences and trends, however, can be
 useful in pointing out areas and raising questions for more specific and
 rigorous research.  We believe the data we have used are adequate for public
 health surveillance.  They should be useful for formulating public health
 strategies to decrease disease burden related to diabetes and for monitoring
 progress toward this goal.
PREVALENCE AND INCIDENCE

 Introduction

 We present data on the prevalence and incidence of diabetes in
 the United States during 1980-1987. The data are limited to those
 persons who were diagnosed and were aware they had diabetes. Prevalence
 is the total number of persons known to have diabetes at a particular
 point in time, whereas incidence is the number of persons who discovered
 they had diabetes for the first time during the preceding year.  Incidence,
 in general, is a more sensitive indicator of trends related to the
 etiology of diabetes. Prevalence, on the other hand, is a measure
 of the disease burden of diabetes, which is useful for public health
 planning purposes.

 We present results by calendar year, age, sex, race, and geographic
 region. The estimated number of persons with diabetes presented here
 will be used in subsequent chapters to calculate mortality and morbidity
 rates among persons with the disease.

 Methods

 Incidence and prevalence of self-reported diabetes were determined
 from the 1980-1987 National Health Interview Surveys (NHIS).
 The NHIS is a national health survey which has been continuously conducted
 since 1957.  Approximately 800 households are surveyed each week,
 totaling about 130,000 persons interviewed each year. Each person
 interviewed represents approximately 1,800 persons within the United
 States.

 The NHIS is designed as a multistage cluster sample survey. Households
 are selected to represent a small geographic unit, such as a county,
 a small group of contiguous counties, or a standard metropolitan statistical
 area.  When information gathered from these households is combined,
 the health status of the civilian, non-institutionalized population
 in four U.S. Bureau of the Census regions can be analyzed: Northeast,
 North Central, South, and West. State-level data are not available
 from the NHIS.

 The NHIS questionnaire consists of two basic parts:  core and supplements.
 The  core interview is administered each year, and the supplements
 can change each year. Chronic disease questions, including questions
 about diabetes, are included on condition lists which are administered
 as part of the core questionnaire. A one-third sample of respondents
 in 1980 and 1981 were asked questions about diabetes as were a one-sixth
 sample of the respondents during 1982-1987. The condition list for
 diabetes asks the following questions: 1) "During the past 12
 months, did anyone in the family have diabetes?" 2) "Who was
 this?" and 3) "During the past 12 months, did anyone else
 have diabetes?"  If a person in the household has diabetes, when
 the person was diagnosed is ascertained.

 In 1987, more than 20,000 persons were asked to respond to the question
 regarding diabetes in their family. For each year of data analyzed,
 diabetes prevalence was determined by counting the number of persons
 in a household with diabetes and projecting the number to reflect
 either a regional or national estimate.  Diabetes incidence was calculated
 by counting only those persons who reportedly discovered their diabetes
 during the past 12 months.

 We calculated incidence and prevalence rates and their relative standard
 errors using the SESUDAAN computer software package (Shah, 1981).  In
 calculating annual incidence and regional prevalence rates, we found
 it necessary to pool three years of data to develop precise estimates.
 These estimates were obtained by using three-year moving averages.

 To interpret yearly trends, we age-adjusted the prevalence and incidence
 rates to remove any influence of a changing age structure of the population.
 The age-adjusted diabetes prevalence and incidence rates were calculated
 by direct standardization (Fleiss, 1981) using the 1980 U.S. resident
 population as the standard.
Results

 Prevalence

 In 1987, 6.8 million persons in the United States were known
 to have diabetes (Table 2.1). From 1980 to 1987, the number
 of persons with diabetes increased by more than one million (Figure
 2.1). Population subgroups with the greatest relative increases between
 1980 and 1987 in the number of persons diagnosed with diabetes were
 the following: 1) those persons younger than age 45 years (35% increase);
 2) those aged 75 years and older (39% increase); 3) white males (33%
 increase); and 4) black females (24% increase) (Tables 2.1-2.5). The
 large increase among white males was attributable to almost a doubling
 of diagnosed diabetes   among   the   youngest  age   group (less
 than 45 years). Meanwhile, the large increase among black females
 was from a doubling of diagnosed diabetes in the 75 years and older
 age group.  Although the numbers fluctuated from year to year, the
 overall trend in the various groups was toward an increased number
 of persons diagnosed with diabetes.

 From 1980 to 1987, the prevalence rate of diabetes in the United States
 increased (Figure 2.2, Table 2.1). The increase cannot be attributed
 to differences in age structure of the population from year to year.
 The age-adjusted prevalence rate was stable from 1980-1982,  dipped
 slightly in 1983, and then increased steadily up to 1986. Trends in
 prevalence rates were similar to the trends noted among numbers of
 persons with diabetes. Black females and white males had the largest
 increases in diabetes prevalence rates (Figure 2.3, Tables 2.2-2.5).
 These increases resulted from the large increases in diagnosed diabetes
 among young white males and older black females. In general, the prevalence
 rate of diabetes increased with increasing age (Tables 2.1-2.5). In
 1987, black females had the highest age-specific rates, and about
 one in four black women 75 years or older had diabetes (Figure 2.4).

 In 1987, the North Central region had the lowest age-adjusted prevalence
 rate of the four regions (Table 2.6). From 1980 to 1987, the prevalence
 rate increased in all regions except the North Central (Figure 2.5).
 The greatest overall increases in the prevalence rate occurred in
 the Northeast and West (17%-18%).

 We present average prevalence rates during 1980-1987 by race, sex,
 and age for the different regions (Tables 2.7-2.10). The highest age-adjusted
 prevalence rates among white males occurred in the Northeast region
 (Table 2.7).  This resulted from high rates among men aged 65 years
 and older. Among white females, the highest age-adjusted rate occurred
 in the South (Table 2.8).  This increase occurred because of higher
 rates among women less than age 65 years. For black males, the highest
 diabetes rates occurred in the West--the rates were especially
 high among black men 45 through 74 years old (Table 2.9). The second
 highest age-adjusted rate for black males occurred in the Northeast
 region as a result of high rates in persons aged 65 years and older.  Among
 black females, the highest rates occurred in the North Central and
 South regions (Table 2.10).  The South had prevalence rates of approximately
 200 per 1,000 black women aged 65 years and older.

 Incidence

 We present the incidence rates of diabetes for various population subgroups
 (Tables 2.11-2.15). The rate of new diabetes cases in the total population
 increased from 1980 to 1983 and then leveled off (Figure 2.6). Among white
 females the incidence rate increased during 1980-1987, whereas among white
 males the rate decreased (Figure 2.7). We did not conduct separate analyses
 of black males and females because sample sizes were too small.

 The lowest age-specific incidence rates in all years occurred among
 persons aged 0-44 years (Table 2.11).  In 1986 and 1987, the incidence
 rate was highest among those 65 years or older, whereas in previous
 years the incidence rate among 45- to 64-year-old persons was similar
 to or higher than the rate among persons aged 65 years and older.  There
 was no definite temporal trend apparent for persons less than 65 years
 old.  Among those persons 65 years old and older, however, the incidence
 rate tended to increase, from slightly more than 5.6 per 1,000 in
 the early 1980s to more than 8 per 1,000 in 1986 and 1987.  The increasing
 incidence rate in the oldest age group was most evident in females,
 among whom the rate increased from 6.3 per 1,000 in 1980 to 10.6 per
 1,000 in 1987 (Table 2.13).

 Discussion

 During 1980-1987, the number of persons known to have diabetes
 increased by more than 1 million, such that by 1987 nearly
 7 million persons in the United States knew that they had diabetes.
 This increase was related to both growth in the United States population
 and an increase in the prevalence rate of diabetes. The prevalence
 rate of diabetes has been increasing since 1959, but the rate of increase
 appears to be leveling off. Prevalence rates estimated from NHIS data
 from 1959 to 1987 have shown the following increases: 1) 67% from
 1959 to 1966; 2) 41% from 1966 to 1973; 3) 21% from 1973 to 1980;
 and 4) 9% from 1980 to 1987.

 During 1980-1987, diabetes prevalence rates were higher among blacks than
 whites. Black males had a rate 1.4 times higher than white males--black
 females had a rate approximately two times higher than white females.
 Black women aged 75 years and older had the highest rate, with almost
 one in four having diabetes. We could not estimate incidence rates
 for blacks and other minorities because the sample sizes were too
 small to provide precise estimates.

 Overall, the South had the highest diabetes prevalence rate and the
 highest rate among women.  Black males had the highest rate in the
 West and in the Northeast.

 Because prevalence is influenced by both disease incidence and duration
 (i.e., mortality rates), we have noted only small changes in the prevalence
 rate.  Our results suggest an increase in diabetes incidence in the
 early 1980s with a leveling off after 1983. Mortality rates among
 persons with diabetes decreased slightly during 1980-1987 (Chapter 3).

 Relying on self-report for estimating incidence and prevalence of
 diabetes has two potential drawbacks: 1) inaccurate reporting of disease
 status; and 2) incomplete disease ascertainment.  Recent research
 indicates excellent agreement between self-report and medical records
 concerning a person's diabetes status (Bush et al., 1989). Thus, self-report
 adequately estimates the incidence and prevalence of diagnosed diabetes.  A
 substantial number of persons with diabetes, however, are not diagnosed.
 According to the second National Health and Nutrition Examination
 Survey (NHANES II), about half of the persons with diabetes have not
 been diagnosed (Harris et al., 1987).  Thus, the NHIS undoubtedly
 underestimates the true prevalence of diabetes.

 For surveillance of temporal trends, diabetes cases not diagnosed
 would not be an impediment if the degree of underascertainment were
 constant over time and similar among different population groups.
 From NHANES II, the proportion of persons with undiagnosed diabetes
 was similar among males and females and among blacks and whites (Harris
 et al., 1987).  Thus, differences among race and sex groups we have
 noted probably do not result from differences in disease ascertainment.
 We do not suspect that diabetes ascertainment changed from 1980 to 1987,
 but we cannot be certain until NHANES III, currently being conducted,
 is completed.

 Unstandardized diagnostic techniques and criteria also can cause the
 rate of diabetes to fluctuate (West, 1978). Because diagnostic criteria
 for diabetes have been standardized since 1979 (National Diabetes
 Data Group, 1979), we believe that changing diagnostic criteria have
 had very little impact on diabetes trends during 1980-1987.

 Random variation may have influenced our results, but we have tried
 to minimize the impact by presenting results that have less than 30%
 relative standard errors. Thus, we restricted race-specific incidence
 results to whites and used wide age groupings for all age-specific
 results.

 Data from NHIS indicate that the number of persons with diabetes
 is increasing, that blacks have higher prevalence rates than whites,
 and that the incidence rate is highest among women older than 64 years
 and is increasing in this group. As the population ages, we can expect
 that the number of persons with diabetes will continue to grow unless
 effective strategies are identified to prevent its occurrence.

 Update

      This section updates data presented in previous sections in light of two
 additional years of prevalence and incidence data.  For a complete description
 of the methods and operational definitions and for a discussion of the
 implications of the findings, see previous sections.

 Prevalence

      In 1989, about 6.7 million persons in the United States (2.7% of the
 population) reported that they had diabetes (Table 2.1).  Although the
 prevalence of diabetes has increased since 1959, the overall rate of increase
 has slowed and leveled off.  Diabetes prevalence as estimated from National
 Health Interview Survey (NHIS) data has increased as follows:  1) 67% increase
 from 1959 to 1966; 2) 41% increase from 1966 to 1973; 3) 21% increase from
 1973 to 1980; and 4) 4% increase from 1980 to 1989.
      During the 1980s, diabetes prevalence was higher among blacks than
 whites (Figure 1.2, Tables 2.2-2.5).  Black females aged 65 years and older
 had the highest rates.  Black males were the only race-sex group to show a
 marked increase in prevalence during the 1980s, increasing 28% between 1980
 and 1989.

 Incidence

      In 1989, there were 677,000 new cases of diabetes (Table 2.11).  The
 rate of new diabetes cases (i.e., diabetes incidence) increased in the early
 1980s and then leveled off (Figure 1.3).  The lowest age-specific incidence
 rates occurred among persons younger than age 45.  Throughout the 1980s, white
 females had higher incidence rates than white males (Tables 2.14-2.15).
 Incidence rates for black males and black females could not be examined
 because of small sample sizes.

 Detailed Tables

 1.1-1.7 Resident Population by Age and Year, U.S., 80-89

 1.1 Age and Year

 Table 1.1  Resident Population (a), by Age and Year, United States, 1980-1985

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4         16457      16931      17297      17651      17830      18004
  5-9         16608      16094      16022      16149      16467      16826
  10-14       18236      18314      18172      17913      17511      17101
  15-19       21104      20503      19889      19277      18789      18555
  20-24       21379      21614      21587      21487      21325      20993
  25-29       19697      20202      20756      21205      21540      21764
  30-34       17753      18787      18809      19213      19698      20271
  35-39       14080      14379      15597      16161      16929      17706
  40-44       11725      12019      12449      13134      13614      14057
  45-49       11048      10991      11026      11228      11461      11646
  50-54       11698      11614      11452      11207      11026      10936
  55-59       11615      11577      11508      11524      11439      11336
  60-64       10145      10372      10596      10695      10859      10980
  65-69        8812       8917       9038       9181       9285       9432
  70-74        6840       6996       7157       7310       7449       7573
  75-79        4827       4951       5085       5223       5360       5499
  80-84        2953       3017       3091       3166       3244       3330
  85+          2269       2353       2449       2538       2623       2694
  Total      227247     229630     231981     234260     236448     238703

 (a) In thousands.

 Table 1.1  Resident Population (a), by Age and Year, United States, 1986-1989

                            Year
               1986       1987       1988       1989
  Age
  0-4         18157      18279      18459      18754
  5-9         17300      17667      18034      18212
  10-14       16567      16487      16630      16951
  15-19       18616      18465      18222      17813
  20-24       20407      19785      19178      18702
  25-29       22013      21986      21886      21699
  30-34       20778      21337      21804      22136
  35-39       18723      18737      19142      19622
  40-44       14351      15572      16129      16883
  45-49       11927      12351      13030      13522
  50-54       10882      10920      11131      11374
  55-59       11267      11120      10892      10725
  60-64       10947      10881      10918      10865
  65-69        9661       9885       9992      10170
  70-74        7670       7776       7901       8011
  75-79        5635       5772       5898       6031
  80-84        3418       3517       3615       3727
  85+          2776       2863       2947       3041
  Total      241096     243400     245807     248239

 (a) In thousands.

 1.2 Age and Year, White Males

 Table 1.2  Resident Population (a) of White Males, by Age and Year,
            United States, 1980-85

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4          6923       7104       7238       7370       7434       7496
  5-9          6987       6742       6699       6747       6863       6990
  10-14        7725       7740       7649       7504       7305       7099
  15-19        8971       8663       8364       8081       7849       7746
  20-24        9127       9204       9157       9084       8991       8807
  25-29        8441       8646       8863       9046       9175       9253
  30-34        7650       8077       8044       8199       8399       8639
  35-39        6065       6191       6744       6970       7285       7607
  40-44        5016       5137       5318       5628       5836       6025
  45-49        4736       4702       4708       4788       4882       4948
  50-54        5011       4972       4895       4775       4686       4634
  55-59        4923       4886       4840       4848       4811       4771
  60-64        4247       4349       4446       4474       4536       4576
  65-69        3531       3578       3634       3704       3753       3823
  70-74        2595       2658       2723       2789       2849       2904
  75-79        1680       1724       1771       1822       1874       1927
  80-84         937        956        978       1000       1023       1049
  85+           626        638        654        668        682        692
  Total       95191      95966      96725      97498      98231      98986

 (a) In thousands.

 Table 1.2  Resident Population (a) of White Males, by Age and Year,
            United States, 1986-89

                            Year
               1986       1987       1988       1989
  Age
  0-4          7541       7573       7634       7716
  5-9          7173       7308       7443       7504
  10-14        6849       6804       6857       6973
  15-19        7757       7664       7527       7327
  20-24        8523       8228       7944       7731
  25-29        9349       9314       9239       9142
  30-34        8850       9074       9261       9385
  35-39        8029       7993       8146       8342
  40-44        6147       6699       6920       7229
  45-49        5062       5241       5546       5758
  50-54        4600       4610       4695       4791
  55-59        4740       4673       4561       4480
  60-64        4540       4499       4517       4498
  65-69        3928       4026       4058       4130
  70-74        2949       3001       3064       3120
  75-79        1980       2036       2088       2147
  80-84        1077       1112       1147       1189
  85+           706        722        739        761
  Total       99802     100579     101387     102224

 (a) In thousands.

 1.3 Age and Year, White Females

 Table 1.3  Resident Population (a) of White Females, by Age and Year,
            United States, 1980-85

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4          6571       6744       6876       7000       7061       7119
  5-9          6635       6403       6355       6397       6508       6633
  10-14        7360       7366       7271       7130       6932       6727
  15-19        8634       8345       8063       7779       7558       7445
  20-24        8985       9056       9026       8956       8860       8694
  25-29        8357       8536       8734       8892       9003       9074
  30-34        7663       8063       8008       8140       8313       8526
  35-39        6153       6275       6814       7032       7332       7634
  40-44        5140       5258       5441       5748       5958       6145
  45-49        4913       4866       4864       4942       5033       5098
  50-54        5332       5269       5168       5031       4926       4871
  55-59        5464       5433       5383       5369       5301       5218
  60-64        4882       4974       5065       5096       5162       5209
  65-69        4387       4425       4473       4529       4564       4616
  70-74        3595       3667       3738       3805       3865       3916
  75-79        2700       2766       2837       2908       2977       3044
  80-84        1784       1822       1864       1908       1954       2003
  85+          1461       1524       1594       1657       1717       1768
  Total      100017     100792     101572     102317     103023     103741

 (a) In thousands.

 Table 1.3  Resident Population (a) of White Females, by Age and Year,
            United States, 1986-89

                            Year
               1986       1987       1988       1989
  Age
  0-4          7164       7194       7252       7335
  5-9          6807       6938       7067       7124
  10-14        6491       6442       6489       6601
  15-19        7448       7349       7214       7015
  20-24        8410       8125       7849       7628
  25-29        9155       9127       9064       8960
  30-34        8706       8907       9074       9182
  35-39        8031       7975       8111       8283
  40-44        6267       6811       7026       7321
  45-49        5211       5391       5697       5915
  50-54        4824       4823       4903       4998
  55-59        5159       5062       4930       4830
  60-64        5180       5129       5122       5071
  65-69        4706       4796       4830       4899
  70-74        3949       3990       4036       4074
  75-79        3109       3171       3225       3282
  80-84        2054       2109       2161       2220
  85+          1825       1884       1940       2000
  Total      104497     105224     105990     106737

 (a) In thousands.

 1.4 Age and Year, Black Males

 Table 1.4  Resident Population (a) of Black Males, by Age and Year,
            United States, 1980-85

                                       Year

               1980       1981       1982       1983       1984       1985
  Age
  0-4          1248       1287       1313       1342       1351       1362
  5-9          1263       1234       1235       1245       1277       1314
  10-14        1350       1362       1367       1367       1356       1347
  15-19        1503       1491       1467       1439       1412       1392
  20-24        1317       1340       1350       1363       1370       1371
  25-29        1106       1149       1201       1242       1277       1302
  30-34         891        963        999       1036       1076       1119
  35-39         671        682        721        757        809        861
  40-44         572        585        604        623        638        653
  45-49         519        522        527        538        550        563
  50-54         508        510        511        512        513        514
  55-59         470        478        486        491        496        500
  60-64         389        398        408        420        430        439
  65-69         334        338        342        347        353        361
  70-74         236        241        246        251        255        259
  75-79         154        158        162        165        169        172
  80-84          76         77         79         80         82         83
  85+            54         56         58         61         63         65
  Total       12659      12870      13074      13279      13475      13678

 (a) In thousands.

 Table 1.4  Resident Population (a) of Black Males, by Age and Year,
            United States, 1986-89

                            Year
               1986       1987       1988       1989
  Age
  0-4          1380       1400       1423       1469
  5-9          1354       1383       1412       1423
  10-14        1314       1315       1327       1362
  15-19        1403       1408       1408       1394
  20-24        1360       1335       1306       1279
  25-29        1326       1334       1342       1342
  30-34        1162       1213       1254       1289
  35-39         930        961        999       1035
  40-44         662        699        735        782
  45-49         575        594        612        626
  50-54         517        523        533        544
  55-59         503        505        506        508
  60-64         448        455        463        467
  65-69         369        380        391        402
  70-74         263        266        269        274
  75-79         176        180        183        187
  80-84          86         88         89         91
  85+            66         68         70         72
  Total       13894      14106      14320      14545

 (a) In thousands.

 1.5 Age and Year, Black Females

 Table 1.5  Resident Population (a) of Black Females, by Age and Year,
            United States, 1980-85

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4          1228       1263       1289       1312       1319       1326
  5-9          1242       1213       1210       1218       1247       1284
  10-14        1334       1341       1343       1338       1322       1310
  15-19        1506       1489       1462       1434       1406       1381
  20-24        1440       1463       1470       1480       1479       1476
  25-29        1259       1301       1351       1392       1426       1449
  30-34        1038       1120       1160       1201       1242       1287
  35-39         806        819        866        910        970       1028
  40-44         692        708        730        752        769        790
  45-49         631        636        643        658        675        692
  50-54         629        631        633        633        632        634
  55-59         575        583        590        595        598        601
  60-64         490        499        510        522        533        543
  65-69         448        453        457        461        465        472
  70-74         332        342        351        360        367        372
  75-79         237        243        250        256        263        270
  80-84         126        131        136        141        145        149
  85+           108        113        120        126        133        138
  Total       14123      14347      14570      14787      14991      15202

 (a) In thousands.

 Table 1.5  Resident Population (a) of Black Females, by Age and Year,
            United States, 1986-89

                            Year
               1986       1987       1988       1989
  Age
  0-4          1340       1357       1380       1421
  5-9          1320       1346       1371       1378
  10-14        1278       1275       1286       1318
  15-19        1386       1387       1384       1365
  20-24        1458       1431       1402       1372
  25-29        1471       1478       1487       1485
  30-34        1329       1378       1420       1455
  35-39        1107       1145       1186       1225
  40-44         802        847        889        945
  45-49         707        729        751        769
  50-54         640        646        661        679
  55-59         605        607        608        608
  60-64         551        557        562        567
  65-69         480        491        503        515
  70-74         378        381        383        386
  75-79         278        285        293        299
  80-84         153        157        161        165
  85+           145        152        158        165
  Total       15427      15648      15882      16115

 (a) In thousands.

 1.6 Age and Year, Other Males

 Table 1.6  Resident Population (a) of Other Males, by Age and Year,
            United States, 1980-85

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4           247        270        294        316        336        353
  5-9           245        256        266        274        288        305
  10-14         238        259        279        294        305        316
  15-19         253        268        278        285        295        308
  20-24         256        279        297        310        321        332
  25-29         254        274        294        307        321        336
  30-34         239        265        284        303        321        339
  35-39         184        197        215        232        251        270
  40-44         149        162        174        185        198        212
  45-49         116        125        136        146        157        169
  50-54          99        105        111        116        123        130
  55-59          86         91         95         99        103        108
  60-64          64         70         77         83         91         96
  65-69          54         57         61         64         68         72
  70-74          41         44         48         50         53         56
  75-79          27         29         31         34         36         40
  80-84          12         14         15         16         17         19
  85+             8          8          9         10         11         12
  Total        2573       2771       2962       3124       3296       3473

 (a) In thousands.

 Table 1.6  Resident Population (a) of Other Males, by Age and Year,
            United States, 1986-89

                            Year
               1986       1987       1988       1989
  Age
  0-4           370        381        391        414
  5-9           326        349        374        394
  10-14         325        332        342        355
  15-19         325        343        360        371
  20-24         339        344        349        357
  25-29         350        362        372        381
  30-34         355        373        389        404
  35-39         295        315        333        354
  40-44         225        244        262        283
  45-49         181        192        204        217
  50-54         140        150        161        174
  55-59         113        119        125        133
  60-64         102        106        110        113
  65-69          79         86         94        100
  70-74          59         62         66         69
  75-79          42         45         49         51
  80-84          20         21         24         26
  85+            14         15         16         17
  Total        3661       3836       4022       4212

 (a) In thousands.

 1.7 Age and Year, Other Females

 Table 1.7  Resident Population (a) of Other Females, by Age and Year,
            United States, 1980-85

                                       Year
               1980       1981       1982       1983       1984       1985
  Age
  0-4           241        265        288        311        330        348
  5-9           237        247        258        268        282        299
  10-14         228        246        263        280        291        302
  15-19         237        247        255        260        269        282
  20-24         254        272        287        295        304        312
  25-29         280        296        314        326        338        350
  30-34         272        299        316        333        347        361
  35-39         199        215        238        259        282        305
  40-44         156        169        183        198        215        233
  45-49         133        140        148        156        165        177
  50-54         119        127        134        140        146        153
  55-59          97        106        114        122        130        138
  60-64          74         82         90         99        108        116
  65-69          59         66         72         77         83         89
  70-74          40         45         51         56         60         66
  75-79          29         32         34         38         42         46
  80-84          17         18         20         21         23         26
  85+            13         14         15         17         17         19
  Total        2685       2884       3077       3255       3431       3623

 (a) In thousands.

 Table 1.7  Resident Population (a) of Other Females, by Age and Year,
            United States, 1986-89

                               Year
               1986       1987       1988       1989
  Age
  0-4           362        373        380        399
  5-9           321        344        368        389
  10-14         310        318        329        342
  15-19         297        314        329        341
  20-24         317        322        328        335
  25-29         362        372        383        389
  30-34         376        393        406        420
  35-39         332        348        366        382
  40-44         249        273        296        322
  45-49         191        204        220        237
  50-54         160        168        178        189
  55-59         146        154        161        167
  60-64         125        135        144        150
  65-69          98        106        116        125
  70-74          72         77         83         89
  75-79          50         55         60         66
  80-84          28         30         33         37
  85+            20         22         25         27
  Total        3816       4007       4205       4406

 (a) In thousands.

 2.1-2.5 Prevalence of Diabetes, Age & Year, U.S., 80-89

 2.1 Age and Year

 Table 2.1  Prevalence of Diabetes, by Age and Year, United States, 1980-1985

                                                  Year
                              1980     1981     1982     1983     1984     1985
  Age
  0-44    Number (a)          1010      952      984     1002      994     1038
          Rate (b)             6.4      6.0      6.1      6.2      6.1      6.3

  45-64   Number              2389     2544     2567     2599     2359     2330
          Rate                53.7     57.1     57.6     58.2     52.7     51.9

  65-74   Number              1522     1365     1525     1305     1757     1851
          Rate                97.3     85.8     94.2     79.1    105.0    108.9

  75+     Number               861      948      810      874     1090     1101
          Rate                85.7     91.8     76.3     80.0     97.1     95.5

  Total   Number              5782     5809     5886     5781     6200     6320
          Rate                25.4     25.1     25.2     24.5     25.9     26.2

  Age-adjusted Rate           25.4     25.3     25.4     24.7     26.0     26.2

 (a) In thousands.
 (b) Per 1,000 people.

 Table 2.1  Prevalence of Diabetes, by Age and Year, United States, 1986-1989

                                         Year
                              1986     1987     1988     1989
  Age
  0-44    Number (a)          1047     1364     1092     1224
          Rate (b)             6.3      8.1      6.4      7.2

  45-64   Number              2847     2552     2460     2707
          Rate                63.2     56.4     53.5     58.2

  65-74   Number              1593     1703     1704     1632
          Rate                91.9     96.4     95.2     89.8

  75+     Number              1284     1193     1094     1096
          Rate               108.6     98.2     87.8     85.7

  Total   Number              6772     6812     6350     6659
          Rate                27.8     27.7     25.6     26.6

  Age-adjusted Rate           27.9     27.6     25.4     26.3

 (a) In thousands.
 (b) Per 1,000 people.

 2.2 Age and Year, White Males

 Table 2.2  Prevalence of Diabetes, by Age and Year, White Males,
            United States, 1980-1985

                                                  Year
                          1980     1981     1982     1983     1984     1985
  Age
  0-44    Number (a)       311      369      384      408      354      392
          Rate (b)         4.7      5.5      5.6      5.9      5.1      5.6

  45-64   Number           917     1017      977      920      813      873
          Rate            48.5     53.8     51.7     48.7     43.0     46.1

  65-74   Number           595      553      430      417      592      679
          Rate            97.1     88.7     67.6     64.2     89.6    101.0

  75+     Number           256      228      301      328      324      350
          Rate            78.8     68.8     88.4     94.0     90.5     95.5

  Total   Number          2079     2168     2092     2073     2083     2295
          Rate            22.0     22.7     21.6     21.2     21.2     23.2

  Age-adjusted Rate       22.9     23.5     22.6     22.2     22.1     24.1

 (a) In thousands.
 (b) Per 1,000 people.

 Table 2.2  Prevalence of Diabetes, by Age and Year, White Males,
            United States, 1986-1989

                                         Year
                              1986     1987     1988     1989
  Age

  0-44    Number (a)           301      578      484      415
          Rate (b)             4.3      8.2      6.8      5.8

  45-64   Number              1237     1052      936     1080
          Rate                65.3     55.3     48.5     55.3

  65-74   Number               625      705      558      535
          Rate                90.9    100.3     78.3     73.8

  75+     Number               405      420      386      257
          Rate               107.6    108.5     97.1     62.8

  Total   Number              2568     2756     2363     2288
          Rate                25.7     27.4     23.3     22.4

  Age-adjusted Rate           26.8     28.2     23.9     22.7

 (a) In thousands.
 (b) Per 1,000 people.

 2.3 Age and Year, White Females

 Table 2.3  Prevalence of Diabetes, by Age and Year, White Females, United
            States, 1980-1985

                                                  Year
                              1980     1981     1982     1983     1984     1985
  Age

  0-44    Number (a)           476      420      475      404      439      500
          Rate (b)             7.3      6.4      7.1      6.0      6.5      7.4

  45-64   Number               980      998      986     1081     1045      913
          Rate                47.6     48.6     48.1     52.9     51.2     44.8

  65-74   Number               749      617      785      630      802      885
          Rate                93.9     76.2     95.6     75.5     95.2    103.8

  75+     Number               519      595      425      458      593      594
          Rate                87.2     97.4     67.5     70.8     89.2     87.1

  Total   Number              2723     2630     2670     2572     2879     2893
          Rate                26.7     25.6     25.9     24.7     27.4     27.4

  Age-adjusted Rate           24.7     23.5     23.9     22.8     25.0     24.9

 (a) In thousands.
 (b) Per 1,000 people.

 Table 2.3  Prevalence of Diabetes, by Age and Year, White Females, United
            States, 1986-1989

                                         Year
                              1986     1987     1988     1989
  Age

  0-44    Number (a)           591      511      356      547
          Rate (b)             8.6      7.4      5.1      7.9

  45-64   Number              1071      955      923     1045
          Rate                52.6     46.8     44.7     50.2

  65-74   Number               677      745      827      801
          Rate                78.2     84.7     93.3     89.3

  75+     Number               681      535      512      644
          Rate                97.4     74.7     69.9     85.9

  Total   Number              3019     2746     2618     3037
          Rate                28.2     25.6     24.2     27.9

  Age-adjusted Rate           25.9     23.4     21.8     25.2

 (a) In thousands.
 (b) Per 1,000 people.

 2.4 Age and Year, Black Males

 Table 2.4  Prevalence of Diabetes, By Age and Year, Black Males,
            United States, 1980-1985

                                                  Year
                              1980     1981     1982     1983     1984     1985
  Age

  0-44    Number (a)            73       64       62       37       55       63
          Rate (b)             7.4      6.4      6.0      3.5      5.2      5.9

  45-64   Number               186      185      180      204      215      222
          Rate                98.7     97.2     93.2    104.2    108.3    110.1

  65-74   Number                62       68       71       85       88       99
          Rate               108.1    116.8    120.1    142.7    145.0    159.2

  75+     Number                29       23       25       24       35       34
          Rate               103.6     79.3     83.7     79.8    111.6    107.3

  Total   Number               350      340      337      351      394      418
          Rate                28.2     26.9     25.8     26.2     29.1     30.7

  Age-adjusted Rate           35.6     37.2     32.4     33.7     42.5     43.1

 (a) In thousands.
 (b) Per 1,000 people.

 Table 2.4  Prevalence of Diabetes, by Age and Year, Black Males,
            United States, 1986-1989

                                         Year
                              1986     1987     1988     1989
  Age
  0-44    Number (a)            83       91       81       82
          Rate (b)             7.6      8.2      7.2      7.3

  45-64   Number               204      210      247      276
          Rate                99.8    100.9    116.8    128.7

  65-74   Number                91      104       85       87
          Rate               143.3    160.5    128.6    128.2

  75+     Number                39       35       51       54
          Rate               119.5    104.4    150.9    155.2

  Total   Number               417      439      464      499
          Rate                30.4     31.6     32.9     34.8

  Age-adjusted Rate           38.7     38.2     46.3     45.5

 (a) In thousands.
 (b) Per 1,000 people.

 2.5 Age and Year, Black Females

 Table 2.5  Prevalence of Diabetes, By Age and Year, Black Females, United
            States, 1980-1985

                                                  Year
                              1980     1981     1982     1983     1984     1985
  Age

  0-44    Number (a)           112       97       86      116      109       91
          Rate (b)            10.6      9.0      7.9     10.5      9.7      8.1

  45-64   Number               251      284      322      301      281      259
          Rate               108.2    120.8    135.6    124.9    115.4    104.8

  65-74   Number               103      137      160      200      186      183
          Rate               132.5    172.3    197.9    243.6    224.0    216.6

  75+     Number                71       70       68       84       92      118
          Rate               151.2    144.9    134.1    160.1    170.6    211.6

  Total   Number               538      588      636      700      669      651
          Rate                37.7     40.6     43.2     46.8     44.1     42.3

  Age-adjusted Rate           43.7     45.0     55.8     53.9     56.9     46.2

 (a) In thousands.
 (b) Per 1,000 people.

 Table 2.5  Prevalence of Diabetes, by Age and Year, Black Females, United
            States, 1986-1989

                                         Year
                              1986     1987     1988     1989
  Age
  0-44    Number (a)            87      109      135      131
          Rate (b)             7.6      9.4     11.4     11.0

  45-64   Number               280      280      243      226
          Rate               112.0    110.2     94.2     86.2

  65-74   Number               144      142      155      176
          Rate               167.8    163.5    174.6    195.6

  75+     Number               126      147      141      135
          Rate               219.7    247.1    230.1    214.7

  Total   Number               638      678      674      669
          Rate                40.9     42.7     41.8     40.9

  Age-adjusted Rate           48.2     50.9     51.6     43.4

 (a) In thousands.
 (b) Per 1,000 people.

 2.6-2.10 Prevalence Rate of Diabetes per 1,000 Pop., U.S., 80-89

 2.6 Region and Year

 Table 2.6  Prevalence (a) of Diabetes, by Region and Year, United States,
            1980-1985
                                                       Year
                                      1980   1981   1982   1983   1984   1985
  Region         Rate

  Northeast      Crude                26.0   25.1   25.3   25.2   26.8   29.5
                 Age-Adjusted         24.8   23.9   23.9   23.8   25.4   28.1

  North Central  Crude                24.6   24.8   24.5   25.0   25.6   26.4
                 Age-Adjusted         24.8   25.1   25.4   25.8   25.9   25.7

  South          Crude                27.8   27.9   27.8   27.9   27.4   27.5
                 Age-Adjusted         28.1   28.2   28.1   28.3   27.7   28.1

  West           Crude                20.8   21.3   20.1   21.0   21.1   22.3
                 Age-Adjusted         21.9   22.4   21.1   21.4   22.1   23.7

 (a) Per 1,000 People

 Table 2.6  Prevalence (a) of Diabetes, by Region and Year, United States,
            1986-1989
                                               Year
                                      1986   1987   1988   1989
  Region          Rate

  Northeast       Crude               30.4   29.8   26.9   25.9
                  Age-Adjusted        28.4   27.7   24.9   23.9

  North Central   Crude               25.7   25.5   26.0   26.8
                  Age-Adjusted        25.0   25.1   25.8   26.4

  South           Crude               28.6   28.7   29.2   28.0
                  Age-Adjusted        29.1   29.1   29.2   28.0

  West            Crude               23.4   23.1   22.9   22.3
                  Age-Adjusted        25.5   24.5   24.1   23.4

 (a) Per 1,000 People

 2.7 Age and Region, White Males

 Table 2.7  Prevalence Rate of Diabetes per 1,000 Population,
            by Age and Region, White Males, United States, 1980-1989

                                             Age

                            0-44  45-64  65-74   75+   Total   Age-adjusted
  Region

  Northeast                  5.6   53.4   97.5   99.2   25.7   25.4

  North Central              5.7   53.7   78.8   83.0   22.5   23.6

  South                      6.2   52.7   92.9   82.5   23.9   24.6

  West                       4.9   44.6   72.2   85.6   19.2   20.9

 2.8 Age and Region, White Females

 Table 2.8  Prevalence Rate of Diabetes per 1,000 Population,
            by Age and Region, White Females, United States, 1980-1989

                                             Age

                            0-44  45-64  65-74   75+   Total   Age-adjusted
  Region

  Northeast                  5.4   47.9   93.4   89.7   27.7   23.5

  North Central              7.1   48.7   94.3   79.9   26.5   24.5

  South                      8.4   52.0   83.0   85.3   27.6   25.5

  West                       6.1   44.1   80.5   80.0   22.5   21.9

 2.9 Age and Region, Black Males

 Table 2.9  Prevalence Rate of Diabetes per 1,000 Population,
            by Age and Region, Black Males, United States, 1980-1989

                                             Age

                            0-44  45-64  65-74   75+   Total   Age-adjusted
  Region

  Northeast                  4.8  111.2  150.9  176.0   30.1   43.3

  North Central              3.8  112.8   93.9  106.8   26.8   35.9

  South                      7.6   87.3  126.8  106.8   27.9   35.8

  West                       8.2  180.0  214.1   78.2   43.7   59.2

 2.10 Age and Region, Black Females

 Table 2.10  Prevalence Rate of Diabetes per 1,000 Population,
             by Age and Region, Black Females, United States, 1980-1989

                                             Age

                            0-44  45-64  65-74   75+   Total   Age-adjusted
  Region

  Northeast                  4.3   93.9  152.4  113.4   30.2   36.9

  North Central             11.0  132.6  102.3  150.8   40.2   47.3

  South                     10.8  115.4  221.2  203.1   47.0   54.3

  West                      13.8   59.4   93.5  273.2   33.1   39.7

 2.11-15 Incidence Rate of Diabetes per 1,000 Pop., U.S., 80-89

 2.11 Age and Year

 Table 2.11  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, United States, 1980-1985

                                                    Year

                                    1980   1981   1982   1983   1984   1985
  Age

  0-44      Number (b)               179    149    218    159    169    151
            Rate                    1.07   1.18   1.11   1.14   0.99   1.10

  45-64     Number                   191    243    367    363    319    294
            Rate                    4.94   6.07   7.34   7.91   7.34   6.54

  65+       Number                   172    103    128    168    145    235
            Rate                    5.65   5.44   5.25   5.68   6.91   6.73

  Total     Number                   541    495    713    690    633    679
            Rate                    2.34   2.61   2.79   2.96   2.88   2.79

  Age-adjusted Rate                 2.35   2.62   2.80   2.98   2.90   2.80

 (a) Three-year moving average
 (b) In thousands

 Table 2.11  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, United States, 1986-1989

                                             Year

                                    1986   1987   1988   1989
  Age

  0-44      Number (b)               218    226    265    256
            Rate                    1.21   1.43   1.50   1.56

  45-64     Number                   260    215    256    335
            Rate                    5.73   5.41   5.90   6.45

  65+       Number                   165    290    156     86
            Rate                    8.34   7.25   6.18   4.18

  Total     Number                   644    731    678    677
            Rate                    2.90   2.87   2.89   2.80

  Age-adjusted Rate                 2.90   2.87   2.89   2.81

 (a) Three-year moving average
 (b) In thousands

 2.12 Age and Year, Males

 Table 2.12  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, Males, United States, 1980-1985

                                                    Year

                                    1980   1981   1982   1983   1984   1985
  Age

  0-44      Number (b)                45     84    110     14     26     56
            Rate                    0.85   1.04   0.89   0.63   0.40   0.69

  45-64     Number                   108    134    208    164    112    115
            Rate                    5.81   7.19   8.05   7.70   6.18   5.26

  65+       Number                    61     33     10     77     50     93
            Rate                    4.67   3.40   3.84   4.31   6.78   4.83

  Total     Number                   215    251    328    255    189    263
            Rate                    2.18   2.45   2.53   2.32   2.11   1.95

  Age-adjusted Rate                 2.26   2.51   2.62   2.43   2.25   2.05

 (a) Three-year moving average
 (b) In thousands

 Table 2.12  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, Males, United States, 1986-1989

                                             Year

                                    1986   1987   1988   1989
  Age

  0-44      Number (b)                85     83    131     51
            Rate                    0.92   1.21   1.06   1.09

  45-64     Number                   107    112    133    188
            Rate                    5.22   5.46   6.63   7.31

  65+       Number                    17     91     54     43
            Rate                    5.91   4.66   5.28   4.06

  Total     Number                   210    286    318    282
            Rate                    2.22   2.35   2.53   2.56

  Age-adjusted Rate                 2.32   2.43   2.63   2.64

 (a) Three-year moving average
 (b) In thousands

 2.13 Age and Year, Females

 Table 2.13  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, Females, United States, 1980-1985

                                                    Year

                                    1980   1981   1982   1983   1984   1985
  Age

  0-44      Number (b)               134     65    108    145    143     95
            Rate                    1.29   1.31   1.34   1.65   1.58   1.51

  45-64     Number                    82    108    159    199    207    179
            Rate                    4.15   5.05   6.69   8.10   8.38   7.70

  65+       Number                   111     71    119     91     95    142
            Rate                    6.33   6.86   6.24   6.63   6.99   8.05

  Total     Number                   327    245    385    435    444    416
            Rate                    2.49   2.76   3.02   3.55   3.61   3.57

  Age-adjusted Rate                 2.42   2.67   2.94   3.47   3.52   3.46

 (a) Three-year moving average
 (b) In thousands

 Table 2.13  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, Females, United States, 1986-1989

                                             Year

                                    1986   1987   1988   1989
  Age

  0-44      Number (b)               133    143    135    206
            Rate                    1.50   1.65   1.92   2.02

  45-64     Number                   153    102    124    147
            Rate                    6.19   5.36   5.23   5.67

  65+       Number                   148    199    102     42
            Rate                   10.05   9.07   6.81   4.26

  Total     Number                   434    445    360    395
            Rate                    3.54   3.35   3.22   3.02

  Age-adjusted Rate                 3.39   3.22   3.13   2.99

 (a) Three-year moving average
 (b) In thousands

 2.14 Age and Year, White Males

 Table 2.14  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, White Males, United States, 1980-1985

                                                    Year

                                    1980   1981   1982   1983   1984   1985
  Age

  0-44      Number (b)                45     74     79     14     26     56
            Rate                    0.93   1.02   0.85   0.60   0.47   0.76

  45-64     Number                    96    109    177     94     53    103
            Rate                    5.52   6.85   6.80   5.78   4.44   4.65

  65+       Number                    61     22     10     65     50     93
            Rate                    4.59   3.38   3.45   4.35   7.10   5.33

  Total     Number                   203    206    266    174    129    251
            Rate                    2.22   2.42   2.28   1.99   1.92   1.99

  Age-adjusted Rate                 2.25   2.43   2.31   2.04   2.00   2.04

 (a) Three-year moving average
 (b) In thousands

 Table 2.14  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, White Males, United States, 1986-1989

                                             Year

                                    1986   1987   1988   1989
  Age

  0-44      Number (b)                73     71     93     51
            Rate                    0.97   1.14   1.03   1.04

  45-64     Number                   107     47    112    149
            Rate                    4.53   4.66   5.35   6.78

  65+       Number                    17     74     50     43
            Rate                    5.98   4.47   5.20   4.31

  Total     Number                   198    192    254    243
            Rate                    2.18   2.17   2.32   2.50

  Age-adjusted Rate                 2.23   2.21   2.35   2.53

 (a) Three-year moving average
 (b) In thousands

 2.15 Age and Year, White Females

 Table 2.15  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, White Females, United States, 1980-1985

                                                    Year

                                    1980   1981   1982   1983   1984   1985
  Age

  0-44      Number (b)                96     60    108    102    125     86
            Rate                    1.21   1.35   1.37   1.68   1.56   1.69

  45-64     Number                    82     94    121    159    170    126
            Rate                    4.36   4.90   6.14   7.37   7.44   7.14

  65+       Number                   101     61     97     80     73    125
            Rate                    6.23   6.52   5.83   5.99   6.57   8.03

  Total     Number                   279    216    325    342    368    338
            Rate                    2.53   2.77   2.94   3.42   3.43   3.66

  Age-adjusted Rate                 2.39   2.63   2.80   3.28   3.28   3.48

 (a) Three-year moving average
 (b) In thousands

 Table 2.15  Incidence Rate (a) of Diabetes per 1,000 Population, by Age
             and Year, White Females, United States, 1986-1989

                                             Year

                                    1986   1987   1988   1989
  Age

  0-44      Number (b)               133    105     99    173
            Rate                    1.58   1.64   1.83   1.97

  45-64     Number                   141     67     98    113
            Rate                    5.47   4.99   4.52   5.11

  65+       Number                   148     92    102     36
            Rate                    8.32   7.65   5.06   4.53

  Total     Number                   422    264    299    323
            Rate                    3.30   3.15   2.82   2.96

  Age-adjusted Rate                 3.11   2.97   2.72   2.88

 (a) Three-year moving average
 (b) In thousands


MORTALITY

 Introduction

 In 1986, diabetes mellitus was the seventh leading cause of death in the
 United States (National Center for Health Statistics, 1988) and the 13th
 leading cause of years of potential life lost before age 65 (Centers for
 Disease Control, 1988). Because these statistics are based on underlying
 cause of death, however, they understate diabetes' overall impact on
 mortality. Previous studies have shown that diabetes is selected as the
 underlying cause on approximately one quarter of the death certificates on
 which it appears in any field, and diabetes is recorded on only half of the
 certificates for persons who have the disease at the time of death (Harris
 and Entmacher, 1985). Thus, diabetes contributes to a much larger number of
 deaths than it directly causes.

 We describe the number of deaths resulting from diabetes, and the associated
 mortality rates, for 1980 through 1986. We examine diabetes both as an
 underlying cause and as any listed (either underlying or contributory) cause
 of death. We evaluate the number and rates of deaths from diabetes by age,
 race, sex, calendar year, and state. We determine mortality rates for the
 general US population, as well as rates among persons with diabetes. Other
 mortality rates of interest are presented somewhere else. These include
 mortality rates for cardiovascular disease among persons with diabetes
 (Chapter 5) and mortality rates associated with diabetic ketoacidosis
 (Chapter 7).

 Methods

 To enumerate deaths from diabetes during 1980 through 1986,
 we used mortality data provided by the National Center for Health
 Statistics (NCHS).  The NCHS creates national mortality data tapes
 by abstracting and coding medical information, including underlying
 and contributing causes of death, recorded on vital records from each
 state.  The underlying cause of death is selected according to standard
 criteria (including order) that determine which cause or contributing
 factor listed on the death certificate presides over others that may
 be listed.  For each record on the mortality tape, a single underlying
 cause and a maximum of 20 contributory causes of death may be coded.  We
 identified deaths attributable to diabetes (as either the underlying
 or contributing cause) by using rubric 250 of the 9th Version of the
 International Classification of Diseases.

 We used 1980 census estimates, and intercensal estimates for subsequent
 years, for calculating diabetes mortality rates in the general population.
 To determine diabetic persons' risks of dying from their disease, we
 calculated mortality rates for the U.S. population known to have diabetes.
 We estimated the number of persons with diabetes using information from
 annual Health Interview Surveys (Chapter 2) and used this estimate
 as the denominator in calculating mortality rates for persons known
 to have diabetes.  Because the Health Interview Survey provides national
 or regional estimates, rather than state-specific estimates, of the
 diabetic population in the United States, we restricted our analysis
 of state diabetes mortality to general population rates.

 Mortality rates were standardized according to the direct method (Fleiss,
 1981).  We used the 1980 resident population of the United States
 to standardize rates in the general population and the estimated 1980
 diabetic population to standardize diabetes-specific mortality rates.

 Results

  Diabetes Mortality in the General Population

 The annual number of deaths attributed to diabetes as an underlying
 cause steadily increased from 1980 to 1986, reaching 37,184
 in 1986 (Figure 3.1).  Between 1980 and 1986, the age-standardized
 mortality rates for diabetes as the underlying cause of death among
 U.S. residents declined 4.6%--from 15.3 to 14.6 per 100,000 population
 (Figure 3.2, Table 3.1).  Most of the secular decline in mortality
 rates occurred among persons 65 years and older; rates in other age
 groups stayed about the same (Table 3.1).  In each year, mortality
 rates increased with age, particularly after age 55.  During these
 7 years, age-adjusted mortality rates decreased for white males and
 females, while the corresponding rates for black males and females
 were unchanged (Tables 3.2-3.5).

 Diabetes-related mortality includes those deaths for which diabetes
 was listed as either an underlying or contributing cause on the vital
 record.  In each year, the number of diabetes-related deaths was about
 four times the number of deaths in which diabetes was the underlying
 cause.  The number of diabetes-related deaths increased each year
 and reached 150,000 in 1986 (Table 3.6).  Age-adjusted mortality rates,
 however, for diabetes-related deaths declined 1.8% between 1980 and
 1986 (Figure 3.2).  As with mortality rates for diabetes as an underlying
 cause, most of the decline in rates during these years was seen among
 persons 65 years and older.

 Temporal trends in mortality rates for diabetes as any listed cause
 varied by race and sex (Figure 3.3).  The age-standardized rates for
 white males and white females generally reflect the temporal trends
 seen in the total population.  Between 1980 and 1986, the rates for
 white males and females declined 1.6% and 4.5%, respectively (Tables
 3.7-3.8).  The corresponding mortality rates for black males and females,
 however, increased 11% and 5.5%, respectively (Tables 3.9-3.10).  Black
 females, the group with the highest mortality rates, had annual mortality
 rates that were two-fold higher than those for white females.  Mortality
 rates for black males were 20%-40% higher than those for white males.

 We present annual unadjusted state-specific mortality rates for
 diabetes-related deaths (Table 3.11).  The large variability in
 state-specific mortality rates reflects, in part, demographic differences
 among state populations.  After adjustment for age and race, this
 variability diminishes, with average annual mortality rates (per 100,000)
 ranging from 37.3 in Arkansas to 76.7 in Rhode Island (Table 3.12).  These
 state-specific rates are grouped by quartile (Figure 3.4).  States with
 rates in the highest quartile appear to be located primarily in the
 Northeast and in the region surrounding the Great Lakes.

  Mortality Rates of Persons with Diabetes

 Among the diabetic population, the age-adjusted mortality rate
 for diabetes as the underlying cause of death declined 14.5%
 between 1980 and 1986 (Figure 3.5).  This temporal trend, however,
 was somewhat erratic, with small rate increases noted during the periods
 1981-1983 and 1984-1985.  During these seven years, trends in age-specific
 mortality rates varied (Table 3.13).  Rates clearly fell for persons
 aged 75 years and older.  Mortality declines were also seen for persons
 aged 45 to 74, but these trends are less striking because of year-to-year
 variability. In contrast, for persons less than 45 years, mortality
 rates increased between 1980 and 1986.

 Mortality rates for diabetes as the underlying cause of death declined
 in each race and sex category.  Between 1980 and 1986, the age-adjusted
 rate fell 18.6% for white males and black females, 12.0% for black
 males, and 7.9% for white females (Tables 3.14-3.17).  Of the four
 groups, black males each year consistently had the highest rates.

 The age-adjusted rate for diabetes-related deaths decreased from 2,350
 per 100,000 persons with diabetes in 1980 to 2,066 per 100,000 in
 1986, a 12.1% decline (Figure 3.5, Table 3.18).  As with age-specific
 mortality rates for diabetes as the underlying cause of death,
 diabetes-related mortality rates declined during this period in those
 75 years and older; meanwhile, mortality rates in those persons less
 than 45 years old appeared to increase.

 Age-standardized mortality rates for diabetes-related deaths decreased
 in each race-sex category (Figure 3.6, Tables 3.19-3.22).  Compared
 with rates in 1980, diabetes-related mortality rates in 1986 declined
 16.6% for white males, 14.0% for black females, 4.9% for white females,
 and 3.6% for black males.  In contrast to the results for mortality
 rates among the general population (Figure 3.3), the highest rates
 of diabetes-related mortality in the diabetic population were among
 white males (Figure 3.6). Moreover, whereas black females have the
 highest diabetes-related mortality rates in the general population,
 they have the lowest rates in the diabetic population.

 Discussion

 National death certificate data for 1980 to 1986 indicate that, although
 the number of deaths attributable to diabetes has increased, age-adjusted
 mortality rates for diabetes have declined.  Compared with the rate
 in 1980, the mortality rate in the general population for diabetes
 as an underlying cause of death declined 4.6% to 14.6 per 100,000
 by 1986.  For diabetes-related mortality (diabetes as any listed cause),
 the age-adjusted mortality rate declined 1.8% to 58.7 per 100,000
 by 1986.  When we calculated mortality rates using the population
 of people with diabetes as the denominator, the declines were more
 substantial--12% for diabetes-related mortality.

 We found that diabetes-related mortality rates in the general population
 varied by race and sex.  Rates for black females were highest and
 were double those for white females.  Black males had the second highest
 mortality rates.  Temporal trends also varied by race.  Whereas
 diabetes-related mortality rates declined among whites during 1980-1986,
 the corresponding mortality rates increased among blacks.  These rate
 increases probably reflect the higher prevalence of diabetes among blacks.
 In support of this explanation, mortality rates for the diabetic population,
 which are not influenced by the prevalence of diabetes, declined for
 both races.  Moreover, in contrast to general population rates, rates
 of diabetes-related mortality among persons with diabetes were highest
 among white males.

 Death certificate data are useful for examining secular trends and
 relative differences within subgroups categorized by age, race, and
 sex. There are, however, several well known limitations associated
 with using death certificate data for monitoring cause-specific mortality.
 Foremost are the misclassification and underreporting of diabetes as a
 cause of death on vital records.  Several studies have shown that diabetes
 is recorded on the death certificate of only about 40% of the people
 who are known to have diabetes (Brousseau, 1987; Ochi et al., 1985;
 Palumbo et al., 1976).  This proportion has been fairly constant from
 studies conducted from the mid-1970s to the mid-1980s.  The proportion
 has also been similar for different race and sex groups.  Therefore,
 the mortality rates reported herein probably represent conservative
 estimates of the actual U.S. rates.  Nonetheless, the temporal trends
 and relative differences between race and sex groups are probably valid.

 In each year, the number of deaths from diabetes as any listed cause
 were about four times greater than the number of deaths from diabetes
 as an underlying cause.  Similarly, rates based on underlying cause
 of death, the usual measure of diabetes mortality, reflect only about
 one-quarter of the deaths to which diabetes may have contributed.  Total
 diabetes-related deaths, and the corresponding mortality rates, more
 accurately reflect the considerable disease burden that diabetes imposes
 upon society.  These results suggest that gradual declines in mortality
 from diabetes are occurring, but that diabetes continues to be a leading
 cause of mortality in the United States.

 During 1980 through 1986, there was a substantial decrease in the
 age-adjusted mortality rate of people with diabetes.  Despite this
 improvement, the annual number of deaths related to diabetes increased.
 These findings indicate that, even with improved care for patients
 with diabetes, decreasing the disease burden from diabetes will be
 difficult because of the increasingly older population age structure
 and the concomitant increasing prevalence of diabetes.

 Update

      This section updates data presented in previous sections in light of two
 additional years of mortality data.  For a complete description of the methods
 and operational definitions and for a discussion of the implications of the
 findings, see previous sections.

 Diabetes Mortality in the General Population

      The annual number of deaths with diabetes as the underlying cause of
 death increased from 1980 (34,851) to 1988 (40,368) (Table 3.1).  Between 1982
 and 1988, the age-standardized mortality rates for both black males and
 females increased (23% and 11%, respectively) (Tables 3.4-3.5).  The rates for
 white males and white females remained relatively constant (Tables 3.2-3.3).
      The annual number of deaths with diabetes listed as any cause of death
 (diabetes-related deaths) increased from 135,931 in 1980 to 157,265 in 1988
 (Table 3.6).  Between 1982 and 1988, age-standardized diabetes-related
 mortality rates increased 21% for black males and 15% for black females
 (Figure 1.4, Tables 3.9-3.10).  The rates remained relatively constant for
 white males and white females (Figure 1.4, Tables 3.7-3.8).
      Between 1980 and 1988, both mortality rates for diabetes as an
 underlying cause of death and diabetes-related mortality rates increased with
 age, with the highest rates occurring among those aged 85 and older (Tables
 3.1-3.6).

 Diabetes Mortality in the Diabetic Population

      When age-standardized mortality rates were calculated using as the
 denominator people known to have diabetes, race-sex trends in age-standardized
 mortality rates were less clear.  Age-standardized rates for diabetes as
 underlying cause of death were lower in 1988 than in 1980 for white males,
 black males, and black females (Figure 1.5, Tables 3.14, 3.16, and 3.17).
 White females were the only group whose rates were higher in 1988 than in 1980
 (Figure 1.5, Table 3.15).  Of the four race-sex groups examined, black males
 had the highest age-standardized rates.
      Race-sex trends for diabetes-related mortality rates were similar to
 those seen for diabetes as underlying cause of death, except that white males
 had the highest age-standardized rates.

 Detailed Tables

 3.1-3.5 Deaths with Diabetes as Underlying Cause & Mort. Rate
 
 3.1 100,000 Pop., by Age and Year, U.S., 80-88

 Table 3.1  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            United States, 1980-1985

                                               Year
                             1980    1981    1982    1983    1984    1985
  Age

  0-14    Number               53      46      63      51      36      44
          Rate                0.1     0.1     0.1     0.1     0.1     0.1

  15-24   Number              128     149     134     129     119     121
          Rate                0.3     0.4     0.3     0.3     0.3     0.3

  25-34   Number              572     554     533     584     578     537
          Rate                1.5     1.4     1.3     1.4     1.4     1.3

  35-44   Number              900     916     922    1064    1072    1165
          Rate                3.5     3.5     3.3     3.6     3.5     3.7

  45-54   Number             2188    2167    2060    2078    2005    1991
          Rate                9.6     9.6     9.2     9.3     8.9     8.8

  55-64   Number             5789    5620    5643    5900    5495    5819
          Rate               26.6    25.6    25.5    26.6    24.6    26.1

  65-74   Number            10111    9841    9711   10185    9934   10159
          Rate               64.6    61.8    60.0    61.8    59.4    59.7

  75-84   Number            10134   10221   10339   10923   10857   11308
          Rate              130.3   128.3   126.5   130.2   126.2   128.1

  85+     Number             4971    5120    5170    5328    5690    5817
          Rate              219.0   217.6   211.1   209.9   217.0   216.0

  Total   Number            34851   34642   34583   36246   35787   36969
          Rate               15.3    15.1    14.9    15.5    15.1    15.5

  Age-Adjusted Rate          15.3    15.0    14.6    15.0    14.5    14.7

 Table 3.1   Number of Deaths with Diabetes as Underlying Cause and
             Mortality Rate per 100,000 Population, by Age and Year,
             United States, 1986-1988

                                   Year
                             1986    1987    1988
  Age

  0-14    Number               36      41      40
          Rate                0.1     0.1     0.1

  15-24   Number              140     119     119
          Rate                0.4     0.3     0.3

  25-34   Number              634     618     656
          Rate                1.5     1.4     1.5

  35-44   Number             1174    1203    1395
          Rate                3.5     3.5     4.0

  45-54   Number             2158    2258    2502
          Rate                9.5     9.7    10.4

  55-64   Number             5780    5914    6109
          Rate               26.0    26.9    28.0

  65-74   Number            10269   10789   11092
          Rate               59.3    61.1    62.0

  75-84   Number            11048   11470   11907
          Rate              122.0   123.5   125.2

  85+     Number             5939    6118    6548
          Rate              213.9   213.7   222.2

  Total   Number            37184   38532   40368
          Rate               15.4    15.8    16.4

  Age-Adjusted Rate          14.6    14.8    15.3

 3.2 100,000 Pop., by Age and Year, U.S., 80-88, White Males

 Table 3.2  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Males, United States, 1980-1985

                                               Year
                             1980    1981    1982    1983    1984    1985
  Age

  0-14    Number               19      20      19      15       9      11
          Rate                0.1     0.1     0.1     0.1     0.0     0.1

  15-24   Number               46      47      59      44      50      34
          Rate                0.3     0.3     0.3     0.3     0.3     0.2

  25-34   Number              260     247     221     239     243     253
          Rate                1.6     1.5     1.3     1.4     1.4     1.4

  35-44   Number              373     391     422     474     486     544
          Rate                3.4     3.5     3.5     3.8     3.7     4.0

  45-54   Number              853     898     841     812     837     793
          Rate                8.8     9.3     8.8     8.5     8.7     8.3

  55-64   Number             2217    2238    2203    2202    2067    2216
          Rate               24.2    24.2    23.7    23.6    22.1    23.7

  65-74   Number             3682    3572    3686    3749    3638    3802
          Rate               60.1    57.3    58.0    57.7    55.1    56.5

  75-84   Number             3314    3289    3380    3449    3650    3673
          Rate              126.6   122.7   123.0   122.2   126.0   123.4

  85+     Number             1361    1362    1261    1353    1470    1432
          Rate              217.4   213.5   192.8   202.6   215.7   207.1

  Total   Number            12125   12066   12092   12337   12450   12758
          Rate               12.7    12.6    12.5    12.7    12.7    12.9

  Age-Adjusted Rate          14.6    14.2    14.0    14.0    14.0    14.0

 Table 3.2  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Males, United States, 1986-1988

                                   Year
                             1986    1987    1988
  Age

  0-14    Number               13      13      14
          Rate                0.1     0.1     0.1

  15-24   Number               55      50      50
          Rate                0.3     0.3     0.3

  25-34   Number              290     288     303
          Rate                1.6     1.6     1.6

  35-44   Number              504     583     622
          Rate                3.6     4.0     4.1

  45-54   Number              843     890    1002
          Rate                8.7     9.0     9.8

  55-64   Number             2201    2307    2293
          Rate               23.7    25.2    25.3

  65-74   Number             3835    4130    4091
          Rate               55.8    58.8    57.4

  75-84   Number             3580    3789    3941
          Rate              117.1   120.3   121.8

  85+     Number             1466    1503    1692
          Rate              207.6   208.1   229.1

  Total   Number            12788   13553   14008
          Rate               12.8    13.5    13.8

  Age-Adjusted Rate          13.8    14.3    14.6

 3.3 100,000 Pop., by Age and Year, U.S., 80-88, White Females

 Table 3.3  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Females, United States, 1980-1985

                                               Year
                             1980    1981    1982    1983    1984    1985
  Age

  0-14    Number               18      15      26      22      19      22
          Rate                0.1     0.1     0.1     0.1     0.1     0.1

  15-24   Number               50      59      43      54      43      44
          Rate                0.3     0.3     0.3     0.3     0.3     0.3

  25-34   Number              192     189     194     216     198     171
          Rate                1.2     1.1     1.2     1.3     1.1     1.0

  35-44   Number              283     289     297     331     307     350
          Rate                2.5     2.5     2.4     2.6     2.3     2.5

  45-54   Number              741     687     664     685     604     596
          Rate                7.2     6.8     6.6     6.9     6.1     6.0

  55-64   Number             2231    2109    2151    2267    2093    2213
          Rate               21.6    20.3    20.6    21.7    20.0    21.2

  65-74   Number             4583    4454    4375    4637    4361    4415
          Rate               57.4    55.0    53.3    55.6    51.7    51.7

  75-84   Number             5507    5607    5632    5963    5716    5941
          Rate              122.8   122.2   119.8   123.8   115.9   117.7

  85+     Number             3137    3273    3431    3474    3675    3791
          Rate              214.7   214.8   215.3   209.7   214.0   214.4

  Total   Number            16743   16684   16818   17650   17016   17547
          Rate               16.7    16.6    16.6    17.3    16.5    16.9

  Age-Adjusted Rate          13.6    13.3    13.1    13.5    12.7    12.9

 Table 3.3  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Females, United States, 1986-1988

                                   Year
                             1986    1987    1988
  Age

  0-14    Number               18      15      19
          Rate                0.1     0.1     0.1

  15-24   Number               56      45      37
          Rate                0.4     0.3     0.2

  25-34   Number              226     186     196
          Rate                1.3     1.0     1.1

  35-44   Number              354     352     395
          Rate                2.5     2.4     2.6

  45-54   Number              671     712     777
          Rate                6.7     7.0     7.3

  55-64   Number             2124    2130    2279
          Rate               20.5    20.9    22.7

  65-74   Number             4471    4561    4782
          Rate               51.7    51.9    53.9

  75-84   Number             5822    5905    6117
          Rate              112.8   111.8   113.6

  85+     Number             3752    3936    4082
          Rate              205.6   208.9   210.4

  Total   Number            17496   17842   18684
          Rate               16.7    17.0    17.6

  Age-Adjusted Rate          12.7    12.7    13.1

 3.4 100,000 Pop., by Age and Year, U.S., 80-88, Black Males

 Table 3.4  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Males, United States, 1980-1985

                                               Year
                             1980    1981    1982    1983    1984    1985
  Age

  0-14    Number               10       4       6       3       6       7
          Rate                0.3     0.1     0.2     0.1     0.2     0.2

  15-24   Number               16      22      13      14       9      21
          Rate                0.6     0.8     0.5     0.5     0.3     0.8

  25-34   Number               55      63      65      69      73      59
          Rate                2.8     3.0     3.0     3.0     3.1     2.4

  35-44   Number              120     117     108     130     142     146
          Rate                9.6     9.2     8.2     9.4     9.8     9.6

  45-54   Number              216     244     223     257     264     259
          Rate               21.0    23.6    21.5    24.5    24.8    24.1

  55-64   Number              489     424     435     540     485     485
          Rate               56.9    48.4    48.7    59.3    52.3    51.6

  65-74   Number              577     560     525     569     621     615
          Rate              101.3    96.7    89.3    95.2   102.1    99.1

  75-84   Number              415     380     390     432     443     504
          Rate              180.9   162.0   162.1   176.2   176.3   197.5

  85+     Number              111     110     113     107     117     132
          Rate              206.9   197.1   195.0   176.2   186.3   203.8

  Total   Number             2010    1925    1878    2123    2160    2230
          Rate               15.9    15.0    14.4    16.0    16.0    16.3

  Age-Adjusted Rate          24.5    22.9    22.0    24.2    24.2    24.7

 Table 3.4  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Males, United States, 1986-1988

                                   Year
                             1986    1987    1988
  Age

  0-14    Number                2       5       1
          Rate                0.0     0.1     0.0

  15-24   Number               17       9      16
          Rate                0.6     0.3     0.6

  25-34   Number               63      71      83
          Rate                2.5     2.8     3.2

  35-44   Number              166     139     210
          Rate               10.4     8.4    12.1

  45-54   Number              264     310     315
          Rate               24.2    27.8    27.5

  55-64   Number              526     550     585
          Rate               55.3    57.3    60.4

  65-74   Number              638     693     727
          Rate              100.8   107.3   110.1

  75-84   Number              467     469     540
          Rate              178.6   175.5   199.1

  85+     Number              150     141     163
          Rate              228.4   208.4   234.1

  Total   Number             2295    2388    2640
          Rate               16.5    16.9    18.4

  Age-Adjusted Rate          24.8    25.2    27.3

 3.5 100,000 Pop., by Age and Year, U.S., 80-88, Black Females

 Table 3.5  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Females, United States, 1980-1985

                                               Year
                             1980    1981    1982    1983    1984    1985
  Age

  0-14    Number                5       6      11      10       1       3
          Rate                0.1     0.2     0.3     0.3     0.0     0.1

  15-24   Number               15      21      15      17      15      21
          Rate                0.5     0.7     0.5     0.6     0.5     0.7

  25-34   Number               58      48      48      56      58      49
          Rate                2.5     2.0     1.9     2.2     2.2     1.8

  35-44   Number              107     105      84     110     127     108
          Rate                7.1     6.9     5.3     6.6     7.3     5.9

  45-54   Number              328     292     285     293     256     294
          Rate               26.0    23.0    22.3    22.7    19.6    22.2

  55-64   Number              739     753     761     785     735     768
          Rate               69.4    69.6    69.1    70.3    65.0    67.1

  65-74   Number             1143    1125    1005    1088    1159    1163
          Rate              146.5   141.5   124.4   132.6   139.3   137.8

  75-84   Number              806     845     815     957     934    1065
          Rate              221.9   226.2   211.2   241.4   229.2   254.4

  85+     Number              330     338     322     351     364     401
          Rate              306.1   299.8   269.2   279.3   274.4   291.0

  Total   Number             3534    3536    3349    3667    3650    3874
          Rate               25.0    24.6    23.0    24.8    24.3    25.5

  Age-Adjusted Rate          31.3    30.7    28.4    30.5    29.7    30.9

 Table 3.5  Number of Deaths with Diabetes as Underlying Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Females, United States, 1986-1988

                                   Year
                             1986    1987    1988
  Age

  0-14    Number                3       7       6
          Rate                0.1     0.2     0.1

  15-24   Number               12      14      12
          Rate                0.4     0.5     0.4

  25-34   Number               48      63      68
          Rate                1.7     2.2     2.3

  35-44   Number              129     111     149
          Rate                6.8     5.6     7.2

  45-54   Number              330     298     336
          Rate               24.5    21.7    23.8

  55-64   Number              800     787     813
          Rate               69.2    67.6    69.5

  65-74   Number             1158    1210    1285
          Rate              135.0   138.9   145.1

  75-84   Number             1014    1151    1133
          Rate              235.4   260.7   249.9

  85+     Number              509     467     530
          Rate              351.7   308.0   336.1

  Total   Number             4004    4109    4332
          Rate               26.0    26.3    27.3

  Age-Adjusted Rate          31.1    31.3    32.3

 3.6-3.10 No. Deaths w/Diabetes as Any Listed Cause & Mort. Rate

  3.6 100,000 Pop., by Age and Year, U.S., 80-88

 Table 3.6  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            United States, 1980-1984

                                              Year
                          1980       1981       1982       1983       1984
  AGE

 0-14    Number             69         75         93         92         61
         Rate              0.1        0.1        0.2        0.2        0.1

 15-24   Number            209        231        180        208        201
         Rate              0.5        0.5        0.4        0.5        0.5

 25-34   Number            918        910        968        953        991
         Rate              2.5        2.3        2.4        2.4        2.4

 35-44   Number           2038       2046       2042       2282       2426
         Rate              7.9        7.8        7.3        7.8        7.9

 45-54   Number           6956       6979       6729       6809       6648
         Rate             30.6       30.9       29.9       30.4       29.6

 55-64   Number          21873      21926      21759      22513      22383
         Rate            100.5       99.9       98.4      101.3      100.4

 65-74   Number          41000      40875      40898      42370      43036
         Rate            262.0      256.9      252.5      256.9      257.2

 75-84   Number          42938      42661      43340      45539      46462
         Rate            551.9      535.4      530.1      542.9      540.0

 85+     Number          19919      20223      20724      21787      22332
         Rate            877.7      859.6      846.1      858.5      851.6

 Total   Number         135931     135939     136764     142570     144548
         Rate             59.8       59.2       59.0       60.9       61.1

 Age-adjusted Rate        59.8       58.7       57.8       59.0       58.7

 Table 3.6  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            United States, 1985-1988

                                             Year
                            1985       1986       1987       1988
  AGE

  0-14    Number              59         57         53         60
          Rate               0.1        0.1        0.1        0.1

  15-24   Number             206        217        209        195
          Rate               0.5        0.6        0.5        0.5

  25-34   Number             960       1094       1117       1135
          Rate               2.3        2.6        2.6        2.6

  35-44   Number            2525       2652       2738       2903
          Rate               7.9        8.0        8.0        8.2

  45-54   Number            6736       6890       7231       7516
          Rate              29.8       30.2       31.1       31.1

  55-64   Number           22803      22809      22647      22646
          Rate             102.2      102.7      102.9      103.8

  65-74   Number           44058      44218      45735      46195
          Rate             259.1      255.1      259.0      258.2

  75-84   Number           47607      48220      48830      50549
          Rate             539.2      532.6      525.7      531.4

  85+     Number           23309      23945      24700      26057
          Rate             865.4      862.6      862.8      884.1

  Total   Number          148284     150120     153271     157265
          Rate              62.1       62.3       63.0       64.0

  Age-adjusted Rate         59.1       58.7       58.9       59.3

 3.7 100,000 Pop., by Age and Year, U.S., 80-88, White Males

 Table 3.7  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Males, United States, 1980-1984

                                                Year
                          1980       1981       1982       1983       1984
 Age

 0-14    Number             21         32         26         31         19
         Rate              0.1        0.1        0.1        0.1        0.1

 15-24   Number             70         78         77         69         80
         Rate              0.4        0.4        0.4        0.4        0.5

 25-34   Number            407        402        409        406        428
         Rate              2.5        2.4        2.4        2.4        2.4

 35-44   Number            854        872        852       1024       1078
         Rate              7.7        7.7        7.1        8.1        8.2

 45-54   Number           2997       3013       2943       2862       2883
         Rate             30.7       31.1       30.6       29.9       30.1

 55-64   Number           9702       9819       9705       9776       9655
         Rate            105.8      106.3      104.5      104.9      103.3

 65-74   Number          17064      17083      17498      17763      18081
         Rate            278.6      273.9      275.3      273.6      273.9

 75-84   Number          15244      15397      15604      16366      17048
         Rate            582.3      574.5      567.7      579.9      588.5

 85+     Number           5806       5610       5619       5946       6122
         Rate            927.5      879.2      859.3      890.2      898.1

 Total   Number          52166      52310      52738      54247      55396
         Rate             54.8       54.5       54.5       55.6       56.4

 Age-adjusted Rate        63.0       62.0       61.4       62.0       62.3

 Table 3.7  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Males, United States, 1985-1988

                                           Year
                           1985       1986       1987       1988
  AGE

  0-14    Number             16         17         19         20
          Rate              0.1        0.1        0.1        0.1

  15-24   Number             73         90         86         75
          Rate              0.4        0.6        0.5        0.5

  25-34   Number            412        487        512        495
          Rate              2.3        2.7        2.8        2.7

  35-44   Number           1111       1129       1261       1302
          Rate              8.2        8.0        8.6        8.6

  45-54   Number           2887       2857       3017       3115
          Rate             30.1       29.6       30.6       30.4

  55-64   Number           9906       9812       9810       9583
          Rate            106.0      105.7      107.0      105.6

  65-74   Number          18688      18746      19364      19688
          Rate            277.8      272.6      275.6      276.4

  75-84   Number          17271      17607      17952      18942
          Rate            580.4      575.8      570.2      585.4

  85+     Number           6284       6325       6591       7095
          Rate            908.7      895.5      912.4      960.7

  Total   Number          56652      57075      58614      60317
          Rate             57.2       57.2       58.3       59.5

  Age-adjusted Rate        62.6       62.0       62.5       63.4

 3.8 100,000 Pop., by Age and Year, U.S., 80-88, White Females

 Table 3.8  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Females, United States, 1980-1984

                                                Year
                          1980       1981       1982       1983       1984
 Age

 0-14    Number             30         30         37         37         32
         Rate              0.1        0.1        0.2        0.2        0.2

 15-24   Number             87         92         60         94         77
         Rate              0.5        0.5        0.4        0.6        0.5

 25-34   Number            304        310        326        335        328
         Rate              1.9        1.9        1.9        2.0        1.9

 35-44   Number            614        577        646        639        694
         Rate              5.4        5.0        5.3        5.0        5.2

 45-54   Number           2195       2154       2043       2154       2001
         Rate             21.4       21.3       20.4       21.6       20.1

 55-64   Number           8012       7997       7812       8157       8221
         Rate             77.4       76.8       74.8       77.9       78.6

 65-74   Number          18034      18039      17759      18468      18450
         Rate            225.9      222.9      216.3      221.6      218.9

 75-84   Number          23437      23065      23461      24247      24411
         Rate            522.6      502.8      499.1      503.4      495.1

 85+     Number          12686      13149      13596      14171      14470
         Rate            868.1      862.8      853.0      855.4      842.5

 Total   Number          65401      65417      65755      68308      68685
         Rate             65.4       64.9       64.7       66.8       66.7

 Age-adjusted Rate        52.7       51.7       50.7       51.7       51.0

 Table 3.8  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            White Females, United States, 1985-1988

                                            Year
                            1985       1986       1987       1988
  AGE

  0-14    Number              30         27         19         29
          Rate               0.1        0.1        0.1        0.1

  15-24   Number              77         88         83         65
          Rate               0.5        0.6        0.5        0.4

  25-34   Number             318        367        331        360
          Rate               1.8        2.1        1.8        2.0

  35-44   Number             749        778        764        778
          Rate               5.4        5.4        5.2        5.1

  45-54   Number            2006       2102       2171       2242
          Rate              20.1       20.9       21.3       21.2

  55-64   Number            8238       8164       7989       8050
          Rate              79.0       79.0       78.4       80.1

  65-74   Number           18621      18425      19198      18975
          Rate             218.2      212.9      218.5      214.0

  75-84   Number           24907      24949      25078      25295
          Rate             493.4      483.2      475.0      469.6

  85+     Number           15099      15443      15934      16547
          Rate             853.8      846.0      845.6      852.8

  Total   Number           70055      70349      71572      72344
          Rate              67.5       67.3       68.0       68.3

  Age-adjusted Rate         51.1       50.4       50.4       50.1

 3.9 100,000 Pop., by Age and Year, U.S., 80-88, Black Males

 Table 3.9  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Males, United States, 1980-1984

                                                 Year
                           1980       1981       1982       1983       1984
 Age

 0-14    Number              11          8         11          5          8
         Rate               0.3        0.2        0.3        0.1        0.2

 15-24   Number              28         26         14         19         15
         Rate               1.0        0.9        0.5        0.7        0.5

 25-34   Number             100        103        106        112        123
         Rate               5.0        4.9        4.8        4.9        5.2

 35-44   Number             290        286        268        307        330
         Rate              23.3       22.6       20.2       22.2       22.8

 45-54   Number             704        781        712        808        796
         Rate              68.6       75.7       68.6       77.0       74.9

 55-64   Number            1590       1555       1561       1787       1768
         Rate             185.1      177.6      174.6      196.1      190.8

 65-74   Number            1946       1996       1889       2125       2208
         Rate             341.6      344.7      321.2      355.4      363.1

 75-84   Number            1309       1227       1304       1452       1483
         Rate             570.4      523.0      542.1      592.3      590.2

 85+     Number             346        357        373        403        406
         Rate             645.0      639.8      643.8      663.5      646.4

 Total   Number            6326       6341       6239       7021       7138
         Rate              50.0       49.3       47.7       52.9       53.0

 Age-adjusted Rate         77.8       76.2       73.9       81.4       81.0

 Table 3.9  Number of Deaths with Diabetes as Any Listed Cause and
            Mortality Rate per 100,000 Population, by Age and Year,
            Black Males, United States, 1985-1988

                                            Year
                            1985       1986       1987       1988
  AGE

  0-14    Number               8          5          6          2
          Rate               0.2        0.1        0.1        0.0

  15-24   Number              26         22         14         28
          Rate               0.9        0.8        0.5        1.0

  25-34   Number             122        119        145        140
          Rate               5.0        4.8        5.7        5.4

  35-44   Number             326        381        354        446
          Rate              21.5       23.9       21.3       25.7

  45-54   Number             791        784        930        953
          Rate              73.5       71.8       83.3       83.3

  55-64   Number            1819       1879       1889       1894
          Rate             193.6      197.6      196.7      195.5

  65-74   Number            2340       2439       2550       2618
          Rate             377.1      385.5      394.7      396.5

  75-84   Number            1585       1725       1720       1869
          Rate             621.0      659.6      643.7      689.2

  85+     Number             446        494        501        518
          Rate             688.6      752.3      740.5      743.9

  Total   Number            7466       7851       8110       8469
          Rate              54.6       56.5       57.5       59.1

  Age-adjusted Rate         83.5       86.4       87.3       89.4

 3.10 100,000 Pop., by Age and Year, U.S., 80-88, Black Females

 Table 3.10  Number of Deaths with Diabetes as Any Listed Cause and
             Mortality Rate per 100,000 Population, by Age and Year,
             Black Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
 Age

 0-14    Number                6          4         18         16          1
         Rate                0.2        0.1        0.5        0.4        0.0

 15-24   Number               22         35         24         25         25
         Rate                0.7        1.2        0.8        0.9        0.9

 25-34   Number               96         83        115         93        100
         Rate                4.2        3.4        4.6        3.6        3.7

 35-44   Number              246        277        246        264        289
         Rate               16.4       18.1       15.4       15.9       16.6

 45-54   Number              935        905        901        866        821
         Rate               74.2       71.4       70.6       67.1       62.8

 55-64   Number             2289       2298       2380       2446       2392
         Rate              215.0      212.3      216.2      218.9      211.4

 65-74   Number             3543       3385       3281       3524       3746
         Rate              454.0      425.9      406.1      429.5      450.2

 75-84   Number             2544       2602       2524       2993       3020
         Rate              700.4      696.4      654.2      755.1      741.2

 85+     Number              930        958        978       1083       1103
         Rate              862.7      849.6      817.6      861.7      831.6

 Total   Number            10617      10550      10477      11313      11501
         Rate               75.2       73.5       71.9       76.5       76.7

 Age-adjusted Rate          94.6       92.0       89.1       94.4       93.9

 Table 3.10  Number of Deaths with Diabetes as Any Listed Cause and
             Mortality Rate per 100,000 Population, by Age and Year,
             Black Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  AGE

  0-14    Number                4          5          7          9
          Rate                0.1        0.1        0.2        0.2

  15-24   Number               28         17         22         21
          Rate                1.0        0.6        0.8        0.8

  25-34   Number               97        103        111        128
          Rate                3.5        3.7        3.9        4.4

  35-44   Number              286        307        304        334
          Rate               15.7       16.1       15.3       16.1

  45-54   Number              901        972        925        993
          Rate               67.9       72.1       67.3       70.3

  55-64   Number             2435       2556       2522       2640
          Rate              212.8      221.0      216.6      225.6

  65-74   Number             3789       4018       3953       4160
          Rate              448.8      468.4      453.6      469.8

  75-84   Number             3303       3314       3458       3721
          Rate              789.0      769.2      783.2      820.8

  85+     Number             1248       1450       1409       1607
          Rate              905.5     1001.8      929.2     1019.0

  Total   Number            12095      12746      12714      13616
          Rate               79.6       82.6       81.3       85.7

  Age-adjusted Rate          96.7       99.6       97.4      102.0

 3.11 No. Deaths with Diabetes as Any Listed Cause, State & Year

 Table 3.11  Number of Deaths with Diabetes as Any Listed Cause and Mortality
             Rate per 100,000 Population, by State and Year, United States,
             1980-1982
                                       Year
                         1980          1981          1982
                     Number  Rate  Number  Rate  Number  Rate
  State

  Alabama              1829   46.9   1856   47.3   1937   49.1
  Alaska                 38    9.4     54   13.0     52   11.7
  Arizona              1004   36.7   1079   38.4   1033   35.9
  Arkansas             1050   45.9   1059   46.0    998   43.2
  California          11922   50.1  12183   50.2  12812   51.7
  Colorado             1003   34.5    993   33.3   1053   34.3
  Connecticut          2189   70.4   2244   71.9   2381   76.1
  Delaware              386   64.9    357   59.8    403   67.2
  Dist of Columbia      469   73.4    418   66.0    428   68.3
  Florida              6548   66.1   6740   66.1   6624   63.3
  Georgia              2563   46.7   2558   45.9   2530   44.7
  Hawaii                406   41.5    419   42.7    492   49.3
  Idaho                 341   36.0    356   36.9    345   35.3
  Illinois             7612   66.6   7453   65.0   7750   67.5
  Indiana              3393   61.8   3469   63.2   3357   61.2
  Iowa                 1759   60.4   1761   60.3   1786   61.4
  Kansas               1296   54.7   1314   55.0   1388   57.6
  Kentucky             2057   56.2   2115   57.5   2011   54.4
  Louisiana            2151   50.9   2308   53.7   2326   53.1
  Maine                 781   69.4    724   63.8    809   71.0
  Maryland             2315   54.8   2325   54.6   2315   54.2
  Massachusetts        4074   71.0   3888   67.6   3913   68.1
  Michigan             6089   65.8   6050   65.7   6104   66.9
  Minnesota            2337   57.2   2297   55.9   2442   59.1
  Mississippi          1499   59.3   1441   56.6   1401   54.6
  Missouri             2971   60.4   2999   60.7   3025   61.2
  Montana               322   40.8    369   46.4    360   44.7
  Nebraska              875   55.7    923   58.3    918   57.7
  Nevada                252   31.1    263   31.1    285   32.5
  New Hampshire         560   60.6    595   63.5    617   65.1
  New Jersey           5958   80.8   5752   77.7   5662   76.2
  New Mexico            434   33.1    374   28.0    476   34.8
  New York            13403   76.3  12923   73.6  12452   70.9
  North Carolina       3601   61.1   3619   60.7   3672   61.0
  North Dakota          400   61.1    374   56.6    420   62.5
  Ohio                 8262   76.5   8241   76.3   7999   74.2
  Oklahoma             1565   51.4   1670   53.7   1623   50.2
  Oregon               1218   46.1   1273   47.7   1232   46.2
  Pennsylvania        10464   88.2  10307   86.8  10280   86.5
  Rhode Island          858   90.5    822   86.3    840   88.1
  South Carolina       1589   50.7   1614   50.7   1629   50.6
  South Dakota          389   56.3    396   57.2    472   68.0
  Tennessee            2075   45.1   2188   47.2   2148   46.0
  Texas                5677   39.6   5853   39.6   5830   37.9
  Utah                  530   36.0    502   33.1    556   35.7
  Vermont               326   63.7    319   61.8    340   65.4
  Virginia             2649   49.4   2617   48.1   2649   48.3
  Washington           1863   44.8   1820   43.0   1955   45.7
  West Virginia        1361   69.8   1410   71.9   1318   67.2
  Wisconsin            3093   65.7   3110   65.7   3164   66.7
  Wyoming               125   26.4    145   29.4    152   29.8

 Table 3.11  Number of Deaths with Diabetes as Any Listed Cause and
             Mortality Rate per 100,000 Population, by State and Year,
             United States, 1983-1985
                                       Year
                         1983          1984          1985
                     Number  Rate  Number  Rate  Number  Rate
  State

  Alabama              1901   48.0   2019   50.6   2002   49.8
  Alaska                 65   13.5     58   11.5     68   13.0
  Arizona              1255   42.5   1252   41.1   1263   40.0
  Arkansas             1065   45.8   1075   45.8   1118   47.4
  California          12943   51.1  13718   53.2  14379   54.6
  Colorado             1094   34.7   1162   36.4   1190   36.8
  Connecticut          2414   76.9   2566   81.4   2492   78.6
  Delaware              365   60.2    336   54.7    416   66.9
  Dist of Columbia      447   71.6    397   63.6    452   72.5
  Florida              7037   65.4   7002   63.4   7486   65.9
  Georgia              2765   48.2   2842   48.6   2920   48.9
  Hawaii                517   50.8    560   54.1    562   53.4
  Idaho                 380   38.5    440   44.0    423   42.1
  Illinois             7942   69.1   7699   66.8   7960   69.0
  Indiana              3712   67.8   3707   67.5   3789   68.9
  Iowa                 1845   63.5   1873   64.5   1921   66.7
  Kansas               1354   55.8   1402   57.4   1372   56.0
  Kentucky             2175   58.5   2047   55.0   2171   58.2
  Louisiana            2455   55.3   2464   55.2   2532   56.4
  Maine                 851   74.2    855   73.9    917   78.7
  Maryland             2438   56.7   2437   56.0   2526   57.5
  Massachusetts        4021   69.8   4303   74.3   4262   73.2
  Michigan             6101   67.4   6379   70.4   6361   70.0
  Minnesota            2543   61.3   2599   62.4   2676   63.8
  Mississippi          1549   60.0   1515   58.3   1623   62.1
  Missouri             3083   62.1   3098   61.9   3100   61.6
  Montana               336   41.2    333   40.4    352   42.6
  Nebraska              947   59.3    944   58.8    912   56.8
  Nevada                310   34.6    348   38.0    363   38.8
  New Hampshire         675   70.4    641   65.5    670   67.1
  New Jersey           6000   80.4   6031   80.3   6278   83.0
  New Mexico            488   34.8    521   36.5    540   37.2
  New York            12607   71.4  12345   69.7  12507   70.5
  North Carolina       3766   61.9   3968   64.3   4130   66.0
  North Dakota          380   55.8    380   55.3    435   63.5
  Ohio                 8514   79.3   8444   78.6   8762   81.5
  Oklahoma             1747   52.7   1739   52.5   1755   53.1
  Oregon               1378   51.8   1443   53.9   1438   53.5
  Pennsylvania        10560   88.8  10750   90.4  10845   91.4
  Rhode Island          893   93.5    888   92.5    857   88.6
  South Carolina       1703   52.3   1807   54.8   1814   54.4
  South Dakota          422   60.4    431   61.1    443   62.5
  Tennessee            2423   51.7   2518   53.2   2515   52.8
  Texas                6411   40.5   6393   39.8   6619   40.4
  Utah                  560   35.1    613   37.8    618   37.6
  Vermont               334   63.6    344   64.9    388   72.5
  Virginia             2825   50.8   2872   51.0   2875   50.4
  Washington           2079   48.3   2132   49.0   2278   51.7
  West Virginia        1541   78.5   1421   72.8   1387   71.6
  Wisconsin            3194   67.3   3264   68.5   3360   70.4
  Wyoming               160   31.0    173   33.7    162   31.8

 Table 3.11  Number of Deaths with Diabetes as Any Listed Cause and
             Mortality Rate per 100,000 Population, by State and Year,
             United States, 1986-1988
                                       Year
                         1986          1987          1988
                     Number  Rate  Number  Rate  Number  Rate
  State

  Alabama              2111   52.1   2045   50.1   2199   53.4
  Alaska                 85   16.0     91   17.3    109   20.1
  Arizona              1393   42.5   1404   41.5   1536   43.6
  Arkansas             1088   45.9   1126   47.1   1224   50.9
  California          14929   55.3  15876   57.4  16624   58.9
  Colorado             1228   37.6   1230   37.3   1293   38.7
  Connecticut          2553   80.0   2475   77.1   2448   75.7
  Delaware              447   70.6    421   65.4    425   65.2
  Dist of Columbia      505   80.8    510   82.0    480   77.5
  Florida              7458   63.8   8063   67.1   7866   64.0
  Georgia              2875   47.1   3151   50.6   3158   49.6
  Hawaii                588   55.2    644   59.5    598   54.3
  Idaho                 423   42.2    441   44.2    464   46.2
  Illinois             8089   70.0   8218   71.0   8297   71.5
  Indiana              3714   67.5   3664   66.2   3831   69.1
  Iowa                 1775   62.3   1861   65.7   1779   63.3
  Kansas               1369   55.7   1382   55.8   1464   58.9
  Kentucky             2097   56.3   2111   56.6   2435   65.2
  Louisiana            2586   57.5   2497   56.0   2771   61.8
  Maine                 879   75.0    890   75.0    930   77.7
  Maryland             2563   57.4   2716   59.9   2725   59.2
  Massachusetts        4446   76.2   4301   73.5   4361   74.2
  Michigan             6443   70.5   6392   69.5   6731   72.8
  Minnesota            2755   65.4   2769   65.2   2806   65.6
  Mississippi          1639   62.5   1604   61.1   1753   66.2
  Missouri             3176   62.7   3141   61.6   3137   61.0
  Montana               357   43.7    365   45.1    435   53.8
  Nebraska              950   59.5    996   62.5    975   61.2
  Nevada                371   38.4    469   46.6    424   41.1
  New Hampshire         744   72.4    691   65.4    735   67.7
  New Jersey           6108   80.1   6268   81.7   6258   80.8
  New Mexico            561   37.9    546   36.4    608   39.4
  New York            12374   69.5  12056   67.6  12495   70.1
  North Carolina       4300   67.9   4744   74.0   4895   75.3
  North Dakota          347   51.1    398   59.2    406   60.7
  Ohio                 8811   82.0   8723   80.9   8747   81.0
  Oklahoma             1843   55.7   1844   56.4   1974   60.2
  Oregon               1401   51.8   1618   59.4   1712   62.5
  Pennsylvania        10802   90.8  10953   91.8  10957   91.9
  Rhode Island          784   80.4    828   84.0    892   90.4
  South Carolina       1955   57.8   2000   58.4   2084   60.1
  South Dakota          432   61.1    433   61.1    439   61.8
  Tennessee            2669   55.6   2688   55.4   2822   57.6
  Texas                6619   39.7   7049   42.0   7212   42.2
  Utah                  634   38.1    600   35.7    683   39.9
  Vermont               374   69.1    395   72.1    383   69.2
  Virginia             3073   53.0   3108   52.6   3158   52.7
  Washington           2311   51.8   2233   49.2   2328   50.7
  West Virginia        1526   79.6   1620   85.4   1521   80.7
  Wisconsin            3413   71.4   3461   72.0   3481   72.3
  Wyoming               147   29.0    162   33.0    197   39.8

 3.12 Avg. Mort. Rate for Diabetes as Listed Cause, State & Rank

 Table 3.12  Average Mortality Rate for Diabetes as Any Listed Cause
             per 100,000 Population, By State and Rank, United States,
             1980-1988
                                            Adjusted Rate
                           Rate       Rank       (a)        Rank
  State

  Alabama                  49.7         38       43.9         47
  Alaska                   14.2         51       51.9         33
  Arizona                  40.4         44       41.2         50
  Arkansas                 46.5         41       37.5         51
  California               53.8         33       59.6         19
  Colorado                 36.0         48       46.3         44
  Connecticut              76.5          5       69.9          6
  Delaware                 63.9         19       63.7         13
  Dist of Columbia         72.9          8       42.1         49
  Florida                  65.0         18       45.9         45
  Georgia                  47.9         40       50.6         36
  Hawaii                   51.4         36       51.6         34
  Idaho                    40.7         43       57.4         21
  Illinois                 68.5         13       65.8         10
  Indiana                  65.9         17       65.4         12
  Iowa                     63.1         20       55.2         26
  Kansas                   56.3         29       50.6         37
  Kentucky                 57.6         27       56.7         23
  Louisiana                55.6         30       57.2         22
  Maine                    73.2          7       61.9         17
  Maryland                 56.8         28       59.0         20
  Massachusetts            72.0          9       63.1         15
  Michigan                 68.8         12       70.4          5
  Minnesota                61.8         21       60.7         18
  Mississippi              60.1         24       53.5         29
  Missouri                 61.5         22       52.0         32
  Montana                  44.3         42       43.0         48
  Nebraska                 58.9         25       52.7         31
  Nevada                   37.2         46       46.9         42
  New Hampshire            66.5         15       66.2          9
  New Jersey               80.1          3       73.2          4
  New Mexico               35.5         49       44.7         46
  New York                 71.1         10       63.0         16
  North Carolina           66.0         16       63.4         14
  North Dakota             58.4         26       47.9         41
  Ohio                     78.9          4       75.7          2
  Oklahoma                 54.0         32       51.0         35
  Oregon                   52.6         34       54.6         27
  Pennsylvania             89.6          1       74.5          3
  Rhode Island             88.3          2       75.7          1
  South Carolina           54.5         31       55.3         25
  South Dakota             61.1         23       50.5         38
  Tennessee                51.7         35       48.1         40
  Texas                    40.2         45       46.3         43
  Utah                     36.6         47       55.4         24
  Vermont                  67.0         14       69.5          8
  Virginia                 50.8         37       53.0         30
  Washington               48.3         39       54.1         28
  West Virginia            75.2          6       69.8          7
  Wisconsin                68.9         11       65.5         11
  Wyoming                  31.6         50       48.1         39

 (a) Ajusted for age and race.

 3.13-3.17 Mort. Rate for Diabetes as Underlying Cause,U.S.,80-88

 3.13 100,000 Diabetic Pop., Age and Year

 Table 3.13  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, United States, 1980-1985

                                               Year
                            1980    1981    1982    1983    1984    1985
  Age

  0-44                      163.7   174.9   167.9   182.4   181.5   179.8

  45-64                     333.8   306.1   300.1   306.9   318.0   335.2

  65-74                     664.2   721.1   636.6   780.4   565.5   548.8

  75+                      1753.9  1619.0  1913.6  1859.0  1517.7  1555.8

  Total                     602.7   596.4   587.5   627.0   577.2   585.0

  Age-Adjusted              602.6   588.0   605.9   641.0   538.0   546.1

 Table 3.13  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, United States, 1986-1988

                                   Year
                            1986    1987    1988
  Age

  0-44                      189.5   145.2   202.4

  45-64                     278.8   320.3   350.0

  65-74                     644.6   633.6   650.9

  75+                      1322.8  1473.7  1686.9

  Total                     549.1   565.7   635.7

  Age-Adjusted              515.0   544.0   602.6

 3.14 100,000 Diabetic Pop., Age and Year, White Males

 Table 3.14  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, White Males, United States,
             1980-1985
                                               Year
                            1980    1981    1982    1983    1984    1985
  Age

  0-44                      224.3   191.0   187.6   189.2   222.8   214.8

  45-64                     334.6   308.3   311.5   327.5   357.0   344.5

  65-74                     619.0   645.8   857.8   900.0   614.9   559.8

  75+                      1828.4  2038.2  1542.7  1463.1  1580.4  1457.0

  Total                     583.2   556.7   578.0   595.1   597.8   556.0

  Age-Adjusted              612.7   634.3   617.1   623.2   583.7   544.3

 Table 3.14  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, White Males, United States,
             1986-1988
                                   Year
                            1986    1987    1988
  Age

  0-44                      286.3   161.5   204.4

  45-64                     246.1   303.8   351.9

  65-74                     613.6   585.8   733.8

  75+                      1245.8  1260.1  1460.1

  Total                     498.0   491.8   592.7

  Age-Adjusted              498.8   495.6   591.7

 3.15 100,000 Diabetic Pop., Age and Year, White Females

 Table 3.15  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, White Females,
             United States, 1980-1985

                                               Year
                            1980    1981    1982    1983    1984    1985
  Age

  0-44                      114.1   131.4   117.9   154.4   129.3   117.3

  45-64                     303.3   280.3   285.6   273.1   258.1   307.6

  65-74                     611.7   722.0   557.6   736.5   543.5   498.7

  75+                      1667.0  1491.7  2131.9  2060.3  1584.6  1639.3

  Total                     614.8   634.5   629.8   686.2   591.1   606.6

  Age-Adjusted              554.6   551.0   602.9   640.5   508.3   523.0

 Table 3.15  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, White Females,
             United States, 1986-1988

                                   Year
                            1986    1987    1988
  Age

  0-44                      110.7   117.0   181.9

  45-64                     261.0   297.5   331.1

  65-74                     660.8   612.6   578.1

  75+                      1406.1  1838.1  1992.2

  Total                     579.5   649.7   713.8

  Age-Adjusted              510.6   578.4   617.5

 3.16 100,000 Diabetic Pop., Age and Year, Black Males

 Table 3.16  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, Black Males, United States,
             1980-1985
                                                Year
                            1980    1981    1982    1983    1984    1985
  Age

  0-44                      275.4   320.0   311.2   588.5   416.6   370.9

  45-64                     378.8   360.2   365.5   390.2   347.8   335.0

  65-74                     937.3   828.1   743.3   667.0   704.1   622.5

  75+                      1793.6  2127.3  2013.9  2207.2  1597.2  1851.8

  Total                     574.3   565.4   556.7   605.4   548.4   533.5

  Age-Adjusted              718.5   739.5   701.0   768.3   639.7   642.9

 Table 3.16  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, Black Males, United States,
             1986-1988
                                    Year
                            1986    1987    1988
  Age

  0-44                      298.9   246.6   385.1

  45-64                     387.6   410.3   364.6

  65-74                     703.8   668.1   856.0

  75+                      1577.9  1744.4  1367.2

  Total                     551.0   543.8   569.4

  Age-Adjusted              632.6   648.3   646.9

 3.17 100,000 Diabetic Pop., Age and Year, Black Females

 Table 3.17  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, Black Females,
             United States, 1980-1985

                                                Year
                            1980    1981    1982    1983    1984    1985
  Age

  0-44                      165.0   186.1   184.2   166.3   184.5   198.2

  45-64                     424.3   368.3   324.5   358.2   352.1   410.4

  65-74                    1105.1   821.5   628.5   544.3   622.0   636.0

  75+                      1595.3  1678.9  1677.1  1564.8  1408.5  1245.3

  Total                     656.6   601.5   526.7   523.5   545.7   595.3

  Age-Adjusted              732.7   651.0   581.5   553.4   551.2   557.1

 Table 3.17  Mortality Rate for Diabetes as Underlying Cause per 100,000
             Diabetic Population, by Age and Year, Black Females,
             United States, 1986-1988

                                   Year
                           1986    1987    1988
  Age

  0-44                      220.3   179.0   174.0

  45-64                     403.0   387.9   472.3

  65-74                     804.8   849.2   831.3

  75+                      1204.5  1103.7  1182.8

  Total                     627.7   606.3   643.2

  Age-Adjusted              596.2   579.5   620.5

 3.18-3.22 Mort. Rate for Diabetes as Any Listed Cause,U.S.,80-88

 3.18 100,000 Diabetic Pop., Age & Year

 Tables 3.18  Mortality Rate for Diabetes as Any Listed Cause per 100,000
              Diabetic Population, by Age and Year, United States, 1980-1984

                                               Year
                           1980       1981       1982       1983       1984
  Age

  0-44                     320.4      342.6      333.7      352.7      370.0

  45-64                   1206.5     1136.1     1110.0     1128.1     1230.8

  65-74                   2693.4     2995.1     2681.1     3246.6     2449.8

  75+                     7298.6     6636.2     7904.7     7701.7     6309.9

  Total                   2350.7     2340.3     2323.4     2466.3     2331.4

  Age-adjusted            2350.5     2306.1     2400.0     2529.5     2157.9

 Table 3.18  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, United States, 1985-1988

                                         Year
                           1985       1986       1987       1988
  Age

  0-44                     361.2      384.0      301.9      393.1

  45-64                   1267.8     1043.0     1171.0     1226.0

  65-74                   2380.1     2775.5     2686.0     2710.9

  75+                     6442.8     5619.7     6161.0     7002.4

  Total                   2346.3     2216.9     2250.1     2476.5

  Age-adjusted            2173.1     2065.7     2161.3     2331.8

 3.19 100,000 Diabetic Pop., Age & Year, White Males

 Table 3.19  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, White Males, United States,
             1980-1984

                                               Year
                           1980       1981       1982       1983       1984
  Age

  0-44                     434.5      375.0      354.9      375.0      453.8

  45-64                   1384.2     1261.5     1294.5     1373.4     1541.3

  65-74                   2868.6     3088.3     4071.9     4264.1     3056.0

  75+                     8232.5     9205.7     7054.7     6798.3     7152.0

  Total                   2509.0     2413.3     2520.9     2616.9     2659.7

  Age-adjusted            2629.1     2770.8     2719.5     2768.1     2585.8

 Table 3.19  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, White Males, United States,
             1985-1988

                                         Year
                           1985       1986       1987       1988
  Age

  0-44                     411.3      572.2      324.7      391.0

  45-64                   1464.9     1024.4     1218.7     1356.2

  65-74                   2751.7     2999.4     2746.6     3531.4

  75+                     6722.7     5908.6     5844.1     6749.0

  Total                   2468.7     2222.7     2126.8     2552.1

  Age-adjusted            2402.8     2192.8     2153.7     2563.5

 3.20 100,000 Diabetic Pop., Age & Year, White Females

 Table 3.20  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, White Females,
             United States, 1980-1984

                                               Year
                           1980       1981       1982       1983       1984
  Age

  0-44                     217.5      240.3      225.0      273.8      257.8

  45-64                   1041.7     1017.6      999.8      953.9      978.3

  65-74                   2407.0     2924.2     2263.4     2933.4     2299.2

  75+                     6966.3     6083.4     8717.1     8387.4     6560.5

  Total                   2401.4     2487.7     2462.3     2655.7     2386.0

  Age-adjusted            2139.6     2138.3     2346.6     2463.4     2031.6

 Table 3.20  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, White Females,
             United States, 1985-1988

                                         Year
                           1985       1986       1987       1988
  Age

  0-44                     234.6      213.3      234.2      346.4

  45-64                   1121.7      958.6     1063.7     1115.2

  65-74                   2103.3     2723.1     2578.5     2294.0

  75+                     6738.7     5932.3     7660.4     8173.0

  Total                   2421.7     2330.1     2606.3     2763.7

  Age-adjusted            2061.8     2033.8     2300.2     2342.5

 3.21 100,000 Diabetic Pop., Age & Year, Black Males

 Table 3.21  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, Black Males, United States,
             1980-1984

                                               Year
                           1980       1981       1982       1983       1984
  Age

  0-44                     587.7      657.2      646.7     1206.9      862.3

  45-64                   1232.7     1259.5     1262.7     1270.4     1190.5

  65-74                   3161.2     2951.5     2674.4     2491.2     2503.4

  75+                     5643.4     6876.8     6714.3     7596.2     5387.6

  Total                   1807.6     1862.3     1849.6     2002.1     1812.4

  Age-adjusted            2284.7     2436.4     2338.7     2522.8     2103.9

 Table 3.21  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, Black Males, United States,
             1985-1988

                                         Year
                           1985       1986       1987       1988
  Age

  0-44                     767.3      635.1      571.4      765.1

  45-64                   1175.3     1306.6     1344.9     1153.5

  65-74                   2368.5     2690.5     2458.5     3082.7

  75+                     5913.5     5674.9     6351.2     4642.3

  Total                   1786.0     1884.8     1846.8     1826.5

  Age-adjusted            2123.9     2204.3     2248.6     2113.1

 3.22 100,000 Diabetic Pop., Age & Year, Black Females

 Table 3.22  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, Black Females,
             United States, 1980-1984

                                               Year
                           1980       1981       1982       1983       1984
  Age

  0-44                     330.1      412.5      469.7      343.0      381.0

  45-64                   1282.1     1128.9     1017.9     1100.6     1141.6

  65-74                   3425.5     2471.8     2051.9     1763.1     2010.4

  75+                     4878.6     5052.4     5165.6     4876.3     4474.0

  Total                   1972.7     1794.6     1647.8     1615.2     1719.5

  Age-adjusted            2215.8     1941.7     1812.2     1705.1     1733.8

 Table 3.22  Mortality Rate for Diabetes as Any Listed Cause per 100,000
             Diabetic Population, by Age and Year, Black Females,
             United States, 1985-1988

                                         Year
                           1985       1986       1987       1988
  Age

  0-44                     454.3      495.7      407.6      364.3

  45-64                   1289.0     1258.1     1232.4     1493.3

  65-74                   2072.1     2792.3     2774.4     2691.1

  75+                     3865.9     3767.6     3320.0     3789.4

  Total                   1858.7     1998.1     1876.1     2021.6

  Age-adjusted            1733.2     1902.7     1805.3     1953.5


HOSPITALIZATIONS

 Introduction

 Hospitalization related to diabetes mellitus is one indicator of the
 morbidity and health care burden associated with this disease.  In
 this chapter, we examine trends in hospitalizations related to diabetes
 in the United States during 1980-1987.  We evaluate the numbers and
 rates of hospitalizations by calendar year, age, sex, race, and geographic
 region of the country.  We present rates based on denominators for
 both the general population and the population with diabetes.  We
 examine hospitalizations related to diabetes both as a primary diagnosis
 and as any listed hospital discharge diagnosis.  We will emphasize
 results based on any listed diagnosis because they more accurately
 represent the disease burden associated with diabetes.

 We present overall hospitalization data in this chapter.  In subsequent
 chapters, we evaluate hospital discharges related specifically to
 cardiovascular disease (Chapter 5), lower extremity amputations (Chapter
 6), and diabetic ketoacidosis (Chapter 7).

 Methods

 We used data from the National Hospital Discharge Survey (NHDS) to
 estimate the number of diabetes-related hospitalizations in U.S.
 noninstitutional, nonfederal hospitals (National Center for Health Statistics,
 1988b).  Conducted by the National Center for Health Statistics, NHDS
 provides a continuous sample of hospital discharge records.  The survey
 collects information on the characteristics of patients, on their
 diagnoses and surgical procedures, and on the characteristics
 of the hospitals from which they are discharged.  Sampling of hospital
 discharges is based on a two-stage, stratified design.  At the first
 stage, sample hospitals are chosen from strata based on geographic
 region and number of beds.  At the second stage, sample discharges
 are selected from each hospital in the survey.  The overall sampling
 fraction for all discharges is 1 in 100.  We used SAS (SAS Institute
 Inc., 1985) to compute the weighted number of discharges and hospital
 discharge rates.  To account for the multistage survey design, we
 used SESUDAAN (Shah, 1981) to compute associated standard errors.

 To determine numbers and rates of diabetes-related discharges, we
 selected all discharges for which any of the up to seven listed discharge
 diagnoses were coded to the International Classification of Diseases,
 Ninth Revision rubric 250.  We used estimates of the total population
 of the United States (Irwin, 1989) as the denominators in calculating
 general population rates.  We used estimates of the prevalence of
 diabetes from the National Health Interview Survey (Chapter 2) to
 estimate numbers of people with diabetes and used these numbers in
 calculating rates of hospital discharges among people with diabetes.

 We standardized rates according to the direct method (Fleiss, 1981).  We
 used the 1980 U.S resident population to standardize rates based on
 the total resident population.  We used the 1980 U.S. population of
 persons with diabetes to standardize rates based on the diabetic population.

 Results

  General Information

 In 1987, the last year for which data are available, an
 estimated 2.8 million hospital discharges listed diabetes as one of
 the discharge diagnoses.  Among these discharges, the most common
 primary discharge diagnosis was for diseases of the circulatory system
 (33.7%), followed by diabetes-specific conditions (17.2%) (Table 4.1).

  General Population Rates

 In 1987, diabetes was the primary diagnosis for 474,000
 hospital discharges (Table 4.2).  From 1980 through 1983, the number
 and rate of hospital discharges with diabetes as the primary discharge
 diagnosis were relatively stable, but both figures declined from 1984
 through 1987.  Trends similar to those noted in the total population
 were also seen among white males and white females (Tables 4.3-4.4).  Among
 black males, however, temporal trends were not as clear as among whites
 (Table 4.5).  Among black females, the rates decreased steadily from
 1981 through 1987 (Table 4.6).

 Many more hospital discharges had diabetes as any listed diagnosis
 than as the primary diagnosis.  Both the numbers and rates of hospitalizations
 with diabetes as any listed diagnosis increased from 1980 through
 1984, decreased in 1985, and then increased again in subsequent years
 (Figures 4.1-4.2).

 In all years, the rate of hospitalization increased with increasing
 age (Table 4.7).  In 1987, the rate of hospitalization for which diabetes
 was any listed diagnosis increased from 8.7 per 10,000 among those
 19 years old or younger to 580.7 per 10,000 among those 75 years old
 or older.

 In all years, black women had the highest age-adjusted rate of
 hospitalizations related to diabetes (Figure 4.3, Tables 4.8-4.11).  In 1987,
 the age-adjusted rate of 183 hospitalizations per 10,000 black women was 36%
 higher than for black men (135 per 10,000), 95% higher than for white women
 (94/10,000), and 108% higher than for white men (88 per 10,000).

  Diabetes Population Rates

 When rates of hospitalization were calculated by using people
 known to have diabetes as the denominator, the rates of hospital
 discharges with diabetes as a primary diagnosis showed a small increase
 from 1980 to 1983, but then steadily decreased after 1983 (Table 4.12).  The
 temporal trends varied among the four race-sex groups (Tables 4.13-4.16).

 Among people known to have diabetes, the rates of hospital discharges
 with diabetes as any listed diagnosis showed a similar temporal trend
 to that seen for diabetes as a primary diagnosis.  The rates increased
 from 1980 to 1983 and decreased after 1983 (Figure 4.4).  The 1987
 rate of 402 hospital discharges per 1,000 persons with diabetes was
 14% lower than the peak rate in 1983 of 469 per 1,000 persons.

 In all years, the age-specific rates were highest in the oldest age
 group, decreased with decreasing age, and leveled off or increased
 slightly in the youngest age group (Table 4.17).  In 1987, the rates
 ranged from 287 hospital discharges per 1,000 people with diabetes
 among those younger than age 45 to 591 per 1,000 people with diabetes
 among those 75 years old or older.

 Among people known to have diabetes, differences in hospitalization
 rates for diabetes as any listed diagnosis were not consistent between the
 four race-sex groups (Figure 4.5, Tables 4.8-4.21). In all except
 two years, white women had the highest hospital discharge rates.  The
 relative rankings of the other three race-sex groups varied from year
 to year.  In 1987, the rates of hospital discharges with diabetes
 as any listed diagnosis per 1,000 people with diabetes were 409 for
 white women, 311 for white men, 365 for black men, and 382 for black
 women.

  Rates by Region

 The rates of hospital discharges with diabetes as a primary
 diagnosis were highest in the South and lowest in the West (Table
 4.22).  The West also had the lowest rates of hospital discharges
 with diabetes as any listed diagnosis (Table 4.23).  When the rates
 were age- and race-adjusted, the rankings between Northeast, Midwest,
 and South tended to vary from year to year.  In all years, the
 hospitalization rates in the West were at least 25% lower than for
 the other three regions.

 Discussion

 In 1987, diabetes was listed as one of the discharge diagnoses
 for 2.8 million hospital discharges.  In general, during 1980-1987,
 hospital discharges with diabetes as any listed diagnosis tended to
 increase; they reached a peak in 1984 and have slightly decreased
 and leveled off subsequently.

 Rates of diabetes-related hospitalizations based on general population
 denominators are influenced by the prevalence of diabetes in the population,
 the severity of the disease, and the availability and use of health
 care.  Except for a dip in 1985, the rates of diabetes-related hospital
 discharges in the general population increased during 1980-1987, similar
 to the trends in numbers of diabetes-related hospital discharges.  The
 rates per 10,000 general population increased with increasing age,
 reflecting both the increasing prevalence of diabetes and the more
 frequent occurrence of complications as people age.

 Rates of diabetes hospitalizations calculated by using the population
 of people known to have diabetes as the denominator are not affected
 by prevalence of diabetes, but rather are dependent on disease severity
 and health care utilization.  In 1987, there were 400 hospital discharges
 related to diabetes for every 1,000 people known to have diabetes.  During
 the years covered in this report, the rates of hospitalization per
 1,000 people with diabetes increased during 1980-1983 and decreased
 thereafter.

 Among people with diabetes, the age-specific rates of hospitalization
 were highest in the oldest age group (75 years or older) and decreased
 with decreasing age until leveling off, or increasing slightly, for
 the age group younger than age 45.  The general tendency of hospitalization
 rates to increase with increasing age reflects the higher prevalence
 of complications among older people with diabetes.  The tendency for
 the age group below age 45 to have rates similar to or higher than
 the 45 to 64 group may reflect the higher proportion, in the younger
 age group, of people with insulin-dependent diabetes relative to
 noninsulin-dependent diabetes.

 We noted some differences in race- and sex-specific rates for diabetes-related
 hospitalizations.  When calculated by using general population denominators,
 the hospital discharge rate for diabetes as any listed diagnosis was
 higher among blacks than among whites, with black women having the
 highest rates and white men having the lowest.  Black men tended to
 have rates about 50% higher than white men, and black women tended
 to have rates nearly twice as high as white women.  When hospital
 discharge rates were calculated for the population of persons known
 to have diabetes, however, white women tended to have the highest
 rates; no consistent differences emerged between the other three race-sex
 groups.  These results suggest that the higher rates of diabetes-related
 hospitalizations seen among blacks in the general population are at
 least partly due to the higher prevalence of diabetes among blacks.

 The most striking regional variation in the hospital discharge rates
 occurred in the West, where rates of diabetes-related hospital discharges
 were lowest among the four regions.  The age- and race-adjusted rates
 of hospital discharges for diabetes as any listed diagnosis were 25%
 to 32% lower in the West than in the other regions.

 We have emphasized the results based on discharges with diabetes as
 any listed diagnosis rather than those based on primary diagnosis because
 the former better indicate the diabetes-related disease burden.  Also,
 listing of primary diagnosis may be more subject to changes in coding
 practices.  For example, in 1983 Medicare instituted the prospective
 payment system and diagnosis-related groups.  After 1983, there was
 a 30% decrease in hospital discharges with diabetes listed as the
 primary diagnosis (from 675,000 in 1983 to 474,000 in 1987).  The
 number of discharges with diabetes as any listed diagnosis, on the
 other hand, slightly decreased (7% decrease) in 1985, but increased
 thereafter.  As a consequence of these different trends, the proportion
 of diabetes-related hospital discharges for which diabetes was listed
 as the primary diagnosis decreased from 25% in 1983 to 17% in 1987.

 The NHDS data also suggest that hospitalization practices for patients
 with diabetes changed after 1983.  As noted, the rate of hospital
 discharges per 1,000 people with diabetes decreased after 1983.  The
 age-adjusted rate decreased 14% from 1983 to 1987 (from 469 to 402
 per 1,000 people with diabetes).  The increasing number of diabetes-related
 hospitalizations, despite decreasing rates of hospitalization among
 people with diabetes, is due to the disease's increasing prevalence.

 The methods we used have some limitations when interpreting the results
 in this chapter.  First, the NHDS is limited to the civilian population
 of the United States and thus probably underestimates diabetes-related
 hospital discharge rates.  This limitation, however, should not affect
 the temporal patterns nor the relative differences between different
 population groups.  Second, the rates calculated for the population
 of people with diabetes were computed from estimates derived from
 the NHIS and thus represent people with diagnosed diabetes.  About
 half of the people with diabetes, however, do not know they have the
 disease (Harris et al., 1987).  Third, the NHDS sample represents
 hospital discharges and not individual persons.  Thus, some people
 who were hospitalized on more than one occasion for the same condition
 may have been counted more than once.  This is not a serious problem
 for public health purposes, however, since we are primarily concerned
 with the impact of diabetes on overall health care utilization-and
 multiple hospitalizations certainly are a part of health care use.
 Although not a perfect surveillance mechanism, the NHDS provides
 useful indicators of the morbidity and public health burden related
 to diabetes in the United States.

 Update

      This section updates data presented in previous sections in light of one
 additional year of hospitalization data.  For a complete description of the
 methods and operational definitions and for a discussion of the implications
 of the findings, see previous sections.

      In 1988, diabetes was the primary diagnosis for 454,000 hospital
 discharges and occurred as any one of seven listed diagnoses for 2.8 million
 hospital discharges (Tables 4.2 and 4.7).  Hospital discharge rates with
 diabetes as primary diagnosis among people known to have diabetes showed a
 small increase from 1980 to 1983, but then decreased and leveled off (Table
 4.12).  This temporal trend varied somewhat among the four race-sex groups
 (Tables 4.13-4.16).  Regardless of race and sex, hospital discharge rates for
 diabetes as primary diagnosis among people known to have diabetes were highest
 among persons younger than 45 years of age.  The next highest rates were found
 among persons aged 75 or older, and only small differences were seen among
 those aged 45-64 and those aged 65-74.
      In general, rates of hospital discharges with diabetes as any listed
 diagnosis among people known to have diabetes (Figure 1.6) showed a similar
 temporal trend as those with diabetes as a primary diagnosis (Tables 4.17-
 4.21).  However, among black females, these rates have tended to increase
 since 1983.  The 1988 rate of 411 hospital discharges per 1,000 black females
 with diabetes was 27% higher than the corresponding 1983 rate of 324 per 1,000
 (Table 4.21).  Among white males and white females with diabetes, hospital
 discharge rates for diabetes as any listed diagnosis tended to increase with
 age.  For black males and black females with diabetes, the rates were higher
 among the youngest (under 45 years of age) and oldest age groups (75 years and
 older) than among the middle two age groups (45-64 and 65-74 years of age).

 Detailed Tables

 4.1 Dist. among Hospital Discharges with Diabetes as Diagnosis

 Table 4.1  Distribution of Primary Diagnosis among all Hospital Discharges
            with Diabetes as Any Listed Diagnosis, United States, 1988

 Primary Diagnosis (ICD-9-CM Codes)            Percent

 Circulatory System (390-459)                    33.9
 Diabetes (250)                                  16.3
 Digestive System (520-579)                       8.4
 Respiratory System (460-519)                     8.3
 Genitourinary System (580-629)                   5.2
 Injury and Poisoning (800-999)                   5.1
 Neoplasms (140-239)                              4.7
 Musculoskeletal System and Connective Tissue     3.3
   (710-739)
 Endocrine, Nutritional, and Metabolic Diseases
   and Immunity Disorders (240-279, not 250)      2.8
 Skin and Subcutaneous Tissue (680-709)           2.7
 Nervous System and Sense Organs (320-389)        2.5
 Mental Disorders (290-319)                       1.9
 Infectious and Parasitic Disease (001-139)       1.9
 Other                                            3.0

 4.2-4.6 Hosp. Discharges & Rates w/Diabetes as Primary Diagnosis

 4.2 10,000 Pop., by Age and Year, U.S., 80-88

 Table 4.2  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            United States, 1980-1984

                                                   Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)           44         44         41         48         45
         Rate                6.1        6.1        5.7        6.8        6.4

 20-44   Number              114        123        139        135        121
         Rate               13.5       14.1       15.6       14.8       13.0

 45-64   Number              245        239        241        237        199
         Rate               55.0       53.6       54.1       53.0       44.4

 65-74   Number              138        144        145        146        130
         Rate               87.9       90.4       89.3       88.6       77.5

 75+     Number              105        106         95        109         98
         Rate              104.0      102.4       89.8       99.8       87.0

 Total   Number              645        655        661        675        593
         Rate               28.4       28.5       28.5       28.8       25.1

 Age-adjusted Rate          28.4       28.5       28.3       28.6       24.8

 (a) In thousands

 Table 4.2  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)           39         40         49         41
          Rate                5.6        5.7        6.9        5.8

  20-44   Number              110        113        109        112
          Rate               11.6       11.7       11.2       11.4

  45-64   Number              160        159        150        134
          Rate               35.5       35.4       33.2       29.2

  65-74   Number               96        107         92         91
          Rate               56.3       61.9       52.1       50.7

  75+     Number               75         72         74         76
          Rate               65.1       61.0       60.8       60.7

  Total   Number              480        491        474        454
          Rate               20.1       20.4       19.5       18.5

  Age-adjusted Rate          19.8       20.0       19.1       18.0

 (a) In thousands

 4.3 10,000 Pop., by Age and Year, U.S., 80-88, White Males

 Table 4.3  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Males, United States, 1980-1984

                                                   Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)           13         16         12         16         13
         Rate                4.2        5.2        3.9        5.3        4.3

 20-44   Number               36         42         53         42         41
         Rate               10.0       11.2       13.8       10.7       10.4

 45-64   Number               63         78         71         67         54
         Rate               33.1       41.0       37.4       35.6       28.7

 65-74   Number               32         45         38         39         32
         Rate               52.5       72.8       59.7       59.9       48.7

 75+     Number               24         28         25         25         25
         Rate               72.8       84.7       74.2       72.4       70.2

 Total   Number              167        209        198        189        166
         Rate               17.6       21.8       20.5       19.4       16.9

 Age-adjusted Rate          18.4       22.6       21.1       20.0       17.3

 (a) In thousands

 Table 4.3  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Males, United States, 1985-1988

                                             Year

                             1985       1986       1987       1988
  Age

  0-19    Number (a)           11         15         16         12
          Rate                3.6        5.1        5.5        4.0

  20-44   Number               34         29         33         36
          Rate                8.4        7.1        7.9        8.6

  45-64   Number               47         42         40         43
          Rate               24.8       22.1       20.9       22.4

  65-74   Number               23         28         26         28
          Rate               34.1       40.1       36.5       39.7

  75+     Number               19         20         16         22
          Rate               51.6       53.9       40.9       54.7

  Total   Number              133        133        130        141
          Rate               13.4       13.4       12.9       13.9

  Age-adjusted Rate          13.7       13.7       13.1       14.0

 (a) In thousands

 4.4 10,000 Pop., by Age and Year, U.S., 80-88, White Females

 Table 4.4  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)           18         18         19         20         22
         Rate                6.0        6.2        6.6        7.2        7.8

 20-44   Number               40         53         48         53         36
         Rate               10.9       14.3       12.7       13.5        9.2

 45-64   Number               97         96        102        100         72
         Rate               47.0       46.9       49.9       48.9       35.2

 65-74   Number               66         74         66         74         59
         Rate               82.9       91.9       80.8       88.5       70.3

 75+     Number               55         64         53         61         53
         Rate               92.0      104.4       84.9       93.8       79.1

 Total   Number              275        305        289        307        242
         Rate               27.5       30.3       28.5       30.0       23.5

 Age-adjusted Rate          25.0       27.4       25.9       27.2       21.1

 (a) In thousands

 Table 4.4  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Females, United States, 1985-1988

                                             Year

                             1985       1986       1987       1988

  Age

  0-19    Number  (a)          19         16         18         16
          Rate                6.9        5.6        6.4        5.8

  20-44   Number               41         38         38         36
          Rate               10.3        9.4        9.2        8.8

  45-64   Number               57         60         52         42
          Rate               28.1       29.4       25.5       20.5

  65-74   Number               41         46         41         38
          Rate               48.0       53.0       47.2       42.6

  75+     Number               35         33         37         35
          Rate               51.8       47.0       51.8       47.9

  Total   Number              194        192        186        167
          Rate               18.7       18.4       17.7       15.8

  Age-adjusted Rate          17.1       16.8       16.0       14.2

 (a) In thousands

 4.5 10,000 Pop., by Age and Year, U.S., 80-88, Black Males

 Table 4.5  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            Black Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)            2          2          2          3          2
         Rate                3.5        3.7        4.4        5.1        3.8

 20-44   Number               12         13         10         13         13
         Rate               25.4       26.6       20.8       25.5       25.6

 45-64   Number               21         20         17         16         15
         Rate              113.2      103.5       86.4       81.5       73.7

 65-74   Number                5          6          7          5          6
         Rate               82.8      107.0      113.3       89.9       93.6

 75+     Number                3          4          2          3          3
         Rate              113.5      151.2       65.9      103.1       88.0

 Total   Number               43         45         38         40         38
         Rate               33.8       34.9       28.9       30.2       28.5

 Age-adjusted Rate          43.5       45.4       36.8       37.8       35.5

 (a) In thousands

 Table 4.5  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            Black Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)            3          3          4          4
          Rate                4.7        5.5        7.3        6.9

  20-44   Number               10         14         12         16
          Rate               19.5       26.0       21.5       28.1

  45-64   Number               14         16         12         14
          Rate               70.8       77.3       56.9       63.9

  65-74   Number                4          6          6          4
          Rate               58.8      100.9       88.3       53.4

  75+     Number                3          3          3          4
          Rate              106.5       82.3      102.9      108.5

  Total   Number               34         42         37         40
          Rate               25.0       30.2       26.2       28.2

  Age-adjusted Rate          31.4       37.2       32.1       33.7

 (a) In thousands

 4.6 10,000 Pop., by Age and Year, U.S., 80-88, Black Females

 Table 4.6  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            Black Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)            5          6          2          3          3
         Rate                9.4       11.9        3.8        5.9        5.8

 20-44   Number               13         13         16         10         11
         Rate               24.5       24.5       28.1       18.1       18.3

 45-64   Number               36         38         29         27         29
         Rate              154.4      159.8      122.9      111.1      117.5

 65-74   Number               14         15         18         16         17
         Rate              180.2      194.3      226.1      201.0      200.8

 75+     Number                9          8          5         10          9
         Rate              193.9      156.2       92.1      186.3      158.6

 Total   Number               77         80         70         66         68
         Rate               54.5       55.9       47.9       45.0       45.2

 Age-adjusted Rate          63.4       64.5       55.4       52.5       52.5

 (a) In thousands

 Table 4.6  Number of Discharges with Diabetes as Primary Diagnosis and
            Hospital Discharge Rate per 10,000 Population, by Age and Year,
            Black Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)            4          4          2          5
          Rate                7.7        7.0        4.1        8.6

  20-44   Number               11         14          8         12
          Rate               18.9       22.1       13.5       18.4

  45-64   Number               19         21         24         16
          Rate               76.8       83.7       94.7       61.7

  65-74   Number               15         13          8         13
          Rate              181.7      147.1       91.4      145.0

  75+     Number                8          7          6          8
          Rate              149.4      121.5      106.2      125.3

  Total   Number               58         58         49         53
          Rate               38.3       37.5       31.3       33.3

  Age-adjusted Rate          43.7       42.4       35.9       37.2

 (a) In thousands

 4.7-4.11 Hosp. Discharge/Rate w/Diabetes as Any Listed Diagnosis

 4.7 10,000 Pop., by Age and Year, U.S., 80-88

 Table 4.7  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            United States, 1980-1984

                                                   Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)           61         58         52         69         63
         Rate                8.5        8.1        7.3        9.7        9.0

 20-44   Number              255        278        311        320        326
         Rate               30.1       32.0       34.9       35.1       35.0

 45-64   Number              798        791        850        873        897
         Rate              179.3      177.5      190.7      195.5      200.3

 65-74   Number              605        647        687        738        800
         Rate              386.8      406.6      424.3      447.5      477.9

 75+     Number              507        549        583        669        720
         Rate              504.9      532.0      549.1      611.9      641.4

 Total   Number             2227       2324       2484       2669       2806
         Rate               98.0      101.2      107.1      113.9      118.7

 Age-adjusted Rate          98.0      100.8      106.2      112.3      116.4

 (a) In thousands

 Table 4.7  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)           54         55         62         56
          Rate                7.7        7.7        8.7        7.8

  20-44   Number              315        316        330        314
          Rate               33.2       32.8       33.9       32.0

  45-64   Number              834        845        863        858
          Rate              185.9      187.6      190.6      186.6

  65-74   Number              738        799        800        807
          Rate              434.1      461.1      453.2      451.1

  75+     Number              663        701        707        743
          Rate              575.7      593.0      581.4      596.6

  Total   Number             2605       2716       2762       2778
          Rate              109.1      112.7      113.5      113.0

  Age-adjusted Rate         106.6      109.4      109.6      108.4

 (a) In thousands

 4.8 10,000 Pop., by Age and Year, U.S., 80-88, White Males

 Table 4.8  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)           18         22         16         23         19
         Rate                5.9        7.2        5.4        7.9        6.3

 20-44   Number               70         82         96         85         92
         Rate               19.4       22.0       25.2       21.8       23.2

 45-64   Number              248        274        282        289        293
         Rate              131.1      145.0      149.2      152.9      155.1

 65-74   Number              186        232        224        234        245
         Rate              303.8      372.7      351.6      360.5      371.5

 75+     Number              129        161        171        203        202
         Rate              398.4      484.6      501.7      580.5      564.5

 Total   Number              652        771        788        834        851
         Rate               68.5       80.3       81.5       85.5       86.7

 Age-adjusted Rate          73.3       86.0       86.7       91.1       91.6

 (a) In thousands

 Table 4.8  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)           16         19         21         17
          Rate                5.4        6.4        7.0        5.7

  20-44   Number               83         76         81         87
          Rate               20.6       18.7       19.7       21.0

  45-64   Number              286        270        276        306
          Rate              151.3      142.7      145.1      158.5

  65-74   Number              245        274        269        289
          Rate              364.9      397.9      382.3      405.6

  75+     Number              185        205        203        223
          Rate              503.8      545.5      524.3      560.5

  Total   Number              815        845        850        922
          Rate               82.4       84.6       84.5       90.9

  Age-adjusted Rate          86.4       88.5       87.5       93.4

 (a) In thousands

 4.9 10,000 Pop., by Age and Year, U.S., 80-88, White Females

 Table 4.9  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-19    Number (a)           28         24         24         29         30
          Rate                9.4        8.2        8.4       10.3       10.8

  20-44   Number              101        123        120        135        126
          Rate               27.7       33.2       31.5       34.9       31.9

  45-64   Number              319        327        337        357        346
          Rate              154.9      159.4      164.8      174.5      169.5

  65-74   Number              274        320        323        353        370
          Rate              343.1      395.7      393.1      423.1      438.7

  75+     Number              272        335        307        356        397
          Rate              456.7      548.0      488.1      550.2      597.6

  Total   Number              993       1130       1111       1230       1269
          Rate               99.2      112.1      109.4      120.2      123.2

  Age-adjusted Rate          87.5       97.7       95.3      103.9      105.1

 (a) In thousands

 Table 4.9  Number of Discharges with Diabetes as Any Listed Diagnosis
            and Hospital Discharge Rate per 10,000 Population, by Age and Year,
            White Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)           27         22         23         22
          Rate                9.5        7.9        8.1        7.9

  20-44   Number              124        120        133        118
          Rate               30.9       29.6       32.5       28.6

  45-64   Number              316        309        316        297
          Rate              154.9      151.9      155.1      143.8

  65-74   Number              319        335        342        323
          Rate              374.3      386.8      389.3      364.0

  75+     Number              338        350        353        383
          Rate              495.4      500.1      493.2      522.7

  Total   Number             1123       1136       1168       1143
          Rate              108.3      108.7      111.0      107.8

  Age-adjusted Rate          92.6       92.1       93.7       89.5

 (a) In thousands

 4.10 10,000 Pop., by Age and Year, U.S., 80-88, Black Males

 Table 4.10  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population,
             by Age and Year, Black Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)            2          2          3          3          2
         Rate                3.5        4.2        5.0        5.1        3.8

 20-44   Number               21         23         19         26         23
         Rate               45.4       48.4       39.4       50.8       45.3

 45-64   Number               51         53         45         53         60
         Rate              272.5      276.3      230.7      271.8      300.8

 65-74   Number               20         22         23         26         29
         Rate              356.9      385.0      399.4      431.3      483.9

 75+     Number               12         14         13         12         16
         Rate              428.5      494.8      436.3      382.6      520.2

 Total   Number              106        114        103        119        131
         Rate               84.1       88.9       78.7       89.7       97.3

 Age-adjusted Rate         114.9      121.9      108.2      120.4      133.3

 (a) In thousands

 Table 4.10  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population,
             by Age and Year, Black Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)            3          4          5          5
          Rate                5.4        6.5        9.3        9.4

  20-44   Number               24         28         26         31
          Rate               44.6       52.3       47.7       54.3

  45-64   Number               62         59         52         61
          Rate              307.2      290.4      249.7      289.6

  65-74   Number               29         31         32         37
          Rate              461.8      490.0      500.9      559.4

  75+     Number               22         24         24         25
          Rate              684.7      745.2      705.8      732.8

  Total   Number              139        147        139        159
          Rate              101.7      105.6       98.8      111.0

  Age-adjusted Rate         140.6      145.1      135.3      150.9

 (a) In thousands

 4.11 10,000 Pop., by Age and Year, U.S., 80-88, Black Females

 Table 4.11  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by Age and Year,
             Black Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

 0-19    Number (a)            6          9          3          7          5
         Rate               11.6       16.5        5.5       12.3        9.1

 20-44   Number               32         40         41         36         36
         Rate               61.8       73.6       73.7       62.5       60.4

 45-64   Number               88        106         99         88        100
         Rate              377.6      450.9      418.5      364.7      410.6

 65-74   Number               42         57         46         58         73
         Rate              536.9      712.0      570.6      710.7      879.3

 75+     Number               27         29         31         35         41
         Rate              563.0      602.9      623.0      675.7      765.5

 Total   Number              195        240        221        224        255
         Rate              137.9      167.6      151.8      151.3      170.1

 Age-adjusted Rate         162.6      196.7      178.0      177.4      200.2

 (a) In thousands

 Table 4.11  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by Age and Year,
             Black Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-19    Number (a)            5          6          4          6
          Rate                9.6       11.2        6.6       10.7

  20-44   Number               42         46         39         38
          Rate               69.0       75.0       62.2       60.1

  45-64   Number               78         96        103         98
          Rate              315.4      382.9      403.8      380.1

  65-74   Number               65         71         62         82
          Rate              765.5      827.7      712.8      931.2

  75+     Number               42         45         40         45
          Rate              745.8      787.5      672.6      729.3

  Total   Number              231        264        247        269
          Rate              151.8      171.4      157.9      169.6

  Age-adjusted Rate         176.2      198.3      183.2      196.6

 (a) In thousands

 4.12-4.16 Hosp. Discharge Rate for Diabetes as Primary Diagnosis

 4.12 1,000 Diabetic Pop., by Age and Year, U.S., 80-88

 Table 4.12  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             United States, 1980-1984

                                               Year
                         1980       1981       1982       1983       1984
  Age

  0-44                   156.7      175.1      183.0      182.4      167.3

  45-64                  102.5       93.9       93.9       91.1       84.3

  65-74                   90.3      105.5       94.8      111.9       73.8

  75+                    121.4      111.6      117.7      124.8       89.6

  Total                  111.6      112.8      112.3      116.7       95.6

  Age-adjusted           111.6      113.7      113.3      117.5       96.8

 Table 4.12  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             United States, 1985-1988

                                         Year
                         1985       1986       1987       1988
  Age

  0-44                   144.0      145.7      115.7      140.1

  45-64                   68.5       55.9       58.9       54.6

  65-74                   51.7       67.4       54.1       53.2

  75+                     68.2       56.2       61.9       69.2

  Total                   75.9       72.5       69.6       71.5

  Age-adjusted            77.2       74.6       68.0       71.3

 4.13 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, White Male

 Table 4.13  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Males, United States, 1980-1984

                                               Year
                         1980       1981       1982       1983       1984
  Age

  0-44                   157.7      156.5      167.5      140.7      152.8

  45-64                   68.2       76.2       72.4       73.1       66.7

  65-74                   54.1       82.1       88.3       93.4       54.3

  75+                     92.4      123.1       83.9       77.0       77.6

  Total                   80.5       96.3       94.8       91.1       79.5

  Age-adjusted            83.7       98.8       94.9       90.8       80.1

 Table 4.13  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Males, United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         112.9      145.6       84.6       97.9

  45-64                         53.7       33.8       37.9       46.3

  65-74                         33.8       44.1       36.4       50.8

  75+                           54.0       50.0       37.7       56.4

  Total                         58.0       52.0       47.3       59.6

  Age-adjusted                  58.9       58.4       45.6       58.0

 4.14 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, White Female

 Table 4.14  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Females, United States, 1980-1984

                                                Year
                          1980       1981       1982       1983       1984
  Age

  0-44                    120.0      168.5      141.4      180.7      132.8

  45-64                    98.8       96.6      103.6       92.4       68.7

  65-74                    88.3      120.5       84.6      117.2       73.9

  75+                     105.5      107.2      125.7      132.6       88.8

  Total                   100.9      116.1      108.3      119.5       84.0

  Age-adjusted            100.7      117.0      108.5      120.3       84.2

 Table 4.14  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Females, United States, 1985-1988

                                           Year
                           1985       1986       1987       1988
  Age

  0-44                     120.4       91.2      108.8      146.9

  45-64                     62.8       55.9       54.6       45.9

  65-74                     46.3       67.8       55.6       45.6

  75+                       59.4       48.2       69.4       68.6

  Total                     67.0       63.7       67.8       64.0

  Age-adjusted              68.0       64.0       66.5       66.8

 4.15 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, Black Male

 Table 4.15  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      184.3      226.4      202.0      422.9      277.2

  45-64                     114.7      106.5       92.8       78.3       68.0

  65-74                      76.6       91.6       94.4       63.0       64.5

  75+                       109.6      190.6       78.7      129.2       78.9

  Total                     122.1      131.9      112.0      114.2       97.5

  Age-adjusted              116.1      136.0      110.2      142.0      105.2

 Table 4.15  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Males, United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         204.9      206.5      175.4      244.5

  45-64                         64.3       77.5       56.4       54.7

  65-74                         36.9       70.4       55.0       41.5

  75+                           99.3       68.8       98.6       71.9

  Total                         81.8      100.8       84.1       87.1

  Age-adjusted                  86.9       96.9       83.1       86.9

 4.16 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, Black Female

 Table 4.16  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Females, United States, 1980-1984

                                                     Year
                               1980       1981       1982       1983       1984
  Age

  0-44                         159.1      202.7      206.3      116.5      127.6

  45-64                        142.7      132.3       90.6       88.9      101.8

  65-74                        136.0      112.8      114.2       82.5       89.7

  75+                          128.2      107.8       68.6      116.4       93.0

  Total                        142.9      136.4      109.8       94.9      101.4

  Age-adjusted                 141.7      135.8      113.7       96.1      101.8

 Table 4.16  Hospital Discharge Rate for Diabetes as Primary Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Females, United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         169.9      199.1       98.0      121.5

  45-64                         73.4       74.8       86.0       65.5

  65-74                         83.9       87.7       55.9       83.0

  75+                           70.6       55.3       43.0       54.5

  Total                         89.4       90.8       72.3       78.4

  Age-adjusted                  92.6       97.0       73.8       78.2

 4.17-4.21 Discharge Rate for Diabetes as Any Listed Diagnosis

 4.17 1,000 Diabetic Pop., by Age & Year, U.S., 80-88

 Table 4.17  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      313.4      353.7      369.3      388.4      391.3

  45-64                     334.0      310.8      331.3      335.8      380.3

  65-74                     397.7      474.2      450.5      565.4      455.2

  75+                       589.2      579.4      719.9      764.8      660.5

  Total                     385.2      400.0      422.0      461.6      452.6

  Age-adjusted              385.2      401.3      427.2      469.3      443.7

 Table 4.17  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         355.5      354.3      287.3      338.5

  45-64                        358.2      296.7      338.1      348.7

  65-74                        398.8      501.6      470.1      473.6

  75+                          602.7      546.3      592.0      679.6

  Total                        412.2      401.1      405.4      437.5

  Age-adjusted                 404.8      397.9      401.8      429.1

 4.18 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, White Male

 Table 4.18  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      284.5      280.7      291.4      265.7      313.0

  45-64                     270.4      269.5      288.4      313.8      360.6

  65-74                     312.8      420.2      520.1      561.9      414.5

  75+                       505.4      704.7      567.5      617.3      623.5

  Total                     313.5      355.7      376.7      402.2      408.7

  Age-adjusted              319.0      376.0      391.5      415.9      405.6

 Table 4.18  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Males, United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         252.2      316.3      176.3      214.7

  45-64                        328.0      218.6      262.3      327.0

  65-74                        361.4      437.8      381.1      518.2

  75+                          527.3      507.0      483.3      577.4

  Total                        355.4      328.9      308.3      390.0

  Age-adjusted                 353.2      336.3      311.5      395.0

 4.19 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, White Female

 Table 4.19  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      269.3      350.3      302.5      407.1      355.9

  45-64                     325.6      328.3      342.4      329.9      331.2

  65-74                     365.5      519.0      411.4      560.0      460.8

  75+                       523.7      562.5      722.8      777.5      670.3

  Total                     364.5      429.6      416.1      478.0      440.9

  Age-adjusted              355.8      417.2      410.2      470.6      420.1

 Table 4.19  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             White Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44                         300.3      240.8      304.9      393.3

  45-64                        346.0      289.0      331.3      321.9

  65-74                        360.7      494.8      459.4      390.1

  75+                          568.7      513.3      660.0      748.0

  Total                        388.3      376.3      425.2      436.5

  Age-adjusted                 375.0      368.2      409.4      415.8

 4.20 1,000 Diabetic Pop., by Age & Year, U.S., 80-88, Black Male

 Table 4.20  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Males, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      309.2      389.8      354.3      770.3      461.8

  45-64                     276.1      284.2      247.7      260.9      277.8

  65-74                     330.3      329.6      332.6      302.3      333.6

  75+                       413.7      623.8      521.4      479.2      466.0

  Total                     304.1      336.1      305.2      339.5      332.8

  Age-adjusted              316.6      365.1      329.4      393.2      352.6

 Table 4.20  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44                         423.6      385.6      347.3      445.1

  45-64                        278.9      291.1      247.4      248.0

  65-74                        290.1      341.9      312.0      434.9

  75+                          637.9      623.6      675.9      485.8

  Total                        332.8      352.2      317.5      342.8

  Age-adjusted                 360.6      370.5      345.7      367.0

 4.21 1,000 Diabetic Pop., by Age/Year, U.S., 80-88, Black Female

 Table 4.21  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Females, United States, 1980-1984

                                                  Year
                            1980       1981       1982       1983       1984
  Age

  0-44                      343.8      502.1      513.6      365.0      370.8

  45-64                     349.1      373.4      308.6      291.9      355.7

  65-74                     405.1      413.2      288.3      291.7      392.6

  75+                       372.4      416.2      464.5      422.0      448.6

  Total                     361.8      409.0      347.8      319.5      381.3

  Age-adjusted              366.4      412.7      362.3      324.0      381.9

 Table 4.21  Hospital Discharge Rate for Diabetes as Any Listed Diagnosis
             per 1,000 Diabetic Population, by Age and Year,
             Black Females, United States, 1985-1988

                                               Year
                               1985       1986       1987       1988
  Age

  0-44                         511.2      598.6      391.2      327.1

  45-64                        301.1      342.0      366.6      403.4

  65-74                        353.4      493.4      435.9      533.4

  75+                          352.5      358.4      272.2      316.9

  Total                        354.6      414.4      364.7      399.9

  Age-adjusted                 359.2      429.1      375.1      411.4

 4.22 Hosp. Discharges & Rates with Diabetes as Primary Diagnosis

 Table 4.22  Number of Discharges with Diabetes as Primary Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by
             Region and Year, United States, 1980-1984


                                                      Year
                                        1980   1981   1982   1983   1984
  Region

  Northeast   Number (a)                 152    143    150    144    137
              Rate                      31.0   29.1   30.4   29.0   27.7
              Adjusted Rate (b)         26.8   28.2   26.4   24.9   21.9

  North       Number                     185    179    180    185    152
  Central     Rate                      31.4   30.3   30.6   31.3   25.7
              Adjusted Rate             27.8   31.1   28.6   28.7   23.8

  South       Number                     232    254    245    255    219
              Rate                      30.7   32.9   31.3   32.0   27.1
              Adjusted Rate             28.0   31.7   29.1   30.4   23.8

  West        Number                      76     79     86     91     84
              Rate                      17.4   17.9   18.9   19.8   17.9
              Adjusted Rate             16.2   19.0   18.0   16.9   16.0

 (a) In thousands
 (b) Adjusted for age and race

 Table 4.22  Number of Discharges with Diabetes as Primary Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by
             Region and Year, United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Region

  Northeast   Number (a)                 119     94     99     96
              Rate                      24.0   18.8   19.7   19.0
              Adjusted Rate (b)         21.8   16.9   17.4   17.4

  North       Number                     115    128    126    120
  Central     Rate                      19.5   21.7   21.1   20.1
              Adjusted Rate             18.0   18.9   18.8   18.2

  South       Number                     172    191    167    172
              Rate                      21.1   23.0   20.0   20.2
              Adjusted Rate             17.8   19.5   16.9   18.0

  West        Number                      73     78     82     66
              Rate                      15.2   15.9   16.4   13.0
              Adjusted Rate             13.3   15.0   14.1    9.7

 (a) In thousands
 (b) Adjusted for age and race

 4.23 Hosp. Discharges/Rates w/ Diabetes as Any Listed Diagnosis

 Table 4.23  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by
             Region and Year, United States, 1980-1984


                                                      Year
                                        1980   1981   1982   1983   1984
  Region

  Northeast   Number (a)                 571    558    594    618    649
              Rate                     116.1  113.2  120.5  124.9  130.7
              Ajusted Rate (b)          99.9  107.2  105.2  108.8  111.0

  North       Number                     641    661    699    719    741
  Central     Rate                     108.8  111.9  118.6  121.9  125.3
              Ajusted Rate              96.1  113.1  108.6  109.8  113.9

  South       Number                     732    802    860    950   1029
              Rate                      96.6  104.0  109.6  119.1  127.3
              Ajusted Rate              88.5  102.7  104.1  113.6  117.0

  West        Number                     284    304    330    382    387
              Rate                      65.3   68.5   73.1   82.9   82.6
              Ajusted Rate              60.7   72.6   66.1   73.3   76.2

 (a) In thousands
 (b) Adjusted for age and race

 Table 4.23  Number of Discharges with Diabetes as Any Listed Diagnosis
             and Hospital Discharge Rate per 10,000 Population, by
             Region and Year, United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Region

  Northeast   Number (a)                 672    635    648    680
              Rate                     134.8  126.9  128.9  134.8
              Ajusted Rate (b)         118.0  111.0  111.9  117.2

  North       Number                     664    707    736    723
  Central     Rate                     112.2  119.3  123.5  121.1
              Ajusted Rate             103.6  105.7  108.0  108.3

  South       Number                     864    954    918   1011
              Rate                     105.5  114.9  109.4  118.8
              Ajusted Rate              92.8  100.3   96.1  108.0

  West        Number                     405    421    460    364
              Rate                      84.8   86.3   92.6   72.0
              Ajusted Rate              74.7   75.5   79.6   54.3

 (a) In thousands
 (b) Adjusted for age and race


CARDIOVASCULAR DISEASE

 Introduction

 Cardiovascular disease is the leading cause of mortality among
 persons with diabetes. The last analysis of national mortality
 data that examined the toll of cardiovascular disease mortality among
 the diabetic population was from 1978 (Harris & Entmacher, 1985).
 We examine the latest national data concerning mortality and hospitalizations
 from cardiovascular disease among people with diabetes. Using national
 vital statistics data from 1980 to 1986, we determined the nu
 age-specific mortality rates and crude and age-adjusted mortality
 rates by calendar year, age, and race-sex groups. Using the National
 Hospital Discharge Survey (NHDS) data from 1980 through 1987, we calculated
 the number of persons with diabetes who were hospitalized for major
 CVD, IHD, and stroke and we calculated age-specific hospital discharge
 rates and crude and age-adjusted hospital discharge rates by calendar
 year, age, and race-sex groups.

 Methods

 For the years 1980-1986, the number of deaths from major CVD
 (ICD-9 390-448), IHD (ICD-9 410-414), and stroke (ICD-9 430-434,
 436-438) coded as the underlying cause of death and diabetes (ICD-9
 250) as a contributing cause of death were determined. For the years
 1980-1987, we determined, using data from the NHDS, the number of
 hospital discharges with major CVD (ICD-9-CM 390-448), IHD (ICD-9-CM
 410-414), and stroke (ICD-9-CM 430-434, 436-438) listed as the primary
 diagnosis and diabetes (ICD-9-CM 250) listed as a secondary diagnosis.

 Rates of mortality and hospitalization were calculated using the estimated
 number of persons with diabetes determined from the 1980-1987 National
 Health Interview Surveys (Chapter 2). Crude, age-adjusted, and age-specific
 rates were calculated. Age-standardization was done using the direct
 method with the 1980 diabetic population of the United States as the
 standard.

 Results

  Major CVD Mortality

 The total number of deaths coded with major CVD as the underlying
 cause and diabetes as a contributing cause increased during the
 7-year period with 75,594 such deaths reported in 1980 compared
 with 80,129 in 1986 (Table 5.1, Figure 5.1).

 Despite this increase in the absolute number of major CVD deaths among
 persons with diabetes, the age-adjusted mortality rate declined, in
 general, during the 7-year period, although the rates increased in
 1982 and 1983 (Figure 5.2). The rate in 1986 was about 16% lower than
 the rate in 1980. Although the age-specific mortality rates vary greatly,
 the decrease occurred primarily among persons with diabetes who were
 75 years or older, for whom the mortality rate in 1986 was 27% lower
 than that in 1980 (Table 5.1). A 28% increase in mortality rates occurred
 in persons aged 44 years or younger. Furthermore, all four race-sex
 groups had lower CVD mortality rates in 1986 than in 1980 (Tables
 5.2-5.5).

 The mortality rate from major CVD increased sharply with age, with
 persons with diabetes aged 75 years or older experiencing mortality
 rates from CVD that were about 30 to 50 times higher than those of
 persons with diabetes who were aged 44 years or younger. During the
 7-year period, the age-adjusted mortality rate was highest for white
 males and was followed by that of white females, black males, and
 black females in order of decreasing rank (Figure 5.3). The age-specific
 rates for white males were higher than those for black males at every
 age group except for those 0-44 years old. The age-specific rates
 for the two oldest age groups of white females exceeded those of black
 females.

 When the mortality rates are calculated based on the number of deaths
 with diabetes and major CVD listed anywhere on the death certificate,
 the trends are the same. The magnitude of the age-adjusted rate, however,
 is about 60% higher in this situation (data not shown).

  IHD Mortality

 Because IHD constitutes the bulk of CVD among persons with diabetes,
 the patterns described for major CVD previously also hold for IHD
 (Tables 5.6-5.10, Figures 5.1-5.2).

  Stroke Mortality

 The number of deaths with stroke as the underlying cause of death
 and diabetes as a contributing cause of death decreased from 12,735 in
 1980 to 11,705 in 1986 (Table 5.11, Figure 5.1). The age-adjusted
 mortality rate declined from 220 deaths per 100,000 diabetic population
 in 1980 to 156 deaths per 100,000 diabetic population in 1986, a 29%
 decline (Figure 5.2). The age-specific rates suggest that this decrease
 occurred primarily in persons aged 45 years and older with the steepest
 decline (38%) occurring in persons with diabetes who were 75 years
 or older. Stroke mortality rates remained essentially unchanged in
 the 0- to 44-year-old age group. With advancing age, the age-specific
 stroke mortality rates increased sharply. The decreases in stroke
 mortality occurred in all four race-sex groups (Tables 5.12-5.15).
 Furthermore, during the 7-year period, the mortality rates for stroke
 were similar for the four race-sex groups.

 The mortality rates calculated based on the number of deaths with
 diabetes and stroke listed anywhere on the death certificate were
 from 2.15 to 2.41 times higher than those based on stroke as the underlying
 cause of death and diabetes as a contributing cause. The trends, however,
 are the same (data not shown).

  Major CVD Hospitalizations

 The number of hospital discharges with major CVD as the primary
 diagnosis and diabetes as a co-diagnosis increased in every
 year from 1980 through 1987 except in 1985. In 1987, an estimated
 902,000 such hospitalizations were recorded (Table 5.16, Figure 5.4).
 From 1980 to 1987, the overall age-adjusted hospital discharge rate
 increased (Table 5.16, Figure 5.5). In 1987, the overall age-adjusted
 hospital discharge rate was 34% higher than in 1980. In every year
 from 1980 to 1987, rates of hospital discharge increased with age,
 with rates among persons 75 years or older 8 to 12.5 times higher
 than rates among persons less than 45 years. Increases occurred in
 all age groups (Table 5.16) and in each of the four race-sex groups
 (Table 5.17). Hospital discharge rates for white males and females
 exceeded those for black males and females in every year.

  IHD Hospitalizations

 In 1980, an estimated 245,000 hospitalizations with IHD as the
 primary diagnosis and diabetes as a co-diagnosis were recorded
 (Table 5.18, Figure 5.4). By 1987, this number had increased to 390,000.
 In general, the IHD hospitalization rate follows the same patterns
 as that for major CVD (Table 5.18, Figure 5.5). In 1987, the overall
 age-adjusted hospital discharge rate was 38% higher than in 1980.
 Hospitalization rates for IHD increased rapidly with increasing age
 and were greatest for white males, followed by those for white females
 (Table 5.19, Figure 5.6). Hospital discharge rates for black males
 and females were similar and were appoximately half those of white
 males and females. Among white males and females, hospital discharge
 rates peaked in 1984 and 1983, respectively, whereas among black males
 and females hospital discharge rates were stable before 1984 and increased
 thereafter.

  Stroke Hospitalizations

 The total number of hospitalizations for stroke as the primary diagnosis
 and diabetes as a co-diagnosis also increased between 1980 and 1987,
 with an estimated 77,000 such hospitalizations occurring in 1980 and
 128,000 in 1987 (Table 5.20). The age-adjusted hospital discharge rate
 increased from 1980 through 1983 and subsequently leveled off (Table 5.20,
 Figure 5.5). In 1983, the overall age-adjusted hospital discharge rate
 was 38% higher than in 1980. In every age group, hospitalizations
 for strokes appear to have increased during the 8-year period. Hospital
 discharge rates increased with age, with hospital discharge rates
 among those older than 74 years of age exceeding the rates among those
 less than 45 years old by a factor ranging from 11 to 56. Hospital
 discharge rates among the four race-sex groups are similar (Table
 5.21). Hospital discharge rates among white females, black males,
 and black females generally increased during the 8-year period, whereas
 hospital discharge rates for white males increased from 1980 to 1983
 and then stabilized.

 Discussion

 The analysis of national mortality data suggests that mortality
 rates from major CVD, IHD, and stroke among persons with diabetes
 decreased between 1980 and 1986 and that this decline occurred
 among all four race-sex groups and all age groups except for those
 less than 45 years of age. Hospital discharge data, on the other hand,
 indicate that hospitalization rates for major CVD, IHD, and stroke
 among people with diabetes increased between 1980 and 1987. In general,
 these increases were observed among all four race-sex groups and all
 age groups.

 Interpreting the mortality data is complicated by several potential
 problems. Death certificate data are known to have limitations. For
 example, as many as 16% of IHD deaths and 40% of stroke deaths may
 not be identified as such on death certificates (Kuller et al., 1969;
 Matsumoto et al., 1973; Corwin et al., 1982; Fortmann et al., 1986;
 Folsom et al., 1987). Furthermore, in as many as half of all deaths
 among persons with diabetes, the death certificate fails to mention
 diabetes (Harris & Entmacher, 1985).

 The National Health Interview Survey results may underestimate the
 diabetic population by half further complicating the interpretation
 of the mortality data (Harris et al., 1987). Consequently, the absolute
 magnitude of the mortality rate remains only an approximation. If
 the sources of variation remained constant during the 7-year period,
 and we have no reason to believe that they did not, the temporal trends
 and relative differences between groups reported herein should be
 generally valid.

 As with the mortality data, sources of error affect the estimates
 of both the numerator and denominator of the hospital discharge rate.
 Changes in the type and frequency of diagnostic procedures and the
 introduction of new treatments may have affected the number of hospitalized
 patients who were diagnosed with coronary heart disease (Kuller, 1988).
 For example, increased utilization of coronary arteriography in patients
 with acute myocardial infarction has been reported (Gore et al., 1988).
 Data from the NHDS have also shown large increases in the number and
 rates of cardiac catheterization in the 1980s. In addition, how the
 increased use of CAT-scans has influenced the diagnosis of stroke
 is unknown. Changes in referral patterns might have contributed to
 changing trends, but no data are available to evaluate this possible
 influence. A major change, however, occurred when diagnosis related
 groups (DRGs) were introduced in 1983. DRGs have complicated the
 interpretation of trend data. Between 1980 and 1987, the co-diagnosis
 of diabetes increased from 12.4% to 17.4% of hospitalizations for CVD,
 from 13.7% to 18.0% of hospitalizations for IHD, and from 12.8% to 18.7%
 of hospitalizations for stroke.

 National data have demonstrated decreases in CVD mortality in the
 population of the United States (Sempos et al., 1988). From 1980 to
 1986, the age-adjusted mortality rates for major CVD, IHD, and cerebrovascular
 disease decreased by about 15.3%, 20.7%, and 24.0%, respectively (NCHS,
 1983, 1988a). Compared with 1980, mortality rates in 1986 among persons
 with diabetes were 16% lower for CVD, 17.5% lower for IHD, and 29%
 lower for stroke. Thus, persons with diabetes appear to have shared
 in the decline in CVD-related mortality in the general population.

 Whereas hospitalization rates for major CVD, IHD, and stroke among
 people with diabetes have increased, mortality rates have decreased
 for these same conditions during the same period. The same trends
 have been described for the total population (CDC, 1989). Although
 DRGs may explain some of the increase in hospitalization rates, other
 explanations include changes in hospital use and better survival from
 IHD and stroke with subsequent readmission for the same conditions.
 Unfortunately, the NHDS cannot separate repeat hospitalizations from
 incident hospitalizations.

 Mortality rates for major CVD and IHD were higher among diabetic men
 than diabetic women regardless of race. Hospitalization rates among
 persons with diabetes also were higher among white men than white
 women but were similar among black men and black women. This contrasts
 with the higher CVD and IHD mortality rates among men in the general
 population. Among diabetic persons of both races, the mortality rates
 and hospitalization rates for stroke were similar among men and women.

 White persons with diabetes have higher age-adjusted mortality rates
 for major CVD and IHD but a similar age-adjusted mortality rate for
 stroke. Similarly, whites are hospitalized at higher rates for major
 CVD and IHD than blacks and at the same rate for stroke. Reasons for the
 lower hospitalization rates among blacks could include fewer complications
 from diabetes among blacks, inaccessability to hospitals, or higher
 out-of- hospital mortality rates.

 During this decade, the mortality rates for major CVD, IHD, and stroke
 among persons with diabetes have decreased. The decreases in mortality
 have occurred in all age groups older than 44 years and have occurred
 among black males and females and white males and females. In contrast,
 the hospitalization rates for these conditions have increased during
 the same period among all four groups.

 Update

      This section updates data presented in previous sections in light of one
 additional year of hospitalization data and two additional years of mortality
 data.  For a complete description of the methods and operational definitions
 and for a discussion of the implications of the findings, see previous
 sections.

      Among persons with diabetes, age-standardized mortality rates attributed
 to major cardiovascular disease (CVD), ischemic heart disease, and stroke
 increase dramatically with age.  Mortality rates from these diseases were
 lower in 1988 than in 1980, with most of the decline occurring between 1983
 and 1984 (Figure 1.7, Tables 5.1, 5.6, and 5.11).  The declines for these two
 years were apparent among persons with diabetes who were 65 years of age or
 older.  Cardiovascular mortality among persons with diabetes younger than 45
 years of age tended to increase rather than decrease.
      Of the four race-sex groups examined, white males had the highest age-
 standardized mortality rates for CVD (Figure 1.8, Tables 5.2-5.5).  Rates for
 black males exceeded those for white males among persons younger than age 45.
 Although the age-standardized rates for white females were higher than those
 for black females, black females under the age of 65 had higher rates than
 white females.

 Detailed Tables
 
 5.1-5.5 Deaths w/ Cardiovascular Disease as Underlying Cause

 5.1 Mortality Rate per 100,000 Diabetic Pop., Age & Year, 80-88

 Table 5.1  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              834        860        859        955       1057
          Rate               82.6       90.3       87.3       95.3      106.3

  45-64   Number            14931      15201      14875      15248      15246
          Rate              624.9      597.5      579.6      586.6      646.4

  65-74   Number            23024      22775      22905      23656      23880
          Rate             1512.5     1668.8     1501.5     1812.6     1359.3

  75+     Number            36802      36206      37002      38527      38812
          Rate             4273.2     3820.9     4565.6     4407.3     3559.9

  Total   Number            75594      75044      75657      78397      78999
          Rate             1307.3     1292.0     1285.3     1356.2     1274.2

  Age-adjusted Rate        1307.2     1271.1     1330.0     1392.6     1173.7

 Table 5.1  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              995       1110       1139       1120
          Rate               95.8      106.0       83.5      102.6

  45-64   Number            15317      15205      15100      14813
          Rate              657.4      534.0      591.8      602.1

  65-74   Number            24379      23910      24527      24221
          Rate             1317.0     1500.8     1440.5     1421.4

  75+     Number            39322      39895      39885      40716
          Rate             3572.5     3106.7     3341.9     3721.7

  Total   Number            80023      80129      80658      80876
          Rate             1266.2     1183.3     1184.1     1273.6

  Age-adjusted Rate        1167.2     1097.0     1136.1     1195.2

 5.2 Mortality Rate per 100,000 Diabetic Pop., White Males

 Table 5.2  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, White Males, United States,
            1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              386        386        371        481        503
          Rate              124.1      104.6       96.5      117.9      142.2

  45-64   Number             7150       7215       7104       7103       7090
          Rate              779.4      709.3      727.1      771.9      871.6

  65-74   Number             9794       9831      10052      10119      10328
          Rate             1646.5     1777.3     2339.2     2429.1     1745.6

  75+     Number            12088      11952      11959      12681      12864
          Rate             4727.5     5237.6     3975.2     3863.8     3970.8

  Total   Number            29419      29384      29491      30387      30787
          Rate             1415.0     1355.6     1409.7     1465.9     1478.2

  Age-adjusted Rate        1481.2     1559.3     1525.1     1554.5     1435.9

 Table 5.2  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, White Males, United States,
            1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              432        514        523        509
          Rate              110.2      170.7       90.4      105.2

  45-64   Number             7189       6942       6956       6638
          Rate              823.2      561.3      660.9      709.0

  65-74   Number            10640      10497      10586      10713
          Rate             1566.7     1679.5     1501.5     1921.6

  75+     Number            12846      12964      13142      13679
          Rate             3666.3     3200.7     3129.3     3545.7

  Total   Number            31109      30921      31208      31541
          Rate             1355.6     1204.2     1132.4     1334.6

  Age-adjusted Rate        1317.9     1180.6     1150.2     1345.3

 5.3 Mortality Rate per 100,000 Diabetic Pop., White Females

 Table 5.3  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, White Females, United States,
            1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              248        242        269        230        310
          Rate               52.1       57.6       56.6       57.0       70.7

  45-64   Number             5108       5136       4914       5128       5215
          Rate              521.3      514.9      498.5      474.4      499.1

  65-74   Number            10271      10144      10012      10422      10334
          Rate             1370.9     1644.4     1276.1     1655.4     1287.8

  75+     Number            21808      21440      22108      22549      22588
          Rate             4205.7     3601.6     5200.6     4922.9     3811.3

  Total   Number            37436      36962      37309      38333      38448
          Rate             1374.6     1405.6     1397.1     1490.3     1335.6

  Age-adjusted Rate        1211.8     1192.1     1326.4     1375.0     1125.2

 Table 5.3  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, White Females, United States,
            1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              302        332        306        311
          Rate               60.3       56.2       59.9       87.4

  45-64   Number             5027       5117       4936       4846
          Rate              550.4      477.8      516.8      525.1

  65-74   Number            10348       9872      10390       9914
          Rate             1168.8     1459.0     1395.5     1198.5

  75+     Number            22911      23123      22917      22897
          Rate             3859.2     3396.0     4280.5     4472.5

  Total   Number            38594      38446      38553      37970
          Rate             1334.2     1273.4     1403.9     1450.6

  Age-adjusted Rate        1120.5     1097.1     1228.9     1213.9

 5.4 Mort. Rate per 100,000 Diabetic Pop., Black Males

 Table 5.4  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, Black Males, United States,
            1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               97        121         97        118        125
          Rate              132.9      188.0      157.2      321.5      226.4

  45-64   Number             1049       1154       1097       1243       1179
          Rate              563.7      622.2      609.4      608.5      547.4

  65-74   Number              949        967        928       1084       1077
          Rate             1541.6     1429.9     1313.8     1270.8     1221.1

  75+     Number              784        734        797        904        873
          Rate             2673.4     3186.6     3191.0     3701.9     2489.9

  Total   Number             2879       2976       2920       3350       3254
          Rate              822.7      874.0      865.7      955.3      826.2

  Age-adjusted Rate        1060.1     1141.0     1100.4     1193.5      958.0

 Table 5.4  Number of Deaths with Major Cardiovascular Disease
            as Underlying Cause and Mortality Rate per 100,000 Diabetic
            Population, by Age and Year, Black Males, United States,
            1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              118        134        159        157
          Rate              187.9      161.5      175.1      195.0

  45-64   Number             1297       1249       1319       1305
          Rate              584.1      612.8      629.3      528.7

  65-74   Number             1166       1197       1220       1230
          Rate             1180.2     1320.5     1176.2     1448.3

  75+     Number              891       1026       1028       1043
          Rate             2594.3     2623.9     2939.7     2028.4

  Total   Number             3472       3607       3726       3736
          Rate              830.6      865.9      848.5      805.7

  Age-adjusted Rate         971.2     1019.8     1038.1      935.9

 5.5 Mortality Rate per 100,000 Diabetic Pop., Black Females

 Table 5.5  Number of Deaths with Major Cardiovascular Disease as Underlying
            Cause and Mortality Rate per 100,000 Diabetic Population, by Age
            and Year, Black Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               91         98        106        113        101
          Rate               81.2      101.3      123.6       97.4       92.7

  45-64   Number             1469       1541       1569       1552       1546
          Rate              584.2      543.1      486.8      515.8      549.3

  65-74   Number             1799       1661       1652       1770       1871
          Rate             1739.3     1212.9     1033.1      885.5     1004.1

  75+     Number             1802       1794       1798       2045       2102
          Rate             2530.6     2546.1     2652.1     2446.5     2280.9

  Total   Number             5162       5096       5129       5483       5621
          Rate              959.1      866.9      806.7      782.8      840.4

  Age-adjusted Rate        1090.4      940.6      889.7      827.6      847.2

 Table 5.5  Number of Deaths with Major Cardiovascular Disease as Underlying
            Cause and Mortality Rate per 100,000 Diabetic Population, by Age
            and Year, Black Females, United States, 1980-1984

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              117        111        126        127
          Rate              128.1      127.4      115.7       94.0

  45-64   Number             1552       1630       1593       1690
          Rate              599.7      581.3      569.6      694.6

  65-74   Number             1905       2039       1992       1991
          Rate             1041.8     1417.0     1398.1     1288.0

  75+     Number             2258       2343       2337       2590
          Rate             1918.1     1853.0     1594.2     1842.1

  Total   Number             5834       6125       6050       6399
          Rate              896.5      960.2      892.7      950.1

  Age-adjusted Rate         830.1      911.4      861.0      916.9

 5.6-5.10 Deaths w/ Ischemic Heart Disease as Underlying Cause

 5.6 Mort. Rate per 100,000 Diabetic Pop., Age & Year, 80-88

 Table 5.6  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              506        509        565        584        637
          Rate               50.1       53.5       57.4       58.3       64.1

  45-64   Number            10448      10511      10398      10530      10329
          Rate              437.2      413.1      405.1      405.1      437.9

  65-74   Number            15487      15178      15618      15755      15899
          Rate             1017.4     1112.2     1023.8     1207.2      905.0

  75+     Number            21725      21519      21951      23002      22867
          Rate             2522.6     2270.9     2708.5     2631.3     2097.4

  Total   Number            48169      47719      48539      49876      49734
          Rate              833.0      821.5      824.6      862.8      802.2

  Age-adjusted Rate         833.0      811.1      850.4      887.3      742.8

 Table 5.6  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              613        671        656        630
          Rate               59.1       64.1       48.1       57.7

  45-64   Number            10204       9975       9815       9485
          Rate              438.0      350.3      384.7      385.5

  65-74   Number            16084      15624      15925      15640
          Rate              868.9      980.7      935.3      917.8

  75+     Number            23170      23518      23166      23677
          Rate             2105.0     1831.4     1941.1     2164.3

  Total   Number            50074      49793      49566      49433
          Rate              792.3      735.3      727.7      778.4

  Age-adjusted Rate         733.5      686.9      702.7      733.3

 5.7 Mort. Rate per 100,000 Diabetic Pop., White Males

 Table 5.7  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, White Males, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              278        269        273        336        345
          Rate               89.3       72.9       71.0       82.4       97.5

  45-64   Number             5411       5455       5360       5316       5152
          Rate              589.8      536.3      548.6      577.7      633.3

  65-74   Number             6979       6936       7258       7170       7298
          Rate             1173.2     1253.9     1689.0     1721.2     1233.5

  75+     Number             7530       7586       7552       8044       8101
          Rate             2944.9     3324.3     2510.3     2451.0     2500.6

  Total   Number            20199      20246      20446      20868      20898
          Rate              971.5      934.0      977.3     1006.7     1003.4

  Age-adjusted Rate        1006.8     1059.5     1057.6     1071.2      975.9

 Table 5.7  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, White Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              300        345        330        322
          Rate               76.5      114.6       57.0       66.6

  45-64   Number             5192       4962       4887       4638
          Rate              594.5      401.2      464.3      495.4

  65-74   Number             7406       7280       7290       7358
          Rate             1090.5     1164.8     1034.0     1319.8

  75+     Number             8037       8174       8115       8472
          Rate             2293.8     2018.1     1932.3     2196.0

  Total   Number            20936      20763      20623      20790
          Rate              912.3      808.6      748.3      879.7

  Age-adjusted Rate         887.7      793.0      761.8      890.8

 5.8 Mort. Rate per 100,000 Diabetic Pop., White Females

 Table 5.8  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, White Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number              144        151        178        138        183
          Rate               30.3       36.0       37.5       34.2       41.7

  45-64   Number             3645       3527       3488       3593       3632
          Rate              372.0      353.6      353.9      332.4      347.6

  65-74   Number             6984       6776       6876       6970       6954
          Rate              932.2     1098.4      876.4     1107.1      866.6

  75+     Number            12825      12522      13025      13312      13146
          Rate             2473.3     2103.5     3063.9     2906.3     2218.1

  Total   Number            23599      22976      23569      24014      23915
          Rate              866.5      873.7      882.6      933.6      830.8

  Age-adjusted Rate         772.8      754.8      839.8      867.6      709.4

 Table 5.8  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, White Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              193        208        194        184
          Rate               38.6       35.2       38.0       51.7

  45-64   Number             3441       3398       3300       3204
          Rate              376.8      317.3      345.5      347.2

  65-74   Number             6868       6513       6792       6463
          Rate              775.8      962.6      912.2      781.3

  75+     Number            13364      13493      13243      13275
          Rate             2251.1     1981.7     2473.6     2593.0

  Total   Number            23867      23614      23532      23127
          Rate              825.1      782.1      856.9      883.5

  Age-adjusted Rate         701.9      685.8      758.0      744.4

 5.9 Mort. Rate per 100,000 Diabetic Pop., Black Males

 Table 5.9  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, Black Males, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               41         49         53         58         51
          Rate               56.2       76.1       85.9      158.0       92.4

  45-64   Number              545        653        575        682        627
          Rate              292.9      352.1      319.4      333.9      291.1

  65-74   Number              509        510        464        568        544
          Rate              826.8      754.1      656.9      665.9      616.8

  75+     Number              396        388        367        444        437
          Rate             1350.3     1684.5     1469.4     1818.2     1246.4

  Total   Number             1491       1600       1459       1753       1659
          Rate              426.0      469.9      432.5      499.9      421.2

  Age-adjusted Rate         549.6      608.2      538.8      611.6      484.4

 Table 5.9  Number of Deaths with Ischemic Heart Disease as Underlying Cause
            and Mortality Rate per 100,000 Diabetic Population, by Age and
            Year, Black Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               53         65         59         67
          Rate               84.4       78.3       65.0       83.2

  45-64   Number              665        639        670        638
          Rate              299.5      313.5      319.6      258.5

  65-74   Number              622        622        651        601
          Rate              629.6      686.1      627.6      707.7

  75+     Number              449        496        487        468
          Rate             1307.3     1268.5     1392.6      910.2

  Total   Number             1789       1822       1867       1774
          Rate              428.0      437.4      425.2      382.6

  Age-adjusted Rate         498.9      512.8      516.1      443.2

 5.10 Mort. Rate per 100,000 Diabetic Pop., Black Females

 Table 5.10  Number of Deaths with Ischemic Heart Disease as Underlying Cause
             and Mortality Rate per 100,000 Diabetic Population, by Age and
             Year, Black Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               38         35         53         45         46
          Rate               33.9       36.2       61.8       38.8       42.2

  45-64   Number              740        781        846        799        784
          Rate              294.3      275.3      262.5      265.5      278.5

  65-74   Number              884        849        855        891        931
          Rate              854.7      620.0      534.7      445.8      499.6

  75+     Number              810        874        821       1007        960
          Rate             1137.5     1240.4     1211.0     1204.7     1041.7

  Total   Number             2473       2541       2577       2743       2721
          Rate              459.5      432.2      405.3      391.6      406.8

  Age-adjusted Rate         521.9      468.0      440.4      413.3      409.2

 Table 5.10  Number of Deaths with Ischemic Heart Disease as Underlying Cause
             and Mortality Rate per 100,000 Diabetic Population, by Age and
             Year, Black Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               56         41         55         51
          Rate               61.3       47.0       50.5       37.8

  45-64   Number              745        813        776        802
          Rate              287.9      289.9      277.4      329.6

  65-74   Number              975       1023        980        981
          Rate              533.2      710.9      687.8      634.6

  75+     Number             1090       1115       1070       1181
          Rate              925.9      881.8      729.9      840.0

  Total   Number             2867       2993       2881       3015
          Rate              440.6      469.2      425.1      447.7

  Age-adjusted Rate         407.9      446.5      413.2      435.0

 5.11-5.15 Deaths with Stroke as Underlying Cause

 5.11 Mort. Rate per 100,000 Diabetic Pop., Age & Year, 80-88

 Table 5.11  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year,
             United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               87        102         68        102        108
          Rate                8.6       10.7        6.9       10.2       10.9

  45-64   Number             1630       1584       1514       1469       1566
          Rate               68.2       62.3       59.0       56.5       66.4

  65-74   Number             3410       3397       3005       3264       3145
          Rate              224.0      248.9      197.0      250.1      179.0

  75+     Number             7608       7042       7145       7125       7265
          Rate              883.4      743.2      881.6      815.1      666.4

  Total   Number            12735      12125      11734      11961      12085
          Rate              220.2      208.7      199.3      206.9      194.9

  Age-adjusted Rate         220.2      203.8      208.7      212.4      175.7

 Table 5.11  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year,
             United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number              103         93         98        101
          Rate                9.9        8.9        7.2        9.2

  45-64   Number             1480       1549       1468       1461
          Rate               63.5       54.4       57.5       59.4

  65-74   Number             3257       3112       3032       2982
          Rate              175.9      195.3      178.1      175.0

  75+     Number             7083       6949       7084       7107
          Rate              643.5      541.1      593.6      649.6

  Total   Number            11925      11705      11683      11653
          Rate              188.7      172.9      171.5      183.5

  Age-adjusted Rate         170.1      156.0      160.3      169.0

 5.12 Mort. Rate per 100,000 Diabetic Pop., White Males

 Table 5.12  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, White
             Males, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               28         28         23         40         44
          Rate                9.0        7.6        6.0        9.8       12.4

  45-64   Number              611        562        552        545        599
          Rate               66.6       55.3       56.5       59.2       73.6

  65-74   Number             1283       1296       1147       1233       1166
          Rate              215.7      234.3      266.9      296.0      197.1

  75+     Number             2306       2055       2101       2115       2152
          Rate              901.9      900.5      698.4      644.4      664.3

  Total   Number             4228       3941       3823       3933       3961
          Rate              203.4      181.8      182.7      189.7      190.2

  Age-adjusted Rate         220.2      220.0      198.7      200.1      183.4

 Table 5.12  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, White
             Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               34         44         39         43
          Rate                8.7       14.6        6.7        8.9

  45-64   Number              572        556        530        529
          Rate               65.5       45.0       50.4       56.5

  65-74   Number             1236       1183       1164       1105
          Rate              182.0      189.3      165.1      198.2

  75+     Number             2087       1980       2064       2157
          Rate              595.6      488.8      491.5      559.1

  Total   Number             3930       3764       3797       3834
          Rate              171.3      146.6      137.8      162.2

  Age-adjusted Rate         165.2      143.8      138.6      160.3

 5.13 Mort. Rate per 100,000 Diabetic Pop., White Females

 Table 5.13  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, White
             Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               34         35         24         30         31
          Rate                7.1        8.3        5.1        7.4        7.1

  45-64   Number              552        560        492        478        530
          Rate               56.3       56.1       49.9       44.2       50.7

  65-74   Number             1488       1529       1292       1423       1346
          Rate              198.6      247.9      164.7      226.0      167.7

  75+     Number             4558       4338       4313       4281       4363
          Rate              879.0      728.7     1014.6      934.6      736.2

  Total   Number             6632       6462       6123       6213       6271
          Rate              243.5      245.7      229.3      241.5      217.8

  Age-adjusted Rate         207.7      198.4      216.0      218.3      176.0

 Table 5.13  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, White
             Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               32         26         16         26
          Rate                6.4        4.4        3.1        7.3

  45-64   Number              479        539        493        472
          Rate               52.4       50.3       51.6       51.1

  65-74   Number             1437       1332       1298       1260
          Rate              162.3      196.9      174.3      152.3

  75+     Number             4206       4176       4209       4058
          Rate              708.5      613.3      786.2      792.6

  Total   Number             6155       6073       6016       5817
          Rate              212.8      201.1      219.1      222.2

  Age-adjusted Rate         171.0      164.7      184.9      180.6

 5.14 Mort. Rate per 100,000 Diabetic Pop., Black Males

 Table 5.14  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, Black
             Males, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               12         15         11         12         17
          Rate               16.4       23.3       17.8       32.7       30.8

  45-64   Number              168        156        160        157        158
          Rate               90.3       84.1       88.9       76.9       73.4

  65-74   Number              189        184        190        209        206
          Rate              307.0      272.1      269.0      245.0      233.6

  75+     Number              175        163        197        180        176
          Rate              596.7      707.7      788.7      737.1      502.0

  Total   Number              544        518        558        558        557
          Rate              155.4      152.1      165.4      159.1      141.4

  Age-adjusted Rate         209.9      215.8      228.1      211.8      171.9

 Table 5.14  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, Black
             Males, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               12         12         23         12
          Rate               19.1       14.5       25.3       14.9

  45-64   Number              159        159        163        177
          Rate               71.6       78.0       77.8       71.7

  65-74   Number              197        189        191        217
          Rate              199.4      208.5      184.1      255.5

  75+     Number              180        200        202        220
          Rate              524.1      511.5      577.6      427.9

  Total   Number              548        560        579        626
          Rate              131.1      134.4      131.9      135.0

  Age-adjusted Rate         163.5      165.8      171.1      163.2

 5.15 Mort. Rate per 100,000 Diabetic Pop., Black Female

 Table 5.15  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, Black
             Females, United States, 1980-1984

                                                   Year
                             1980       1981       1982       1983       1984
  Age

  0-44    Number               11         19         10         19         15
          Rate                9.8       19.6       11.7       16.4       13.8

  45-64   Number              289        284        284        253        250
          Rate              114.9      100.1       88.1       84.1       88.8

  65-74   Number              415        355        334        359        380
          Rate              401.2      259.2      208.9      179.6      203.9

  75+     Number              479        405        448        463        486
          Rate              672.7      574.8      660.8      553.9      527.4

  Total   Number             1194       1063       1076       1094       1131
          Rate              221.9      180.8      169.2      156.2      169.1

  Age-adjusted Rate         255.0      198.6      191.9      167.4      171.3

 Table 5.15  Number of Deaths with Stroke as Underlying Cause and Mortality
             Rate per 100,000 Diabetic Population, by Age and Year, Black
             Females, United States, 1985-1988

                                             Year
                             1985       1986       1987       1988
  Age

  0-44    Number               21         10         19         19
          Rate               23.0       11.5       17.4       14.1

  45-64   Number              245        257        250        249
          Rate               94.7       91.6       89.4      102.3

  65-74   Number              341        363        334        350
          Rate              186.5      252.3      234.4      226.4

  75+     Number              530        501        510        562
          Rate              450.2      396.2      347.9      399.7

  Total   Number             1137       1132       1114       1181
          Rate              174.7      177.5      164.4      175.3

  Age-adjusted Rate         159.3      165.3      153.5      163.9

 5.16-5.17 Discharges & Rates for Major Cardiovascular Disease

 5.16 1,000 Diabetic Pop., by Age and Year, U.S., 80-88

 Table 5.16  Number of Discharges for Major Cardiovascular Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Age and Year, United States, 1980-1984

                                                  Year
                                1980     1981     1982     1983     1984
  Age

  0-44     Number (a)             16       21       20       27       26
           Rate                 15.9     22.2     20.4     27.0     25.9

  45-64    Number                198      195      226      232      255
           Rate                 83.1     76.5     88.1     89.3    108.1

  65-74    Number                193      205      226      237      263
           Rate                126.6    150.4    148.3    181.9    149.9

  75+      Number                166      189      207      235      249
           Rate                193.0    199.1    255.6    269.1    228.4

  Total    Number                573      610      680      732      793
           Rate                 99.2    104.9    115.5    126.6    127.9

  Age-adjusted Rate             99.2    104.7    117.1    129.6    122.7

 (a) In thousands

 Table 5.16  Number of Discharges for Major Cardiovascular Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Age and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-44     Number (a)              27       28       26       31
           Rate                  26.1     26.5     18.8     28.5

  45-64    Number                 246      268      296      288
           Rate                 105.6     94.2    116.0    117.2

  65-74    Number                 260      298      310      311
           Rate                 140.4    187.1    182.0    182.3

  75+      Number                 231      255      270      278
           Rate                 210.0    198.3    226.5    254.1

  Total    Number                 764      849      902      908
           Rate                 120.9    125.3    132.4    143.0

  Age-adjusted Rate             116.4    122.3    132.9    139.2

 (a) In thousands

 5.17 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88

 Table 5.17  Number of Discharges for Major Cardiovascular Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Race, Sex, and Year, United States,
             1980-1984
                                                      Year
                                        1980   1981   1982   1983   1984
  Race     Sex

  White    Male     Number (a)           197    217    244    257    264
                    Rate                95.0  100.0  116.5  124.2  126.9
                    Adjusted Rate (b)   95.2  107.3  123.5  130.5  125.3

           Female   Number               245    305    293    333    362
                    Rate                89.8  116.1  109.7  129.6  125.7
                    Adjusted Rate       85.0  108.6  106.4  124.8  114.5

  Black    Male     Number                21     20     21     26     34
                    Rate                59.0   58.1   61.6   74.7   86.0
                    Adjusted Rate       65.5   69.8   65.4   81.2   89.9

           Female   Number                36     53     51     53     60
                    Rate                67.4   90.5   79.9   75.6   89.2
                    Adjusted Rate       72.9   92.6   82.4   76.0   88.3

  Total    Total    Number               573    610    680    732    793
                    Rate                99.2  104.9  115.5  126.6  127.9
                    Adjusted Rate       99.2  104.7  117.1  129.6  122.7

 (a) In thousands
 (b) Adjusted for age

 Table 5.17  Number of Discharges for Major Cardiovascular Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Race, Sex, and Year, United States,
             1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Race     Sex

  White    Male     Number (a)           271    300    314    335
                    Rate               118.0  116.9  114.0  141.5
                    Adjusted Rate (b)  116.4  114.8  117.5  146.2

           Female   Number               323    359    374    372
                    Rate               111.5  118.8  136.4  142.3
                    Adjusted Rate      104.5  115.4  129.9  129.2

  Black    Male     Number                35     38     39     38
                    Rate                82.7   91.9   89.3   81.3
                    Adjusted Rate       89.8  102.3  102.6   87.5

           Female   Number                58     65     68     78
                    Rate                89.8  101.3  100.0  115.9
                    Adjusted Rate       86.7  102.7  101.6  121.1

  Total    Total    Number               764    849    902    908
                    Rate               120.9  125.3  132.4  143.0
                    Adjusted Rate      116.4  122.3  132.9  139.2

 (a) In thousands
 (b) Adjusted for age

 5.18-5.19 Hosp. Discharges & Rates for Ischemic Heart Disease

 5.18 1,000 Diabetic Pop., by Age and Year, U.S., 80-88

 Table 5.18  Number of Discharges for Ischemic Heart Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Age and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-44     Number (a)               9        8       10        9       11
           Rate                   9.1      7.9     10.2      8.9     11.5

  45-64    Number                  98       90      111      111      130
           Rate                  41.0     35.5     43.3     42.6     55.1

  65-74    Number                  76       73       91       94      113
           Rate                  49.9     53.8     59.8     72.0     64.4

  75+      Number                  62       65       78       89       86
           Rate                  71.5     68.6     96.4    101.5     79.3

  Total    Number                 245      236      290      302      341
           Rate                  42.3     40.7     49.3     52.3     55.0

  Age-adjusted Rate              42.3     40.4     49.8     53.2     53.5

 (a) In thousands

 Table 5.18  Number of Discharges for Ischemic Heart Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Age and Year, United States, 1985-1988

                                                   Year
                                 1985     1986     1987     1988
  Age

  0-44     Number (a)              12       13       12       16
           Rate                  11.4     12.3      9.1     15.0

  45-64    Number                 117      137      156      144
           Rate                  50.3     48.0     61.0     58.7

  65-74    Number                 111      124      134      129
           Rate                  59.8     77.8     78.9     75.8

  75+      Number                  80       91       87       96
           Rate                  72.6     71.1     73.2     87.9

  Total    Number                 320      365      390      386
           Rate                  50.6     53.9     57.2     60.8

  Age-adjusted Rate              49.3     53.1     58.4     59.9

 (a) In thousands

 5.19 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88

 Table 5.19  Number of Discharges for Ischemic Heart Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Race, Sex, and Year, United States,
             1980-1984

                                                      Year
                                        1980   1981   1982   1983   1984
  Race     Sex

  White    Male     Number (a)            96     98    116    122    133
                    Rate                46.0   45.0   55.5   59.1   63.6
                    Adjusted Rate (b)   45.8   46.9   57.9   61.5   63.4

           Female   Number               103    112    127    136    149
                    Rate                37.9   42.7   47.6   52.8   51.6
                    Adjusted Rate       36.5   40.2   46.7   51.0   48.0

  Black    Male     Number                 6      6      5      7     13
                    Rate                18.2   17.6   14.8   19.1   32.7
                    Adjusted Rate       20.0   19.7   15.8   18.7   31.9

           Female   Number                10     14     15     14     18
                    Rate                19.0   23.7   23.4   20.6   27.6
                    Adjusted Rate       21.4   23.8   24.3   20.8   27.2

  Total    Total    Number               245    236    290    302    341
                    Rate                42.3   40.7   49.3   52.3   55.0
                    Adjusted Rate       42.3   40.4   49.8   53.2   53.5

 (a) In thousands
 (b) Adjusted for age

 Table 5.19  Number of Discharges for Ischemic Heart Disease as
             Primary Diagnosis and Hospital Discharge Rate per 1,000
             Diabetic Population, by Race, Sex, and Year, United States,
             1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Race     Sex

  White    Male     Number (a)           125    141    153    160
                    Rate                54.3   55.1   55.7   67.9
                    Adjusted Rate (b)   54.0   53.9   57.8   70.5

           Female   Number               132    155    163    158
                    Rate                45.8   51.3   59.2   60.3
                    Adjusted Rate       44.3   51.3   58.3   56.7

  Black    Male     Number                10     13     14     10
                    Rate                24.3   32.3   31.1   21.9
                    Adjusted Rate       25.0   35.7   34.3   22.0

           Female   Number                18     18     19     19
                    Rate                26.9   28.9   28.3   28.9
                    Adjusted Rate       25.6   29.3   30.2   30.2

  Total    Total    Number               320    365    390    386
                    Rate                50.6   53.9   57.2   60.8
                    Adjusted Rate       49.3   53.1   58.4   59.9

 (a) In thousands
 (b) Adjusted for age

 5.20-5.21 Hosp. Discharges/Rates for Stroke as Primary Diagnosis

 5.20 1,000 Diabetic Pop., by Age & Year, U.S., 80-88

 Table 5.20  Number of Discharges for Stroke as Primary Diagnosis and
             Hospital Discharge Rate per 1,000 Diabetic Population, by
             Age and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-44     Number (a)               1        1        1        3        1
           Rate                   1.2      1.0      1.1      3.3      0.8

  45-64    Number                  18       19       21       25       27
           Rate                   7.6      7.4      8.1      9.5     11.5

  65-74    Number                  30       36       31       36       39
           Rate                  19.8     26.3     20.3     28.0     22.2

  75+      Number                  28       31       40       41       49
           Rate                  32.4     32.6     49.1     46.5     44.9

  Total    Number                  77       87       93      105      116
           Rate                  13.4     14.9     15.7     18.2     18.7

  Age-adjusted Rate              13.4     15.0     16.2     18.8     17.4

 (a) In thousands

 Table 5.20   Number of Discharges for Stroke as Primary Diagnosis and
              Hospital Discharge Rate per 1,000 Diabetic Population, by
              Age and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-44     Number (a)               3        3        2        1
           Rate                   2.8      2.9      1.7      1.2

  45-64    Number                  28       27       32       32
           Rate                  12.2      9.5     12.4     13.1

  65-74    Number                  47       46       46       38
           Rate                  25.1     28.7     27.1     22.4

  75+      Number                  41       41       48       43
           Rate                  36.9     31.9     40.1     39.1

  Total    Number                 118      117      128      114
           Rate                  18.7     17.2     18.8     18.0

  Age-adjusted Rate              17.6     16.7     18.5     17.3

 (a) In thousands

 5.21 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88

 Table 5.21  Number of Discharges for Stroke as Primary Diagnosis and
             Hospital Discharge Rate per 1,000 Diabetic Population, by
             Race, Sex, and Year, United States, 1980-1984

                                                      Year
                                        1980   1981   1982   1983   1984
  Race     Sex

  White    Male     Number (a)            26     27     33     38     32
                    Rate                12.5   12.2   15.9   18.3   15.2
                    Adjusted Rate (b)   12.8   13.2   17.1   19.8   14.8

           Female   Number                33     45     38     44     54
                    Rate                12.0   17.0   14.2   17.2   18.8
                    Adjusted Rate       11.0   15.7   13.5   16.4   16.1

  Black    Male     Number                 3      4      4      5      5
                    Rate                 7.2   10.4   12.5   13.4   12.7
                    Adjusted Rate        9.6   13.5   13.9   15.5   13.7

           Female   Number                 5      9      6      7     11
                    Rate                 9.7   14.7    9.7   10.6   16.3
                    Adjusted Rate       10.8   16.1   10.1   10.9   16.3

  Total    Total    Number                77     87     93    105    116
                    Rate                13.4   14.9   15.7   18.2   18.7
                    Adjusted Rate       13.4   15.0   16.2   18.8   17.4

 (a) In thousands
 (b) Adjusted for age

 Table 5.21  Number of Discharges for Stroke as Primary Diagnosis and
             Hospital Discharge Rate per 1,000 Diabetic Population, by
             Race, Sex, and Year, United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Race     Sex

  White    Male     Number (a)            37     40     36     36
                    Rate                16.2   15.4   13.0   15.3
                    Adjusted Rate (b)   15.8   15.5   13.3   15.7

           Female   Number                52     43     55     46
                    Rate                18.0   14.3   20.0   17.8
                    Adjusted Rate       15.9   13.2   18.3   15.2

  Black    Male     Number                 6      5      7      5
                    Rate                15.4   11.9   15.3   10.1
                    Adjusted Rate       16.9   13.2   17.1   11.8

           Female   Number                11     15     11     11
                    Rate                17.0   23.6   16.3   16.3
                    Adjusted Rate       16.4   24.4   16.6   17.6

  Total    Total    Number               118    117    128    114
                    Rate                18.7   17.2   18.8   18.0
                    Adjusted Rate       17.6   16.7   18.5   17.3

 (a) In thousands
 (b) Adjusted for age


LOWER EXTREMITY AMPUTATIONS

 Introduction

 Diabetes is the leading cause of lower extremity amputation (LEA)
 in the United States.  The relative risk for a LEA among persons with
 diabetes is about 15 times that of persons without diabetes.  About
 half of all nontraumatic LEAs occur among persons with diabetes (Bild
 et al., 1989).  We examine hospitalization trends for LEA among persons
 with diabetes in the United States during 1980-1987.  When appropriate,
 we present LEA hospitalization rates categorized by age, race, sex,
 region, and calendar year.  We determine LEA rates for the general
 United States population, as well as rates among persons with diabetes.

 Methods

 The methods have been described previously (Chapter 4).  Data for
 amputations were obtained from the National Hospital Discharge
 Survey (NHDS), and the diabetic population was estimated using data
 from the National Health Interview Survey (Chapter 2).  LEAs were
 identified using International Classification of Diseases-9th Revision
 (ICD-9) procedure code 84.1.  Traumatic amputations of the toe, foot,
 or leg (ICD-9 disease codes 895, 896, and 897) were excluded from
 the analysis.  Thus, for our purposes, the term LEA refers to nontraumatic
 amputations.  Diabetes-related discharges were identified by selecting
 for ICD-9 disease code 250.  Because of small sample sizes, when calculating
 race-specific rates, we combined results for males and females.  Similarly,
 when calculating sex-specific rates, we combined results for all races.

 Results

 The number of LEAs performed among persons with diabetes was
 relatively stable from 1980 to 1982, increased about 50% in 1983,
 and then leveled off through 1987 (Figure 6.1).  A similar pattern
 was seen for the LEA rates in the diabetic population (Figure 6.2)
 and within each age category (Table 6.1).

 Hospital discharge rates for LEA increased with age.  In 1987, 68%
 of the discharges occurred among those persons older than 64 years of
 age and 95% were among those 45 years of age or older (Table 6.1).  Rates
 among males and females exhibited the same temporal trends as noted
 in the total diabetic population (Figure 6.3, Table 6.2).  Discharge
 rates for LEA among males with diabetes were from 10% to 64% higher
 than among females with diabetes.

 From 1980 to 1987, blacks accounted for 13% to 25% of all hospital
 discharges for LEAs related to diabetes (Table 6.3).  The hospital
 discharge rates for blacks with diabetes were consistently higher
 than those for whites with diabetes, particularly from 1980 to 1981
 and 1984 to 1987, when the rates were 1.5 to 2 times higher (Figure
 6.4, Table 6.3).

 Using the general population as the denominator resulted in similar
 trends as seen using diabetic population denominators (Tables 6.4-6.6).
 Because stable diabetic population estimates were not available by region,
 we calculated region-specific rates using general population denominators
 only.  Discharge rates for LEAs varied by geographic region (Table 6.7).
 Unadjusted rates and rates adjusted for age and race were consistently
 highest in the Northeast and, for the most part, lowest in the West.

 Discussion

 One of the most striking findings from this analysis was
 the dramatic increase in numbers and rates of LEAs among persons with
 diabetes that occurred in 1983.  In 1983, Medicare instituted the
 prospective payment system with diagnosis-related groups for reimbursement.
 This reimbursement change may have influenced the listing of diabetes on
 hospital records as a contributing cause for LEA and may, in part,
 be responsible for the increases seen in hospital discharges for LEA
 related to diabetes in 1983.

 The hospital discharge rates for LEA among persons with diabetes were
 higher for males than for females and for blacks than for whites.  These
 findings are consistent with the findings of previous research, which
 has shown that the risk of LEA in blacks (as well as certain groups
 of Native Americans) with diabetes is 2 to 4 times higher than the
 corresponding risk in whites, and that the risk among males is 1.5
 to 3 times higher than among females (Bild et al., 1989).

 The rate of LEA related to diabetes also increased with age.  The
 major pathogenetic mechanisms by which diabetes can lead to a LEA
 are peripheral vascular disease and peripheral neuropathy.  Both of
 these conditions are more prevalent with increasing age and with longer
 duration of diabetes.  Other factors that can lead to LEA among persons
 with diabetes are infection, hyperglycemia, improper foot care, extant
 foot lesions, and a history of a previous amputation (Most & Sinnock,
 1983).

 LEA is a significant contributor to morbidity, mortality, disability,
 and costs among persons with diabetes.  The direct cost of an amputation
 has been estimated to be 8,000 to 12,000 dollars.  Therefore, the
 56,000 LEAs that were performed among persons with diabetes in 1987
 represent a direct cost of about 500 million dollars.  Intensive glycemic
 and hypertension control, coupled with proper foot care, have been
 shown to be effective in reducing the frequency of amputations among
 persons with diabetes (Davidson et al., 1981).  Applying these measures
 among patients with diabetes could result in substantial savings in
 morbidity and costs.

 Update

      This section updates data presented in previous sections in light of one
 additional year of hospitalization data.  For a complete description of the
 methods and operational definitions and for a discussion of the implications
 of the findings, see previous sections.

      Among persons with diabetes, the number and rate of hospital discharges
 coded with lower extremity amputation (LEA) were relatively stable from 1980
 to 1982, increased dramatically in 1983 (see Chapter 6 for discussion), and
 then leveled off (Figure 1.9, Table 6.1).  Hospital discharge rates for LEA
 increased with age and were higher for males than for females (Table 6.2) and
 for blacks than for whites (Table 6.3).

 Detailed Tables

 6.1-6.7 Nontraumatic Lower Extremity Amputation
 
 6.1 No./Rate of Discharges per 1,000 Diabetic Pop., Age & Year

 Table 6.1  Number of Discharges for Nontraumatic Lower Extremity Amputation
            and Hospital Discharge Rate per 1,000 Diabetic Population, by Age
            and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-44     Number (a)               2        2        2        3        2
           Rate                   1.6      1.6      1.6      2.8      2.4

  45-64    Number                  11       10       10       16       17
           Rate                   4.7      3.8      3.9      6.1      7.2

  65-74    Number                  12        9        9       17       14
           Rate                   7.6      6.4      6.0     13.1      8.0

  75+      Number                  12       10       10       12       14
           Rate                  13.5     10.5     12.6     13.2     12.9

  Total    Number                  36       30       31       47       47
           Rate                   6.3      5.1      5.3      8.2      7.6

  Age-adjusted Rate               6.3      5.1      5.4      8.4      7.4

 (a) In thousands

 Table 6.1  Number of Discharges for Nontraumatic Lower Extremity Amputation
            and Hospital Discharge Rate per 1,000 Diabetic Population, by Age
            and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-44     Number (a)               4        2        3        3
           Rate                   4.2      2.3      2.1      2.5

  45-64    Number                  19       15       15       20
           Rate                   8.1      5.4      5.8      8.0

  65-74    Number                  16       17       20       13
           Rate                   8.6     10.5     12.0      7.5

  75+      Number                  14       13       18       20
           Rate                  12.4     10.2     14.8     18.0

  Total    Number                  53       48       56       55
           Rate                   8.4      7.1      8.2      8.6

  Age-adjusted Rate               8.2      6.9      8.1      8.4

 (a) In thousands

 6.2 No./Rate of Discharges per 1,000 Diabetic Pop., Sex & Year

 Table 6.2  Number of Discharges for Nontraumatic Lower Extremity Amputation
            and Hospital Discharge Rate per 1,000 Diabetic Population, by Sex
            and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  SEX

  Male     Number (a)                19       15       15       23       22
           Rate                     7.9      5.7      6.1      9.5      8.8
           Age-adjusted Rate        8.3      6.4      6.5     10.3      8.8

  Female   Number                    17       15       16       24       25
           Rate                     5.1      4.7      4.7      7.2      6.8
           Age-adjusted Rate        4.9      4.5      4.7      7.2      6.6

  Total    Number                    36       30       31       47       47
           Rate                     6.3      5.1      5.3      8.2      7.6
           Age-adjusted Rate        6.3      5.1      5.4      8.4      7.4

 (a) In thousands

 Table 6.2  Number of Discharges for Nontraumatic Lower Extremity Amputation
            and Hospital Discharge Rate per 1,000 Diabetic Population, by Sex
            and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  SEX

  Male     Number (a)                24       27       28       35
           Rate                     8.6      9.0      8.6     11.9

           Age-adjusted Rate        8.7      9.0      8.8     12.2

  Female   Number                    29       21       28       20
           Rate                     8.2      5.5      7.8      5.8
           Age-adjusted Rate        7.7      5.5      7.4      5.3

  Total    Number                    53       48       56       55
           Rate                     8.4      7.1      8.2      8.6
           Age-adjusted Rate        8.2      6.9      8.1      8.4

 (a) In thousands

 6.3 No./Rate of Discharges per 1,000 Diabetic Pop., Race & Year

 Table 6.3  Number of Discharges for Nontraumatic Lower Extremity
            Amputation and Hospital Discharge Rate per 1,000
            Diabetic Population, by Race and Year, United States
            1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Race

  White    Number (a)              23       24       24       36       32
           Rate                   4.7      4.9      5.0      7.7      6.5
           Age-adjusted           4.6      4.8      5.0      7.9      6.3

  Black    Number                   8        6        4        8       10
           Rate                   9.2      6.2      4.5      7.3      9.0
           Age-adjusted          10.7      7.0      4.6      8.7      9.4

  Total    Number                  36       30       31       47       47
           Rate                   6.3      5.1      5.3      8.2      7.6
           Age-adjusted           6.3      5.1      5.4      8.4      7.4

 (a) In thousands

 Table 6.3  Number of Discharges for Nontraumatic Lower Extremity
            Amputation and Hospital Discharge Rate per 1,000
            Diabetic Population, by Race and Year, United States
            1985-1988
                                              Year
                                 1985     1986     1987     1988
  Race

  White    Number (a)              32       29       35       38
           Rate                   6.3      5.1      6.4      7.6
           Age-adjusted           6.2      5.1      6.3      7.3

  Black    Number                  13       12       10        9
           Rate                  12.2     11.6      8.6      8.2
           Age-adjusted          12.4     11.8      8.7      8.1

  Total    Number                  53       48       56       55
           Rate                   8.4      7.1      8.2      8.6
           Age-adjusted           8.2      6.9      8.1      8.4

 (a) In thousands

 6.4 Discharge Rate (Diabetes Listed Diagnosis), by Age & Year

 Table 6.4  Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation
            With Diabetes as a Listed Diagnosis per 10,000 Population, by Age
            and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-44                            0.1      0.1      0.1      0.2      0.1

  45-64                           2.5      2.1      2.3      3.5      3.8

  65-74                           7.4      5.5      5.6     10.4      8.4

  75+                            11.6      9.7      9.6     10.6     12.5

  Total                           1.6      1.3      1.3      2.0      2.0

  Age-adjusted Rate               1.6      1.3      1.3      2.0      2.0

 Table 6.4  Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation
            With Diabetes as a Listed Diagnosis per 10,000 Population, by Age
            and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-44                            0.3      0.1      0.2      0.2

  45-64                           4.2      3.4      3.3      4.3

  65-74                           9.3      9.7     11.5      7.1

  75+                            11.9     11.1     14.5     15.8

  Total                           2.2      2.0      2.3      2.2

  Age-adjusted Rate               2.2      1.9      2.2      2.1

 6.5 Discharge Rate (Diabetes Listed Diagnosis), by Sex & Year

 Table 6.5  Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation
            with Diabetes as a Listed Diagnosis per 10,000 Population, by Sex
            and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  SEX

  Male     Rate                     1.8      1.3      1.3      2.0      1.9
           Age-adjusted Rate        2.0      1.5      1.5      2.3      2.1

  Female   Rate                     1.4      1.3      1.3      2.0      2.1
           Age-adjusted Rate        1.3      1.2      1.2      1.8      1.9

  Total    Rate                     1.6      1.3      1.3      2.0      2.0
           Age-adjusted Rate        1.6      1.3      1.3      2.0      2.0

 Table 6.5  Hospital Discharge Rate for Nontraumatic Lower Extremity Amputation
            with Diabetes as a Listed Diagnosis per 10,000 Population, by Sex
            and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  SEX

  Male     Rate                     2.1      2.3      2.4      2.9
           Age-adjusted Rate        2.3      2.5      2.6      3.2

  Female   Rate                     2.4      1.7      2.2      1.6
           Age-adjusted Rate        2.1      1.5      1.9      1.3

  Total    Rate                     2.2      2.0      2.3      2.2
           Age-adjusted Rate        2.2      1.9      2.2      2.1

 6.6 Discharge Rate (Diabetes Listed Diagnosis), by Race & Year

 Table 6.6  Hospital Discharge Rate for Nontraumatic Lower Extremity
            Amputation With Diabetes as a Listed Diagnosis per 10,000
            Population, by Race and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race

  White    Rate                     1.2      1.2      1.2      1.8      1.6
           Age-adjusted             1.1      1.1      1.1      1.7      1.5

  Black    Rate                     3.0      2.1      1.6      2.8      3.4
           Age-adjusted             4.2      2.8      2.1      3.7      4.5

  Total    Rate                     1.6      1.3      1.3      2.0      2.0
           Age-adjusted             1.6      1.3      1.3      2.0      2.0

 Table 6.6  Hospital Discharge Rate for Nontraumatic Lower Extremity
            Amputation With Diabetes as a Listed Diagnosis per 10,000
            Population, by Race and Year, United States, 1980-1984

                                                Year
                                   1985     1986     1987     1988
  Race

  White    Rate                     1.6      1.4      1.7      1.8
           Age-adjusted             1.5      1.3      1.6      1.7

  Black    Rate                     4.5      4.2      3.2      3.1
           Age-adjusted             5.8      5.5      4.3      4.0

  Total    Rate                     2.2      2.0      2.3      2.2
           Age-adjusted             2.2      1.9      2.2      2.1

 6.7 Discharge Rate/No. (Diabetes Listed Diagnosis),Region & Year

 Table 6.7  Number of Discharges for Nontraumatic Lower Extremity
            Amputation With Diabetes as a Listed Diagnosis and Hospital
            Discharge Rate per 10,000 Population, by Region and Year,
            United States, 1980-1984

                                                      Year
                                        1980   1981   1982   1983   1984
  Region

  Northeast   Number (a)                  13     10     11     12     13
              Rate                       2.6    2.0    2.3    2.5    2.7
              Adjusted Rate (b)          2.2    2.0    1.9    2.2    2.3

  North       Number                       7      9     10     13     13
  Central     Rate                       1.2    1.6    1.6    2.2    2.2
              Adjusted Rate              1.0    1.6    1.4    2.1    1.9

  South       Number                      11      7      7     16     16
              Rate                       1.4    0.8    0.9    2.0    2.0
              Adjusted Rate              1.2    0.8    0.8    1.9    1.8

  West        Number                       5      4      3      6      5
              Rate                       1.3    0.9    0.7    1.2    1.0
              Adjusted Rate              1.1    1.1    0.6    1.2    1.0

 (a) In thousands
 (b) Adjusted for age and race

 Table 6.7  Number of Discharges for Nontraumatic Lower Extremity
            Amputation With Diabetes as a Listed Diagnosis and Hospital
            Discharge Rate per 10,000 Population, by Region and Year,
            United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Region

  Northeast   Number (a)                  12      9     11     13
              Rate                       2.4    1.8    2.2    2.7
              Adjusted Rate (b)          2.1    1.6    1.9    2.3

  North       Number                      14     14     13     16
  Central     Rate                       2.3    2.4    2.3    2.6
              Adjusted Rate              2.1    2.4    2.0    2.1

  South       Number                      18     14     20     20
              Rate                       2.2    1.7    2.4    2.3
              Adjusted Rate              1.8    1.3    2.0    1.9

  West        Number                       9     10     11      6
              Rate                       1.9    2.1    2.3    1.2
              Adjusted Rate              1.3    2.2    1.5    0.7

 (a) In thousands
 (b) Adjusted for age and race


DIABETIC KETOACIDOSIS

 Introduction

 Diabetic ketoacidosis (DKA) is an acute, life-threatening disorder
 that can strike a person with diabetes at any age.  Expert
 consensus regards DKA morbidity and mortality as largely preventable
 (Schlade and Eaton, 1979).  Prevention strategies include improved
 compliance with glucose control regimens, early recognition of symptoms
 and signs of DKA, and prompt treatment of any precipitating medical
 conditions, such as infections (National Diabetes Advisory Board,
 1983).

 We examine hospitalization and mortality trends for DKA in the United
 States during the years 1980-1987.  Data on overall diabetic hospitalizations
 and mortality, and on the other complications of diabetes, are presented
 elsewhere.  We present DKA hospitalization and mortality rates categorized
 by age, race, region, and calender year.  We determine DKA rates for
 the general U.S. population, as well as rates among people with diabetes
 (diabetes-specific rates).

 Methods

 We used information from the National Hospital Discharge Survey
 (NHDS) to determine the annual number of hospitalizations for
 DKA (Chapter 4). Rubric 250.1 (diabetes with ketoacidosis) from the
 clinical modification of the 9th revision of the International
 Classification of Diseases (ICD9-CM) was used to identify discharges
 in which DKA was listed as either a primary or secondary diagnosis.
 To calculate denominators for annual rates in the general population,
 we used intercensal estimates based on 1980 census data.  To calculate
 denominators for diabetes-specific rates, we estimated the U.S. diabetic
 population using information from National Health Interview Surveys
 (Chapter 2).

 ICD-9 rubric 250.1 was also used to identify deaths in which DKA was
 listed as either an underlying or a contributing cause on mortality
 records supplied by the National Center for Health Statistics.  Methods
 (Chapter 3) for calculating general population and diabetes-specific
 mortality rates were similar to those used for hospitalization rates.

 For both hospital discharge and mortality analyses, general population
 rates were age- and race-adjusted using the direct method, with the
 1980 U.S. resident population as the standard.  To adjust diabetes-specific
 rates, we used the estimated 1980 U.S. population of persons with
 diabetes as the standard.

 Results

  Hospital Discharges for DKA in the General Population

 In 1987, the latest year for which data are available, there
 were about 110,000 hospitalizations in which DKA was listed as a
 discharge diagnosis (Figure 7.1).  In 1980 there were about 70,000
 hospital discharges with DKA as a listed diagnosis.

 The number and rate of hospital discharges with DKA as a primary diagnosis
 has steadily increased during 1980-1987 (Figure 7.2).  The age-adjusted
 rate was 2.6 discharges per 10,000 population in 1980, whereas the
 corresponding rate in 1987 was 3.8 per 10,000, an average annual increase
 of 7% (Table 7.1).  Age-specific data indicate that rising rates among
 persons less than 45 years old account for much of this overall increase.
 Discharge rates were relatively unchanged among those in older age groups
 (Table 7.1).

 Hospital discharge rates for DKA were consistently higher among blacks
 than among whites (Table 7.2).  In 1987, the age-adjusted rate for
 black males, 7.8 discharges per 10,000, was 2.7-fold higher than the
 corresponding rate of 2.8 for white males.  Similarly, the rate of
 discharges for black females, 5.6 per 10,000, was 1.8-fold higher
 than the rate of 3.2 per 10,000 for white females.  Among white males
 and females, the temporal trends were comparable, with each group
 showing increases in rates of DKA as a primary hospital discharge
 diagnosis.  Among blacks, the temporal trends were less evident because
 of sizable year-to-year variability resulting from smaller sample
 sizes.

 In each of four geographic regions, hospital discharge rates for DKA
 as a primary diagnosis exhibited similar trends--a gradual secular
 increase (Table 7.3).  Rates were generally lower in the Northeast
 and higher in the South.  In all regions and for each year, age- and
 race-adjusted discharge rates were lower than the corresponding unadjusted
 rates (Table 7.3).

 During the period 1980 through 1987, most (greater than 78%) hospital
 records that mention DKA as a discharge diagnosis list this condition
 as the primary diagnosis (Figure 7.2).  Thus, although hospital discharge
 rates are roughly 20% higher for DKA as any listed diagnosis, the
 rate trends parallel those for hospital discharges in which DKA is
 the primary diagnosis.  Age-specific rates for DKA as any listed diagnosis
 are presented in Table 7.4, race- and sex-specific rates in Table
 7.5, and region-specific rates in Table 7.6.

  Hospital Discharges for DKA Among Persons With Diabetes

 During 1980-1987, the age-adjusted rate (per 1,000 persons with diabetes)
 of hospital discharges for DKA as a primary diagnosis has shown an
 overall gradual increase (Figure 7.3).  The age-adjusted rate, which
 was 10.3 discharges per 1,000 persons in 1980, peaked at 14.6 discharges
 per 1,000 in 1984 and then declined slightly to 12.5 per 1,000 in
 1987. The overall increase during this period resulted from rising
 rates within the 0- to 44-year age category (Table 7.7).  Within this
 age group, rates increased yearly--from 36.6 discharges per 1,000
 persons with diabetes in 1980--until 1985, when they peaked at
 58.6 per 1,000 and then declined to 49.9 per 1,000 in 1987.  In contrast,
 rates within older age categories were stable during this time.  In
 each year, rates were highest in the youngest age category and decreased
 with age.

 During this period, black males consistently had the highest annual
 DKA hospital discharge rates whereas, with few exceptions, white males
 had the lowest rates (Table 7.8).  In 1987, for example, the age-adjusted
 rate among black males, 24.7 per 1,000 persons with diabetes, was
 nearly threefold higher than the corresponding rate of 8.7 per 1,000
 among white males.  In contrast, rates among black females were only
 slightly higher than those among white females.  Regarding temporal
 trends, the most striking rate increases were seen among black males,
 although there was considerable variability, particularly during 1983-1984,
 because of small sample sizes. Temporal trends were less discernible
 in other race-sex categories.

 In general, the trends in hospital discharge rates for DKA as any
 listed diagnoses were similar to those for which DKA was listed as
 the primary diagnosis.  One exception, however, was that the discharge
 rate for DKA as any listed diagnosis increased during 1980-1987 in
 the 45- to 64-year age group, as well as in the 0- to 44-year age
 group (Table 7.9). Race- and sex-specific rates are also presented
 (Table 7.10).

  DKA Mortality in the General Population

 From 1980 to 1986, age-adjusted rates declined for DKA
 as an underlying cause of death (Figure 7.4)  The mortality rate declined
 from 1.60 per 100,000 population in 1980 to 1.37 per 100,000 in 1986,
 an average annual decrease of 2%.  During this period, however, the
 temporal trends varied by age group (Table 7.11).  Mortality rates
 remained the same, about 0.2 per 100,000, in persons less than 45
 years old<197>meanwhile, they decreased in all older age categories.  Within
 each year, mortality rates increased with age.  In 1987, for example,
 the mortality rate was 0.23 per 100,000 for those persons 0 to 44
 years old, 0.88 for those 45 to 64 years old, 2.06 for those 65 to
 74 years old, and 5.02 for those more than 74 years old.

 For mortality resulting from DKA as an underlying cause, each race
 and sex category showed similar temporal trends: gradual declines
 since 1980 (Table 7.12).  In all years, black males and females had
 the highest rates, whereas white males had the lowest rates.  Declining
 rates were seen in each geographic region (Table 7.13).  In all years,
 the unadjusted mortality rate for DKA as an underlying cause was lowest
 in the West. After rates were standardized for age and race, regional
 differences in mortality were less pronounced (Table 7.13).

 Total DKA-related mortality reflects those deaths in which DKA is
 listed on the death certificate as either an underlying or contributing
 cause.  In 1986, of the 2,969 total DKA-related deaths, there were
 1,735 deaths (58%) for which DKA was the underlying cause (Tables
 7.11 and 7.14).  During 1980-1985, DKA as an underlying cause of death
 constituted a similar proportion of total DKA-related deaths.

 Temporal trends in total DKA-related mortality rates resemble those
 for which DKA is listed as the underlying cause of death (Figure 7.4,
 Tables 7.14-7.16).  Overall, the age-adjusted mortality rate has slightly
 declined (Table 7.14).  Although age-specific rates appear to have
 declined for older age groups, rate declines were less evident for
 persons less than 45 years old.  From 1980 to 1986, rates declined
 in all race-sex categories (Table 7.15), as well as in all geographic
 regions (Table 7.16).

  DKA Mortality in Persons with Diabetes

 During 1980 through 1986, among persons with diabetes, mortality
 rates for DKA as either an underlying or contributing cause of
 death declined (Figure 7.5).  For DKA as an underlying cause, the
 age-adjusted mortality rate of 30.6 per 100,000 persons with diabetes
 in 1980 fell to 25 per 100,000 by 1986--an annual average decrease
 of 3% (Table 7.17).  Temporal trends in age-specific rates among persons
 with diabetes resembled rate trends among persons in the general population:
 there was little change in rates for persons aged 0 to 44 years, whereas
 rates declined among all older age categories.  Among the 45- to 64-year
 age group, the rate dropped from 21.2 per 100,000 in 1980 to 13.9
 per 100,000 in 1986, an average annual decline of 5.7%.

 In contrast to rates based on the general population, the lowest
 age-specific mortality rates for DKA among persons with diabetes were
 not in persons less than 45 years old (Table 7.17).  Rather, average
 age-specific mortality rates were lowest among the 45- to 64-year
 age group, and only the rate among persons 75 years and older exceeded
 the rate among the youngest age group (Figure 7.6).

 Mortality rates for DKA as an underlying cause of death declined
 among all race-sex groups during 1980-1986 (Table 7.18).  Within each
 year, the lowest rates were seen among white males and females (Figure
 7.7).  For black males and females, DKA mortality rates decreased,
 on average, 4.3% annually.  The corresponding average annual rate
 decreases for white males and females were 3.4% and 1.7%, respectively.

 Total DKA-related mortality rates among persons with diabetes are
 shown for each age group and for each race-sex group (Tables 7.19-7.20).
 Because total DKA-related mortality includes those deaths in which
 DKA is listed on the death certificate as a contributing cause, rates
 are higher than those based solely on DKA as the underlying cause
 of death (Figure 7.5).  Temporal trends for total DKA-related mortality
 were similar to those for underlying-cause mortality, with declining
 rates in persons older than 45 years old and in each race-sex category.

 Discussion

 We present hospital discharge and mortality rates for DKA during
 1980 through 1987.  Overall, mortality rates for DKA in the general
 population have declined during this period.  At the same time, however,
 hospitalization rates for DKA have increased.  One difficulty in
 interpreting these data is that the increasing prevalence of diabetes,
 as described in Chapter 2, may be influencing these findings.  Because
 DKA, by definition, is a condition restricted to those with diabetes,
 examining diabetes-specific data provides more useful information
 about temporal patterns within the appropriate population-at-risk
 for this largely preventable condition.  Thus, more emphasis should
 be placed on examining rates in the diabetic population.

 We found that mortality rates for DKA among persons with diabetes
 varied by race.  Although mortality rates declined in each race and
 sex group during this period, blacks consistently had higher mortality
 rates than whites.  For DKA as an underlying cause of death, the 1986
 age-adjusted mortality rates among black males and females were 2.7
 to 2.9 times higher than the corresponding rates in white males and
 females. Because these are diabetes-specific rates, these rate ratios
 are not influenced by the higher prevalence of diabetes among blacks.
 Thus, differences in patient and provider actions (Fishbein, 1985) or
 other elements related to health care use may account for the higher
 rates seen among blacks with diabetes.

 Among persons with diabetes, the age-adjusted rate of hospital discharges
 for DKA has gradually increased during 1980-1987.  Whether DKA is
 listed as a primary or secondary diagnosis, similar patterns are seen.
 Hospital discharge rates for DKA were highest in 1984 and have declined
 slightly since then, but were still higher during 1985-1987 than they
 were during 1980-1983.  This temporal increase can be attributed primarily
 to rising rates of hospitalization among persons less than 45 years
 old.  In contrast, hospitalization rates were relatively unchanged
 in older age groups during these years.

 At the same time, overall age-adjusted mortality rates for DKA among
 persons with diabetes have been declining.  Yet, as with hospital
 discharge trends, the secular mortality experience has varied by age.
 Among persons older than 45 years old, mortality rates from DKA as
 an underlying cause of death have clearly declined during this decade.
 The same is not true, however, for those younger.  For persons less than
 45 years old, mortality rates for DKA as an underlying cause of death
 have not changed.  Similar age-specific patterns are seen when total
 DKA-related mortality is examined.

 Hospital discharge and mortality rates may vary over time for several
 reasons.  Changes in reporting practices may influence the enumeration
 of episodes of DKA.  Prospective payment mechanisms with diagnostic
 related groups (DRGs) were implemented in 1983.  Such a reimbursement
 system might alter diagnostic coding practices for certain conditions,
 but probably has less impact on recording serious, life-threatening
 disorders, such as DKA.  Further, if DRGs influenced DKA diagnoses,
 similar relative changes should occur within all age categories, which
 is not the case.  Reporting artifacts unlikely influence the secular
 trends seen in DKA mortality rates, because reporting and coding practices
 for death certificates did not change during this time.

 Other factors that may influence trends in DKA morbidity and mortality
 include changes in medical care access and treatment.  Medical care
 treatment changes include improved and more widespread use of self-care
 techniques designed to prevent ketoacidosis and avert hospitalization
 (National Diabetes Advisory Board, 1983), as well as technological
 advances, such as life support techniques for the critically ill.  That
 hospital discharge rates for DKA in older persons stayed the same
 while the corresponding mortality rates declined would suggest that
 advances in hospital treatment, or perhaps improving access to them,
 is responsible for these trends.

 Unlike their older counterparts with diabetes, persons less than 45
 years old have unchanging mortality rates but increasing hospitalization
 rates for DKA.  Together, these findings suggest that, although certain
 advances may have occurred in preventing and treating DKA among certain
 groups, DKA remains a significant source of morbidity among younger
 persons with diabetes.  Additional studies should be directed toward
 identifying any subgroups within this age group who are at increased
 risk for DKA.  Identifying these subgroups would help to target resources
 to reduce morbidity, as well as mortality, from this largely preventable
 complication of diabetes.

 Update

      This section updates data presented in previous sections in light of one
 additional year of hospitalization data and two additional years of mortality
 data.  For a complete description of the methods and operational definitions
 and for a discussion of the implications of the findings, see previous
 sections.

      Among the diabetic population, the age-standardized rates of hospital
 discharge for diabetic ketoacidosis (DKA) as a primary diagnosis and as any
 listed diagnosis increased between 1980 and 1984, decreased slightly in 1985,
 and then leveled off (Tables 7.7 and 7.9).  DKA hospital discharge rates for
 both primary cause and any listed cause were highest among persons with
 diabetes younger than 45 years of age.  Among the race-sex groups examined,
 discharge rates were highest among black males, followed by black females,
 white females, and white males (Tables 7.8-7.9).
      During the period 1980-1987, among persons with diabetes, mortality
 rates for DKA as both an underlying and any listed cause of death declined
 (Figure 1.10, Tables 7.17 and 7.19).  These declines were followed by
 increases in 1988.  Temporal trends were similar by age except for rates among
 persons younger than age 45, which showed little change between 1980 and 1987.
 The highest mortality rates for DKA as either an underlying or any listed
 cause of death were found among persons 75 years of age and older.  Among the
 race-sex groups examined, mortality rates were highest among black males,
 followed by black females and then by whites, with little difference between
 the sexes (Tables 7.18 and 7.20).

 Detailed Tables

 7.1-7.3 Discharges w/ Diabetic Ketoacidosis as Primary Diagnosis

 7.1 10,000 Pop., by Age and Year, U.S., 80-88

 Table 7.1  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population,
            by Age and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-19     Number (a)              16       15       16       20       21
           Rate                   2.2      2.0      2.3      2.9      3.0

  20-44    Number                  21       23       24       31       37
           Rate                   2.5      2.7      2.6      3.4      4.0

  45-64    Number                  12       18       15       12       16
           Rate                   2.8      4.0      3.3      2.6      3.7

  65+      Number                  10        8        6        9       10
           Rate                   3.9      3.2      2.2      3.1      3.7

  Total    Number                  59       64       60       72       85
           Rate                   2.6      2.8      2.6      3.1      3.6

  Age-adjusted Rate               2.6      2.8      2.6      3.1      3.6

 (a) In thousands

 Table 7.1  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population,
            by Age and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-19     Number (a)              21       21       29       25
           Rate                   3.0      2.9      4.0      3.6

  20-44    Number                  32       37       39       39
           Rate                   3.4      3.8      4.0      4.0

  45-64    Number                  16       16       13        9
           Rate                   3.6      3.6      2.9      2.0

  65+      Number                  11       11       11       10
           Rate                   3.9      3.9      3.8      3.3

  Total    Number                  81       85       93       84
           Rate                   3.4      3.5      3.8      3.4

  Age-adjusted Rate               3.4      3.5      3.8      3.4

 (a) In thousands

 7.2 10,000 Pop., by Race, Sex, and Year, U.S., 80-88

 Table 7.2  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population,
            by Race, Sex and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Number (a)           16       18       18       17       23
                Rate                1.6      1.8      1.8      1.8      2.3
                Age-adjusted Rate   1.7      1.8      1.8      1.8      2.3

         Female Number               27       29       24       33       35
                Rate                2.7      2.9      2.4      3.3      3.4
                Age-adjusted Rate   2.7      2.8      2.4      3.3      3.4

  Black  Male   Number                5        6        6        8       12
                Rate                4.2      4.9      4.3      6.2      9.0
                Age-adjusted Rate   4.8      5.6      4.6      6.1      9.8

         Female Number                7       10        7        8        7
                Rate                4.8      6.8      4.6      5.4      4.7
                Age-adjusted Rate   5.0      7.1      4.9      5.7      5.1

  Total  Total  Number               59       64       60       72       85
                Rate                2.6      2.8      2.6      3.1      3.6
                Age-adjusted Rate   2.6      2.8      2.6      3.1      3.6

 (a) In thousands

 Table 7.2  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population,
            by Race, Sex and Year, United States, 1980-1984

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Number (a)           24       23       28       21
                Rate                2.4      2.3      2.7      2.0
                Age-adjusted Rate   2.4      2.3      2.8      2.0

         Female Number               32       32       34       28
                Rate                3.1      3.0      3.2      2.6
                Age-adjusted Rate   3.1      3.0      3.2      2.7

  Black  Male   Number                6       10       10       12
                Rate                4.7      7.2      7.3      8.6
                Age-adjusted Rate   4.6      7.4      7.8      8.5

         Female Number               11       12        8       11
                Rate                7.0      7.6      5.2      6.8
                Age-adjusted Rate   7.4      8.0      5.6      6.7

  Total  Total  Number               81       85       93       84
                Rate                3.4      3.5      3.8      3.4
                Age-adjusted Rate   3.4      3.5      3.8      3.4

 (a) In thousands

 7.3 10,000 Pop., by Region and Year, U.S., 80-88

 Table 7.3  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Region and Year, United States, 1980-1984

                                                      Year
                                        1980   1981   1982   1983   1984
  Region

  Northeast   Number (a)                  12     12     12     13     17
              Rate                       2.5    2.4    2.3    2.7    3.4
              Adjusted Rate (b)          2.3    2.3    2.1    2.7    3.2

  North       Number                      19     16     14     20     18
  Central     Rate                       3.2    2.7    2.3    3.3    3.1
              Adjusted Rate              3.0    2.7    2.1    3.2    2.9

  South       Number                      19     24     24     23     30
              Rate                       2.5    3.2    3.0    2.9    3.7
              Adjusted Rate              2.3    2.8    2.8    2.6    3.4

  West        Number                       9     12     11     16     20
              Rate                       2.2    2.8    2.4    3.5    4.2
              Adjusted Rate              2.1    2.9    2.3    3.3    3.9

 (a) In thousands
 (b) Adjusted for age and race

 Table 7.3  Number of Discharges with Diabetic Ketoacidosis as Primary
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Region and Year, United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Region

  Northeast   Number (a)                  16     15     16     14
              Rate                       3.1    3.1    3.1    2.9
              Adjusted Rate (b)          3.0    2.8    3.0    2.8

  North       Number                      17     21     24     24
  Central     Rate                       2.9    3.6    4.0    4.1
              Adjusted Rate              2.6    3.3    3.5    3.4

  South       Number                      30     32     31     33
              Rate                       3.7    3.8    3.7    3.9
              Adjusted Rate              3.4    3.2    3.3    3.3

  West        Number                      18     17     22     13
              Rate                       3.8    3.5    4.4    2.5
              Adjusted Rate              3.6    3.1    3.9    2.1

 (a) In thousands
 (b) Adjusted for age and race

 7.4-7.6 Discharges w/ Diabetic Detoacidosis as Listed Diagnosis

 7.4 10,000 Pop., by Age and Year, U.S., 80-88

 Table 7.4  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Age and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-19     Number (a)              17       16       17       22       23
           Rate                   2.4      2.2      2.4      3.1      3.2

  20-44    Number                  24       26       25       35       42
           Rate                   2.8      3.0      2.8      3.8      4.5

  45-64    Number                  15       21       18       14       22
           Rate                   3.3      4.7      4.0      3.2      4.9

  65+      Number                  15       11        9       12       18
           Rate                   5.7      4.3      3.5      4.5      6.5

  Total    Number                  70       74       70       84      105
           Rate                   3.1      3.2      3.0      3.6      4.4

  Age-adjusted Rate               3.1      3.2      3.0      3.6      4.4

 (a) In thousands

 Table 7.4  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Age and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-19     Number (a)              22       22       29       26
           Rate                   3.1      3.1      4.0      3.7

  20-44    Number                  38       44       45       43
           Rate                   4.0      4.6      4.6      4.4

  45-64    Number                  20       22       19       17
           Rate                   4.6      4.8      4.2      3.7

  65+      Number                  18       19       17       17
           Rate                   6.3      6.7      5.8      5.5

  Total    Number                  98      108      110      103
           Rate                   4.1      4.5      4.5      4.2

  Age-adjusted Rate               4.1      4.4      4.5      4.2

 (a) In thousands

 7.5 10,000 Pop., by Race, Sex, and Year, U.S., 80-88

 Table 7.5  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Race, Sex, and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Number (a)           19       20       21       20       29
                Rate                2.0      2.1      2.2      2.1      2.9
                Age-adjusted Rate   2.0      2.1      2.2      2.1      2.9

         Female Number               31       35       28       39       45
                Rate                3.1      3.5      2.7      3.8      4.4
                Age-adjusted Rate   3.1      3.4      2.8      3.7      4.2

  Black  Male   Number                6        6        7        9       13
                Rate                4.9      5.0      5.0      7.1      9.5
                Age-adjusted Rate   5.5      5.8      5.6      7.3     10.4

         Female Number                8       11        7        9        8
                Rate                5.9      7.5      5.1      6.0      5.2
                Age-adjusted Rate   6.1      8.0      5.4      6.3      5.6

  Total  Total  Number               70       74       70       84      105
                Rate                3.1      3.2      3.0      3.6      4.4
                Age-adjusted Rate   3.1      3.2      3.0      3.6      4.4

 (a) In thousands

 Table 7.5  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Race, Sex, and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Number (a)           29       30       32       25
                Rate                2.9      3.0      3.2      2.5
                Age-adjusted Rate   3.0      3.0      3.2      2.5

         Female Number               39       41       40       36
                Rate                3.8      4.0      3.8      3.4
                Age-adjusted Rate   3.7      3.8      3.7      3.4

  Black  Male   Number                7       11       12       15
                Rate                5.3      8.0      8.5     10.1
                Age-adjusted Rate   5.2      8.2      9.4     10.5

         Female Number               12       13       10       14
                Rate                8.0      8.4      6.7      8.7
                Age-adjusted Rate   8.6      8.8      7.4      8.9

  Total  Total  Number               98      108      110      103
                Rate                4.1      4.5      4.5      4.2
                Age-adjusted Rate   4.1      4.4      4.5      4.2

 (a) In thousands

 7.6 10,000 Pop., by Region and Year, U.S., 80-88

 Table 7.6  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Region and Year, United States, 1980-1984

                                                      Year
                                        1980   1981   1982   1983   1984
  Region

  Northeast   Number (a)                  15     13     14     15     20
              Rate                       3.1    2.7    2.9    3.0    4.0
              Adjusted Rate (b)          2.8    2.6    2.6    3.0    3.7

  North       Number                      21     19     16     22     23
  Central     Rate                       3.6    3.2    2.7    3.8    3.9
              Adjusted Rate              3.4    3.3    2.5    3.6    3.7

  South       Number                      23     29     28     28     39
              Rate                       3.0    3.7    3.5    3.5    4.8
              Adjusted Rate              2.7    3.4    3.2    3.2    4.3

  West        Number                      11     13     12     19     23
              Rate                       2.5    3.0    2.7    4.1    4.9
              Adjusted Rate              2.4    3.1    2.6    3.6    4.5

 (a) In thousands
 (b) Adjusted for age and race

 Table 7.6  Number of Discharges with Diabetic Ketoacidosis as Any Listed
            Diagnosis and Hospital Discharge Rate per 10,000 Population
            by Region and Year, United States, 1985-1988

                                                  Year
                                        1985   1986   1987   1988
  Region

  Northeast   Number (a)                  19     19     20     18
              Rate                       3.9    3.7    3.9    3.6
              Adjusted Rate (b)          3.7    3.4    3.6    3.5

  North       Number                      19     27     28     29
  Central     Rate                       3.3    4.5    4.6    4.9
              Adjusted Rate              3.0    4.1    4.1    4.4

  South       Number                      37     41     37     40
              Rate                       4.5    5.0    4.4    4.7
              Adjusted Rate              4.1    4.3    3.9    4.2

  West        Number                      22     21     25     15
              Rate                       4.6    4.3    5.1    3.0
              Adjusted Rate              4.3    3.9    4.6    2.7

 (a) In thousands
 (b) Adjusted for age and race

 7.7-7.8 Discharge for Diabetic Ketoacidosis as Primary Diagonsis

 7.7 1,000 Diabetic Pop., by Age and Year, U.S., 80-88

 Table 7.7  Hospital Discharge Rate for Diabetic Ketoacidosis as Primary
            Diagnosis per 1,000 Diabetic Population, by Age and Year,
            United States, 1980-1984

                                              Year
                            1980     1981     1982     1983     1984
  Age

  0-19                      36.6     39.7     40.3     51.5     58.6

  20-44                      5.2      7.1      5.7      4.5      6.9

  45-64                      4.2      3.6      2.5      3.9      3.6

  Total                     10.3     11.0     10.2     12.4     13.7

  Age-adjusted Rate         10.3     11.3     10.4     12.4     14.6

 Table 7.7  Hospital Discharge Rate for Diabetic Ketoacidosis as Primary
            Diagnosis per 1,000 Diabetic Population, by Age and Year,
            United States, 1985-1988

                                           Year
                              1985     1986     1987     1988
  Age

  0-19                        51.7     55.2     49.9     59.3

  20-44                        6.9      5.7      5.2      3.8

  45-64                        3.8      3.9      3.9      3.6

  Total                       12.8     12.6     13.6     13.2

  Age-adjusted Rate           13.4     13.6     12.5     13.4

 7.8 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88

 Table 7.8  Hospital Discharge Rate for Diabetic Ketoacidosis as
            Primary Diagnosis per 1,000 Diabetic Population,
            by Race, Sex and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Rate                7.5      8.1      8.5      8.3     10.9
                Age-adjusted Rate   8.3      8.1      8.1      7.7     11.2

         Female Rate                9.9     11.0      9.1     13.0     12.1
                Age-adjusted Rate   9.9     11.6      9.1     14.0     13.3

  Black  Male   Rate               15.2     18.5     16.7     23.5     30.9
                Age-adjusted Rate  13.1     16.5     16.1     35.1     36.0

         Female Rate               12.7     16.6     10.5     11.5     10.5
                Age-adjusted Rate  11.3     16.4     11.5     11.8     10.7

  Total  Total  Rate               10.3     11.0     10.2     12.4     13.7
                Age-adjusted Rate  10.3     11.3     10.4     12.4     14.6

 Table 7.8  Hospital Discharge Rate for Diabetic Ketoacidosis as
            Primary Diagnosis per 1,000 Diabetic Population,
            by Race, Sex and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Rate               10.3      8.8     10.0      8.7
                Age-adjusted Rate  10.6     11.8      8.7      7.9

         Female Rate               11.1     10.5     12.4     10.7
                Age-adjusted Rate  11.3      9.9     12.0     12.9

  Black  Male   Rate               15.4     23.9     23.4     26.6
                Age-adjusted Rate  16.9     21.1     21.1     26.8

         Female Rate               16.4     18.4     12.0     16.0
                Age-adjusted Rate  18.4     21.0     12.4     14.7

  Total  Total  Rate               12.8     12.6     13.6     13.2
                Age-adjusted Rate  13.4     13.6     12.5     13.4

 7.9-7.10 Discharge for Diabetic Ketoacidosis as Listed Diagnosis

 7.9 1,000 Diabetic Pop., by Age and Year, U.S., 80-88

 Table 7.9  Hospital Discharge Rate for Diabetic Ketoacidosis as Any
            Listed Diagnosis per 1,000 Diabetic Population,
            by Age and Year, 1980-1984

                                              Year
                            1980     1981     1982     1983     1984
  Age

  0-19                      40.7     44.0     43.3     56.6     65.1

  20-44                      6.1      8.3      7.0      5.6      9.2

  45-64                      6.1      4.9      4.0      5.7      6.4

  Total                     12.1     12.8     11.9     14.5     16.9

  Age-adjusted Rate         12.1     13.1     12.1     14.5     17.8

 Table 7.9  Hospital Discharge Rate for Diabetic Ketoacidosis as Any
            Listed Diagnosis per 1,000 Diabetic Population,
            by Age and Year, 1985-1988

                                         Year
                            1985     1986     1987     1988
  Age

  0-19                      57.3     63.5     53.7     63.7

  20-44                      8.8      7.6      7.5      6.8

  45-64                      6.1      6.8      6.0      6.0

  Total                     15.5     15.9     16.1     16.2

  Age-adjusted Rate         16.1     17.0     15.0     16.4

 7.10 1,000 Diabetic Pop., by Race, Sex, and Year, U.S., 80-88

 Table 7.10  Hospital Discharge Rate for Diabetic Ketoacidosis as
             Any Listed Diagnosis per 1,000 Diabetic Population,
             by Race, Sex and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Rate                9.1      9.3     10.0      9.7     13.7
                Age-adjusted Rate   9.9      9.3      9.7      9.2     14.1

         Female Rate               11.5     13.3     10.4     15.0     15.6
                Age-adjusted Rate  11.5     14.0     10.4     16.1     16.7

  Black  Male   Rate               17.7     19.0     19.5     26.9     32.3
                Age-adjusted Rate  15.2     17.0     19.0     38.1     37.3

         Female Rate               15.4     18.4     11.6     12.7     11.5
                Age-adjusted Rate  14.1     18.3     12.8     13.0     11.8

  Total  Total  Rate               12.1     12.8     11.9     14.5     16.9
                Age-adjusted Rate  12.1     13.1     12.1     14.5     17.8

 Table 7.10  Hospital Discharge Rate for Diabetic Ketoacidosis as
             Any Listed Diagnosis per 1,000 Diabetic Population,
             by Race, Sex and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Rate               12.7     11.6     11.6     10.7
                Age-adjusted Rate  13.0     15.2     10.2      9.8

         Female Rate               13.5     13.7     14.6     13.6
                Age-adjusted Rate  13.8     13.0     14.3     16.0

  Black  Male   Rate               17.4     26.7     27.3     31.3
                Age-adjusted Rate  19.3     23.5     25.5     32.2

         Female Rate               18.8     20.2     15.4     20.4
                Age-adjusted Rate  20.8     22.9     15.8     19.5

  Total  Total  Rate               15.5     15.9     16.1     16.2
                Age-adjusted Rate  16.1     17.0     15.0     16.4

 7.11-7.13 Deaths w/ Diabetic Ketoacidosis as Underlying Cause

 7.11 Mortality Rate per 100,000 Pop., Age & Year, U.S., 80-88

 Table 7.11  Number of Deaths with Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Age
             and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Age

  0-44     Number                   321      309      308      334      352
           Rate                    0.20     0.19     0.19     0.21     0.22

  45-64    Number                   506      511      434      451      403
           Rate                    1.14     1.15     0.97     1.01     0.90

  65-74    Number                   392      334      384      318      374
           Rate                    2.50     2.10     2.37     1.93     2.23

  75+      Number                   553      552      574      566      553
           Rate                    5.50     5.35     5.40     5.18     4.93

  Total    Number                  1772     1707     1700     1669     1682
           Rate                    0.78     0.74     0.73     0.71     0.71

  Age-adjusted Rate                0.78     0.74     0.73     0.70     0.70

 Table 7.11  Number of Deaths with Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Age
             and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Age

  0-44     Number                   331      388      375      457
           Rate                    0.20     0.23     0.22     0.27

  45-64    Number                   407      396      404      435
           Rate                    0.91     0.88     0.89     0.95

  65-74    Number                   358      357      296      341
           Rate                    2.11     2.06     1.68     1.91

  75+      Number                   590      594      584      572
           Rate                    5.12     5.02     4.81     4.59

  Total    Number                  1686     1735     1660     1805
           Rate                    0.71     0.72     0.68     0.73

  Age-adjusted Rate                0.69     0.70     0.66     0.71

 7.12 Mortality Rate per 100,000 Pop., Race,Sex,Year, U.S., 80-88

 Table 7.12  Number of Deaths With Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Race,
             Sex, and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Number              582      535      569      504      553
                Rate               0.61     0.56     0.59     0.52     0.56
                Age-adjusted Rate  0.67     0.61     0.63     0.55     0.60

         Female Number              733      755      743      749      695
                Rate               0.73     0.75     0.73     0.73     0.67
                Age-adjusted Rate  0.63     0.64     0.61     0.62     0.56

  Black  Male   Number              185      160      157      187      192
                Rate               1.46     1.24     1.20     1.41     1.42
                Age-adjusted Rate  2.00     1.63     1.60     1.90     1.87

         Female Number              246      237      212      213      219
                Rate               1.74     1.65     1.46     1.44     1.46
                Age-adjusted Rate  2.07     1.95     1.72     1.69     1.70

  Total  Total  Number             1772     1707     1700     1669     1682
                Rate               0.78     0.74     0.73     0.71     0.71
                Age-adjusted Rate  0.78     0.74     0.73     0.70     0.70

 Table 7.12  Number of Deaths With Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Race,
             Sex, and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Number              541      549      597      607
                Rate               0.55     0.55     0.59     0.60
                Age-adjusted Rate  0.58     0.58     0.62     0.62

         Female Number              755      762      666      723
                Rate               0.73     0.73     0.63     0.68
                Age-adjusted Rate  0.60     0.60     0.51     0.55

  Black  Male   Number              148      174      166      210
                Rate               1.08     1.25     1.18     1.47
                Age-adjusted Rate  1.44     1.59     1.51     1.80

         Female Number              219      224      204      241
                Rate               1.44     1.45     1.30     1.52
                Age-adjusted Rate  1.67     1.69     1.51     1.73

  Total  Total  Number             1686     1735     1660     1805
                Rate               0.71     0.72     0.68     0.73
                Age-adjusted Rate  0.69     0.70     0.66     0.71

 7.13 Mortality Rate per 100,000 Pop., Region & Year, U.S., 80-88

 Table 7.13  Number of Deaths With Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Region
             and Year, United States, 1980-1984

                                                  Year
                                    1980   1981   1982   1983   1984
  Region

  Northeast Number                   417    353    378    354    370
            Rate                    0.85   0.72   0.77   0.72   0.74
            Adjusted Rate (a)       0.81   0.68   0.71   0.67   0.69

  North     Number                   434    429    424    443    389
  Central   Rate                    0.74   0.73   0.72   0.75   0.66
            Adjusted Rate           0.75   0.73   0.71   0.75   0.65

  South     Number                   645    652    608    598    645
            Rate                    0.85   0.85   0.77   0.75   0.80
            Adjusted Rate           0.77   0.78   0.71   0.68   0.72

  West      Number                   276    273    290    274    278
            Rate                    0.64   0.62   0.64   0.59   0.59
            Adjusted Rate           0.75   0.73   0.73   0.68   0.69

 (a) Adjusted for age and race

 Table 7.13  Number of Deaths With Diabetic Ketoacidosis as Underlying
             Cause and Mortality Rate per 100,000 Population, by Region
             and Year, United States, 1985-1988

                                              Year
                                    1985   1986   1987   1988
  Region

  Northeast Number                   354    371    348    370
            Rate                    0.71   0.74   0.69   0.73
            Adjusted Rate (a)       0.65   0.68   0.63   0.66

  North     Number                   430    412    393    412
  Central   Rate                    0.73   0.69   0.66   0.69
            Adjusted Rate           0.70   0.67   0.64   0.68

  South     Number                   614    663    617    667
            Rate                    0.75   0.80   0.74   0.78
            Adjusted Rate           0.67   0.72   0.66   0.69

  West      Number                   288    289    302    356
            Rate                    0.60   0.59   0.61   0.70
            Adjusted Rate           0.67   0.66   0.69   0.80

 (a) Adjusted for age and race

 7.14-7.16 Deaths w/ Diabetic Ketoacidosis as Any Listed Cause

 7.14 Mort. Rate per 100,000 Pop., by Age & Year, U.S., 80-88

 Table 7.14  Number of Deaths with Diabetic Ketoacidosis as Any Listed
             Diagnosis and Mortality Rate per 100,000 Population, by Age
             and Year, United States, 1980-1984

                                                   Year
                                 1980     1981     1982     1983     1984
  Age

  0-44     Number                 413      391      393      413      442
           Rate                  0.26     0.25     0.24     0.25     0.27

  45-64    Number                 818      857      725      767      696
           Rate                  1.84     1.92     1.63     1.72     1.55

  65-74    Number                 719      665      699      653      748
           Rate                  4.59     4.18     4.32     3.96     4.47

  75+      Number                 965      940      948     1033     1045
           Rate                  9.60     9.11     8.92     9.45     9.31

  Total    Number                2915     2855     2765     2866     2931
           Rate                  1.28     1.24     1.19     1.22     1.24

  Age-adjusted Rate              1.28     1.24     1.18     1.20     1.21

 Table 7.14  Number of Deaths with Diabetic Ketoacidosis as Any Listed
             Diagnosis and Mortality Rate per 100,000 Population, by Age
             and Year, United States, 1985-1988

                                              Year
                                 1985     1986     1987     1988
  Age

  0-44     Number                 428      483      472      561
           Rate                  0.26     0.29     0.28     0.33

  45-64    Number                 720      694      669      741
           Rate                  1.60     1.54     1.48     1.61

  65-74    Number                 734      691      635      664
           Rate                  4.32     3.99     3.60     3.71

  75+      Number                1097     1101     1102     1045
           Rate                  9.52     9.31     9.07     8.39

  Total    Number                2979     2969     2879     3012
           Rate                  1.25     1.23     1.18     1.23

  Age-adjusted Rate              1.21     1.19     1.13     1.17

 7.15 Mort. Rate per 100,000 Pop., Race, Sex, Year, U.S., 80-88

 Table 7.15  Number of Deaths with Diabetic Ketoacidosis as Any Listed
             Cause and Mortality Rate per 100,000 Population, by Race
             Sex, and Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Number              984      880      942      904      944
                Rate               1.03     0.92     0.97     0.93     0.96
                Age-adjusted Rate  1.13     1.00     1.05     1.00     1.03

         Female Number             1234     1305     1208     1305     1277
                Rate               1.23     1.29     1.19     1.28     1.24
                Age-adjusted Rate  1.05     1.10     0.99     1.06     1.01

  Black  Male   Number              270      265      244      282      300
                Rate               2.13     2.06     1.87     2.12     2.23
                Age-adjusted Rate  2.96     2.77     2.56     2.88     3.02

         Female Number              391      376      340      341      369
                Rate               2.77     2.62     2.33     2.31     2.46
                Age-adjusted Rate  3.32     3.12     2.76     2.74     2.90

  Total  Total  Number             2915     2855     2765     2866     2931
                Rate               1.28     1.24     1.19     1.22     1.24
                Age-adjusted Rate  1.28     1.24     1.18     1.20     1.21

 Table 7.15  Number of Deaths with Diabetic Ketoacidosis as Any Listed
             Cause and Mortality Rate per 100,000 Population, by Race
             Sex, and Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Number              990      972      989     1013
                Rate               1.00     0.97     0.98     1.00
                Age-adjusted Rate  1.07     1.03     1.03     1.03

         Female Number             1327     1309     1213     1241
                Rate               1.28     1.25     1.15     1.17
                Age-adjusted Rate  1.04     1.01     0.91     0.93

  Black  Male   Number              252      265      269      320

                Rate               1.84     1.91     1.91     2.23
                Age-adjusted Rate  2.55     2.50     2.53     2.85

         Female Number              367      383      363      388
                Rate               2.41     2.48     2.32     2.44
                Age-adjusted Rate  2.82     2.90     2.71     2.81

  Total  Total  Number             2979     2969     2879     3012
                Rate               1.25     1.23     1.18     1.23
                Age-adjusted Rate  1.21     1.19     1.13     1.17

 7.16 Mort. Rate per 100,000 Pop., by Region & Year, U.S., 80-88

 Table 7.16  Number of Deaths With Diabetic Ketoacidosis as Any Listed
             Cause and Mortality Rate per 100,000 Population, by Region
             and Year, United States, 1980-1984

                                                  Year
                                    1980   1981   1982   1983   1984
  Region

  Northeast Number                   716    619    665    652    666
            Rate                    1.46   1.26   1.35   1.32   1.34
            Adjusted Rate (a)       1.39   1.18   1.25   1.22   1.23

  North     Number                   742    721    690    729    698
  Central   Rate                    1.26   1.22   1.17   1.24   1.18
            Adjusted Rate           1.29   1.23   1.16   1.22   1.16

  South     Number                   996   1059    970   1039   1103
            Rate                    1.31   1.37   1.24   1.30   1.37
            Adjusted Rate           1.21   1.27   1.13   1.20   1.24

  West      Number                   461    456    440    446    464
            Rate                    1.06   1.03   0.97   0.97   0.99
            Adjusted Rate           1.26   1.24   1.13   1.10   1.12

 (a) Adjusted for age and race

 Table 7.16  Number of Deaths With Diabetic Ketoacidosis as Any Listed
             Cause and Mortality Rate per 100,000 Population, by Region
             and Year, United States, 1985-1988

                                              Year
                                    1985   1986   1987   1988

  Region

  Northeast Number                   693    682    657    672
            Rate                    1.39   1.36   1.31   1.33
            Adjusted Rate (a)       1.26   1.23   1.17   1.19

  North     Number                   755    739    675    688
  Central   Rate                    1.28   1.25   1.13   1.15
            Adjusted Rate           1.23   1.20   1.09   1.11

  South     Number                  1032   1077   1084   1113
            Rate                    1.26   1.30   1.29   1.31
            Adjusted Rate           1.13   1.17   1.15   1.16

  West      Number                   499    471    463    539
            Rate                    1.04   0.97   0.93   1.06
            Adjusted Rate           1.17   1.10   1.07   1.20

 (a) Adjusted for age and race

 7.17-7.18 Mort. for Diabetic Ketoacidosis as Underlying Cause

 7.17 100,000 Diabetic Population, by Age & Year, U.S., 80-88

 Table 7.17  Mortality Rate for Diabetic Ketoacidosis as Underlying
             Cause per 100,000 Diabetic Population, by Age and Year,
             United States, 1980-1984

                                                Year
                              1980     1981     1982     1983     1984
  Age

  0-44                        31.8     32.5     31.3     33.3     35.4

  45-64                       21.2     20.1     16.9     17.4     17.1

  65-74                       25.8     24.5     25.2     24.4     21.3

  75+                         64.2     58.3     70.8     64.7     50.7

  Total                       30.6     29.4     28.9     28.9     27.1

  Age-adjusted Rate           30.6     29.1     29.6     29.0     26.4

 Table 7.17  Mortality Rate for Diabetic Ketoacidosis as Underlying
             Cause per 100,000 Diabetic Population, by Age and Year,
             United States, 1985-1988

                                           Year
                              1985     1986     1987     1988
  Age

  0-44                        31.9     37.1     27.5     41.8

  45-64                       17.5     13.9     15.8     17.7

  65-74                       19.3     22.4     17.4     20.0

  75+                         53.6     46.3     48.9     52.3

  Total                       26.7     25.6     24.4     28.4

  Age-adjusted Rate           25.9     25.0     23.2     27.7

 7.18 100,000 Diabetic Population, Race, Sex, Year, U.S., 80-88

 Table 7.18  Mortality Rate for Diabetic Ketoacidosis as Underlying
             Cause per 100,000 Diabetic Population, by Race, Sex, and
             Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984
  Race   Sex

  White  Male   Rate               28.0     24.7     27.2     24.3     26.6
                Age-adjusted Rate  29.7     27.0     28.1     24.3     26.5

         Female Rate               26.9     28.7     27.8     29.1     24.1
                Age-adjusted Rate  25.2     26.2     26.9     27.9     22.0

  Black  Male   Rate               52.9     47.0     46.5     53.3     48.8
                Age-adjusted Rate  58.4     53.0     53.4     67.7     55.2

         Female Rate               45.7     40.3     33.3     30.4     32.7
                Age-adjusted Rate  47.3     41.7     36.7     32.0     33.1

  Total  Total  Rate               30.6     29.4     28.9     28.9     27.1
                Age-adjusted Rate  30.6     29.1     29.6     29.0     26.4

 Table 7.18  Mortality Rate for Diabetic Ketoacidosis as Underlying
             Cause per 100,000 Diabetic Population, by Race, Sex, and
             Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988
  Race   Sex

  White  Male   Rate               23.6     21.4     21.7     25.7
                Age-adjusted Rate  23.6     23.5     20.9     24.6

         Female Rate               26.1     25.2     24.3     27.6
                Age-adjusted Rate  23.5     22.5     22.0     25.8

  Black  Male   Rate               35.4     41.8     37.8     45.3
                Age-adjusted Rate  41.1     43.3     39.7     46.2

         Female Rate               33.7     35.1     30.1     35.8
                Age-adjusted Rate  33.5     35.0     28.9     34.2

  Total  Total  Rate               26.7     25.6     24.4     28.4
                Age-adjusted Rate  25.9     25.0     23.2     27.7

 7.19-7.20 Mort. for Diabetic Ketoacidosis as Any Listed Cause

 7.19 100,000 Diabetic Pop., by Age & Year, U.S., 80-88

 Table 7.19  Mortality Rate for Diabetic Ketoacidosis as Any Listed
             Cause per 100,000 Diabetic Population, by Age and Year,
             United States, 1980-1984

                                                Year
                              1980     1981     1982     1983     1984

  Age

  0-44                        40.9     41.1     39.9     41.2     44.5

  45-64                       34.2     33.7     28.2     29.5     29.5

  65-74                       47.2     48.7     45.8     50.0     42.6

  75+                        112.1     99.2    117.0    118.2     95.8

  Total                       50.4     49.2     47.0     49.6     47.3

  Age-adjusted Rate           50.4     48.7     48.1     50.2     45.4

 Table 7.19  Mortality Rate for Diabetic Ketoacidosis as Any Listed
             Cause per 100,000 Diabetic Population, by Age and Year,
             United States, 1985-1988

                                           Year
                              1985     1986     1987     1988

  Age

  0-44                        41.2     46.1     34.6     51.4

  45-64                       30.9     24.4     26.2     30.1

  65-74                       39.7     43.4     37.3     39.0

  75+                         99.7     85.7     92.3     95.5

  Total                       47.1     43.8     42.3     47.4

  Age-adjusted Rate           45.2     42.3     40.4     45.9

 7.20 100,000 Diabetic Pop., by Race, Sex, & Year, U.S., 80-88

 Table 7.20  Mortality Rate for Diabetic Ketoacidosis as Any Listed
             Cause per 100,000 Diabetic Population, by Race, Sex, and
             Year, United States, 1980-1984

                                                     Year
                                   1980     1981     1982     1983     1984

  Race   Sex

  White  Male   Rate               47.3     40.6     45.0     43.6     45.3
                Age-adjusted Rate  49.7     44.4     46.8     44.3     44.8

         Female Rate               45.3     49.6     45.2     50.7     44.4
                Age-adjusted Rate  42.2     45.4     43.6     48.3     39.8

  Black  Male   Rate               77.2     77.8     72.3     80.4     76.2
                Age-adjusted Rate  86.8     89.0     83.8     98.7     86.1

         Female Rate               72.6     64.0     53.5     48.7     55.2
                Age-adjusted Rate  76.9     66.6     58.8     50.9     55.9

  Total  Total  Rate               50.4     49.2     47.0     49.6     47.3
                Age-adjusted Rate  50.4     48.7     48.1     50.2     45.4

 Table 7.20  Mortality Rate for Diabetic Ketoacidosis as Any Listed
             Cause per 100,000 Diabetic Population, by Race, Sex, and
             Year, United States, 1985-1988

                                                Year
                                   1985     1986     1987     1988

  Race   Sex

  White  Male   Rate               43.1     37.9     35.9     42.9
                Age-adjusted Rate  42.9     40.1     35.2     41.8

         Female Rate               45.9     43.4     44.2     47.4
                Age-adjusted Rate  40.9     38.8     39.9     43.2

  Black  Male   Rate               60.3     63.6     61.3     69.0
                Age-adjusted Rate  71.2     66.4     66.9     71.3

         Female Rate               56.4     60.0     53.6     57.6
                Age-adjusted Rate  55.8     59.5     51.9     55.5

  Total  Total  Rate               47.1     43.8     42.3     47.4
                Age-adjusted Rate  45.2     42.3     40.4     45.9


END-STAGE RENAL DISEASE

 Introduction

 End-stage renal disease (ESRD), which requires dialysis or
 transplantation for survival, is a leading complication of diabetes.
 Because Medicare supplies reimbursement for more than 90% of ESRD
 treatment in the United States, its information system is a basis
 for surveillance of ESRD (Eggers et al., 1984).  To examine trends
 in treating ESRD attributed to diabetes (ESRD-DM) in the United States
 during 1980-1986, we evaluate the numbers and rates of ESRD by calendar
 year, age, sex, race, and state of residence.  We present rates based
 on both general and diabetic population denominators.

 Methods

 Data on when ESRD treatment began were provided by the Bureau of
 Data Management and Strategy, Health Care Financing Administration,
 from the ESRD program's management and medical information system,
 which includes demographic information on beneficiaries treated for
 ESRD.  This data set is frequently updated.  Thus, the results in
 our tables differ slightly from those in other reports (U.S. Renal
 Data System, 1989; Eggers, 1988). We use the term "incidence"
 to mean initiation of treatment for ESRD.

 The Chronic Renal Disease Medical Evidence Report, filled out by
 treatment providers, is the source for the "primary diagnosis".  While
 this designation was often missing in earlier years, since 1982 it
 is available for over 90% of cases.

 We used estimates of the resident population of the United States
 as the denominators in calculating general population rates of ESRD-DM.
 We used estimates of the diabetic population from the National Health
 Interview Survey (NHIS) in calculating rates among persons with diabetes
 (Chapter 2).

 We standardized rates according to the direct method.  We used the
 1980 U.S. resident population to standardize general population rates
 and the estimated 1980 U.S. diabetic population to standardize rates
 among persons with diabetes.

 Results

 The number of persons being treated for ESRD-DM increased from 5,955
 in 1980 to 27,919 in 1986 (Table 8.1).  The increase was greater for
 blacks and other races.  During this period, their percentage of the
 total increased from 29.4% to 34.0%.

 The number of incident ESRD-DM cases steadily increased each year
 from 2,202 in 1980 to 8,994 in 1986 (Figure 8.1).  The age-adjusted
 incidence rate of ESRD-DM increased from 9.6 to 36.7 per 1,000,000
 (Table 8.2).  This increase was more prominent among older age groups
 (Figure 8.2).  The rate of increase was similar among different sex
 and race groups (Figure 8.3, Tables 8.3-8.8).

 The 1986 incidence rate of ESRD-DM in the resident population increased
 with age, except for the 75+ group (Table 8.2).  For males, the age-adjusted
 incidence among blacks was 2.9 times and  among other races 3.4 times
 the incidence among whites (Tables 8.3, 8.5, and 8.7).  For females,
 the black and other race rate ratios were 4.3 and 4.4, respectively
 (Tables 8.4, 8.6, and 8.8).  The sex differences varied by race: the
 incidence among white males was 1.2 times that for white females,
 whereas the incidence for black males was 0.8 times that of black
 females.

 Using the estimated diabetic population in the denominator, the
 age-adjusted incidence rate per 100,000 of ESRD-DM increased from 37.9
 in 1980 to 138.0 in 1986 (Table 8.9).  This increase was also more
 prominent in older age groups (Figure 8.4), whereas the rate of increase
 was similar for the different sex and race groups (Figure 8.5 and Tables
 8.10-8.13).  In 1986, compared with white females, the age-adjusted
 incidence ratios were 2.2 for black females, 2.1 for black males,
 and 1.3 for white males.  The largest age-specific male-female ratio
 (2.8) was for whites less than 45 years old.

 We present the state-specific prevalence and incidence of ESRD-DM
 (Tables 8.14-8.15).  We also present the age- and race-standardized
 incidence rates by state and grouped by quartile based on the average
 annual rates for the years 1980-1986 (Figure 8.6).

 Discussion

 There has been a striking increase in treatment for ESRD-DM in the
 United States.  In 1982, the classification of primary etiology of ESRD
 in the Medicare system improved (U.S. Renal Data System, 1989).  From
 1982 through 1986, the proportion of new ESRD treatment attributed
 to diabetes increased from 23.0% to 28.9%.  In this period, the incidence
 of ESRD-DM increased 11.8% per year.

 Rates of ESRD-DM based on general population denominators are influenced
 by diabetes prevalence in the population, disease severity, and treatment
 access and use.  From 1982 to 1986, in the general population, the
 rates of ESRD-DM increased most in older age groups, reflecting both
 the higher prevalence of diabetes with increasing age, as well as
 the more frequent occurrence of complications with increasing age.

 Rates of ESRD-DM calculated using the population of people known to
 have diabetes as the denominator are not affected by prevalence of
 diabetes, but rather are dependent on disease severity and health
 care utilization. From 1982 to 1986, the rates of ESRD-DM per 100,000
 persons with diabetes increased by 67.5%.  The age-specific rates
 of ESRD-DM were highest in the youngest age group (0-44 years old),
 reflecting the higher proportion with insulin-dependent relative to
 non-insulin-dependent diabetes mellitus (NIDDM).  The rates increased
 most, however, in older age groups, suggesting that ESRD related to
 NIDDM is a faster growing public health problem (Centers for Disease
 Control, 1989).

 We noted some differences in ESRD-DM according to race and sex.  When
 calculated using general population denominators, the  incidence of
 ESRD-DM was higher among blacks than among whites. The incidence was
 highest among black females and lowest among white males.  The rates
 for black males were about 3 times those for white males, and the
 rates for black females were about 4 times those for white females.

 When ESRD-DM rates were calculated using diabetic population denominators,
 the rates for black males and females were more than twice those for
 white males and females, respectively.  These results suggest that
 the higher rates of ESRD-DM seen among blacks in the general population
 are not only due to higher prevalence of diabetes among blacks relative
 to whites.  Differences in severity of diabetes and higher prevalence
 of hypertension are potential co-factors that might account for the
 higher rates seen in blacks.

 The large male-female ratio in whites in the less than 45-year age
 group suggests that males are at particular risk for ESRD associated
 with IDDM.

 The methods we used had some limitations that need to be considered
 when interpreting our results.  First, ESRD is defined by treatment
 with dialysis or transplantation.  In two recent population studies,
 approximately 30% of persons with advanced renal failure received
 neither therapy (Humphrey et al., 1989; Nelson et al., 1988).  Regarding
 the observed increase in ESRD-DM, we cannot distinguish increased
 disease incidence from increased availability and use of treatment.
 Renal mortality investigations (Geiss et al., 1985) and additional
 cohort studies may clarify disease incidence trends.

 Second, because Medicare reimburses approximately 90% of treatment
 for ESRD in the United States, its ESRD program incidence slightly
 underestimates the U.S. total.  Third, diabetes as the primary diagnosis
 of ESRD may be imprecisely classified.  In one clinical series, 8%
 of advanced renal disease among persons with diabetes was attributed
 to other etiologies (Balakuntalam et al., 1983). Fourth, the rates
 using the diabetic population were calculated from estimates derived
 from the NHIS and, thus, represent persons with diagnosed diabetes.
 Approximately one-half of persons with diabetes, however, do not know
 they have the disease (Harris et al., 1987).

 Despite these limitations, the Medicare ESRD program provides useful
 indicators of the morbidity and public health burden related to ESRD-DM
 in the United States.  The rapidly increasing number of persons treated
 for ESRD represents growing costs (estimated $4.4 billion in 1987,
 more than $1 billion for ESRD-DM) (U.S. Renal Data System, 1989
 of renal disease and improving blood pressure control in persons with
 diabetes (Herman et al., 1989).  Recent studies of ESRD in Mexican-Americans
 in Texas (Pugh et al., 1988) and Native Americans in the United States
 (Newman et al., in press), have revealed excessive incidence of ESRD-DM
 among these groups compared with the corresponding white populations.  In
 addition to blacks, these populations are appropriate high-risk target
 groups for public health interventions.

 Update

      This section updates data presented in previous sections in light of
 three additional years of Medicare data on end-stage renal disease.  In
 addition, Medicare data on end-stage renal disease for years 1980-1986 have
 been updated in the detailed tables.

      Based on treatment reimbursed by the Medicare program, the number of new
 U.S. cases of end-stage renal disease attributed to diabetes (ESRD-DM)
 increased fivefold during the 1980s, from 2,220 in 1980 to 13,332 in 1989
 (Table 8.2).  Similarly, the age-standardized incidence rate of ESRD-DM among
 persons with diabetes increased from 38.39 to 201.98 per 100,000 diabetic
 population (Table 8.9).  Age differences in incidence rates tended to decrease
 during this decade (Table 8.9).  Rates were higher among blacks than among
 whites (Figure 1.11, Tables 8.10-8.13).  Among both races, males had higher
 rates than females, until 1985, when rates for black females rates began to
 exceed those for black males.

 Detailed Tables

 8.1 Persons Undergoing Treatment for End-stage Renal Disease

 Table 8.1  Number of Persons Undergoing Treatment for End-Stage Renal
            Disease (ESRD) Related to Diabetes, by Race, Sex, and Year,
            United States, 1980-1985

  Race and Sex         1980     1981     1982     1983     1984     1985

  White Males          2361     3189     4423     5649     7074     8567

  White Females        1767     2620     3748     4939     6135     8816

  Black Males           631      915     1275     1725     2148     2777

  Black Females         909     1318     1943     2609     3379     4142

  Other Males            15       41      106      187      268      349

  Other Females          21       57      143      231      312      439

  Total                5704     8140    11638    15340    19316    23699

 Table 8.1  Number of Persons Undergoing Treatment for End-Stage Renal
            Disease (ESRD) Related to Diabetes, by Race, Sex, and Year,
            United States, 1986-1989

  Race and Sex              1986     1987     1988     1989

  White Males              10079    11494    12978    14965

  White Females             8816    10260    11737    13669

  Black Males               3341     3818     4457     5090

  Black Females             4886     5773     6564     7608

  Other Males                436      541      658      787

  Other Females              566      655      816      988

  Total                    28124    32541    37210    43107

 8.2-8.8  Persons Initiating Treatment for ESRD Rel. to Diabetes

 8.2 1,000,000 Pop., Age & Year, U.S., 80-89

 Table 8.2  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            United States, 1980-1985

 Age                      1980    1981    1982    1983    1984    1985


 0-34    Number            415     615     798     824     950    1053
         Rate              3.2     4.6     6.0     6.2     7.1     7.9

 35-44   Number            334     523     673     808     979    1066
         Rate             12.9    19.8    24.0    27.6    32.1    33.6

 45-54   Number            421     653     919    1042    1179    1401
         Rate             18.5    28.9    40.9    46.4    52.4    62.0

 55-64   Number            598    1017    1430    1703    2044    2282
         Rate             27.5    46.3    64.7    76.6    91.7   102.3

 65-74   Number            375     679     903    1169    1456    1779
         Rate             24.0    42.7    55.8    70.9    87.0   104.6

 75+     Number             77      96     200     250     360     479
         Rate              7.7     9.3    18.8    22.9    32.1    41.6

 Total   Number           2220    3583    4923    5796    6968    8060
         Rate              9.8    15.6    21.2    24.7    29.5    33.8
         Age-adjusted Rate 9.8    15.6    21.2    24.6    29.2    33.4

 Table 8.2  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            United States, 1986-1989

 Age                       1986    1987    1988    1989


 0-34    Number            1080    1077    1018    1204
         Rate               8.1     8.0     7.6     9.0

 35-44   Number            1199    1233    1316    1499
         Rate              36.3    35.9    37.3    41.1

 45-54   Number            1553    1683    1897    2245
         Rate              68.1    72.3    78.5    90.2

 55-64   Number            2527    2859    3142    3593
         Rate             113.8   129.9   144.1   166.4

 65-74   Number            2221    2512    2975    3619
         Rate             128.2   142.2   166.3   199.1

 75+     Number             576     745     832    1172
         Rate              48.7    61.3    66.8    91.6

 Total   Number            9156   10109   11180   13332
         Rate              38.0    41.5    45.5    53.7
         Age-adjusted Rate 37.5    40.9    44.7    52.6

 8.3 1,000,000 Pop., Age & Year, U.S., 80-89, White Males

 Table 8.3  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            White Males, United States, 1980-1985

 Age                         1980    1981    1982    1983    1984    1985

 0-34    Number               195     285     391     375     458     477
         Rate                 3.5     5.1     7.0     6.7     8.2     8.5

 35-44   Number               176     264     339     389     501     518
         Rate                15.9    23.3    28.1    30.9    38.2    38.0

 45-54   Number               166     257     308     351     433     497
         Rate                17.0    26.6    32.1    36.7    45.3    51.9

 55-64   Number               184     253     412     516     622     703
         Rate                20.1    27.4    44.4    55.4    66.5    75.2

 65-74   Number               118     182     287     327     417     538
         Rate                19.3    29.2    45.1    50.4    63.2    80.0

 75+     Number                25      28      53      84     115     135
         Rate                 7.7     8.4    15.6    24.1    32.1    36.8

 Total   Number               864    1269    1790    2042    2546    2868
         Rate                 9.1    13.2    18.5    20.9    25.9    29.0
         Age-adjusted Rate    9.1    13.2    18.5    20.9    25.7    28.8

 Table 8.3  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            White Males, United States, 1986-1989

 Age                         1986    1987    1988    1989

 0-34    Number               523     503     471     565
         Rate                 9.3     9.0     8.4    10.1

 35-44   Number               564     602     631     691
         Rate                39.8    41.0    41.9    44.4

 45-54   Number               540     568     672     800
         Rate                55.9    57.7    65.6    75.8

 55-64   Number               788     871     937    1088
         Rate                84.9    95.0   103.2   121.2

 65-74   Number               657     719     868    1137
         Rate                95.5   102.3   121.9   156.8

 75+     Number               178     226     268     352
         Rate                47.3    58.4    67.4    85.9

 Total   Number              3250    3489    3847    4633
         Rate                32.6    34.7    37.9    45.3
         Age-adjusted Rate   32.3    34.3    37.4    44.7

 8.4 1,000,000 Pop., Age & Year, U.S., 80-89, White Females

 Table 8.4  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            White Females, United States, 1980-1985

 Age                       1980    1981    1982    1983    1984    1985


 0-34     Number            151     235     290     323     351     408
          Rate              2.8     4.3     5.3     5.9     6.5     7.5

 35-44    Number             97     163     194     247     261     292
          Rate              8.6    14.1    15.8    19.3    19.6    21.2

 45-54    Number             99     173     282     287     318     368
          Rate              9.7    17.1    28.1    28.8    31.9    36.9

 55-64    Number            178     354     468     547     681     696
          Rate             17.2    34.0    44.8    52.3    65.1    66.7

 65-74    Number            112     224     327     444     522     631
          Rate             14.0    27.7    39.8    53.3    61.9    74.0

 75+      Number             29      33      61      87     123     193
          Rate              4.9     5.4     9.7    13.4    18.5    28.3

 Total    Number            666    1182    1622    1935    2256    2588
          Rate              6.7    11.7    16.0    18.9    21.9    24.9
          Age-adjusted Rate 6.4    11.2    15.2    17.8    20.5    23.2

 Table 8.4  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            White Females, United States, 1986-1989

 Age                          1986    1987    1988    1989


 0-34     Number               393     397     362     435
          Rate                 7.3     7.3     6.7     8.1

 35-44    Number               377     367     372     417
          Rate                26.4    24.8    24.6    26.7

 45-54    Number               427     437     498     568
          Rate                42.6    42.8    47.0    52.0

 55-64    Number               804     881    1014    1160
          Rate                77.8    86.4   100.9   117.2

 65-74    Number               811     936    1132    1358
          Rate                93.7   106.5   127.7   151.4

 75+      Number               194     309     323     459
          Rate                27.8    43.1    44.1    61.2

 Total    Number              3006    3327    3701    4397
          Rate                28.8    31.6    34.9    41.2
          Age-adjusted Rate   26.6    28.9    31.8    37.3

 8.5 1,000,000 Pop., Age & Year, U.S., 80-89, Black Males

 Table 8.5  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Black Males, United States, 1980-1985

 Age                         1980    1981    1982    1983    1984    1985

 0-34     Number               31      46      47      54      72      85
          Rate                3.6     5.2     5.3     6.0     7.9     9.2

 35-44    Number               28      47      68      86      93     121
          Rate               22.5    37.1    51.3    62.3    64.3    80.0

 45-54    Number               56      86     118     162     165     227
          Rate               54.5    83.3   113.7   154.4   155.3   210.9

 55-64    Number               70     122     173     185     217     283
          Rate               81.5   139.3   193.5   203.0   234.2   301.2

 65-74    Number               35      76      80     120     143     175
          Rate               61.4   131.3   136.0   200.7   235.2   282.0

 75+      Number                3      11      27      18      33      47
          Rate               10.6    37.9    90.5    58.8   105.1   146.9

 Total    Number              223     388     513     625     723     938
          Rate               17.6    30.1    39.2    47.1    53.7    68.6
          Age-adjusted Rate  22.6    39.6    52.1    61.8    70.7    90.3

 Table 8.5  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Black Males, United States, 1986-1989

 Age                         1986    1987    1988    1989


 0-34     Number               68      72      83      90
          Rate                7.3     7.7     8.8     9.4

 35-44    Number              125     123     157     167
          Rate               78.5    74.1    90.5    91.9

 45-54    Number              234     265     281     350
          Rate              214.3   237.4   245.5   299.2

 55-64    Number              307     326     404     441
          Rate              322.8   339.4   417.1   452.5

 65-74    Number              211     220     265     291
          Rate              333.5   340.5   401.4   430.7

 75+      Number               42      47      63      85
          Rate              128.4   140.4   184.8   243.2

 Total    Number              987    1053    1253    1424
          Rate               71.0    74.6    87.5    97.9
          Age-adjusted Rate  94.2    98.8   115.7   129.6

 8.6 1,000,000 Pop., Age & Year, U.S., 80-89, Black Females

 Table 8.6  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Black Females, United States, 1980-1985

 Age                        1980    1981    1982    1983    1984    1985

 0-34     Number              13      29      58      61      57      64
          Rate               1.4     3.2     6.2     6.5     6.0     6.7

 35-44    Number              21      36      54      71      97     103
          Rate              14.0    23.6    33.8    42.7    55.8    56.7

 45-54    Number              72     106     164     188     223     229
          Rate              57.2    83.6   128.5   145.6   170.6   172.7

 55-64    Number             128     218     311     368     428     501
          Rate             120.2   201.4   282.6   329.4   378.3   437.7

 65-74    Number              71     141     182     227     324     346
          Rate              91.0   177.4   225.3   276.7   389.4   409.9

 75+      Number              13      15      52      51      72      75
          Rate              27.6    30.8   102.9    97.7   133.3   134.8

 Total    Number             318     545     821     966    1201    1318
          Rate              22.5    38.0    56.3    65.3    80.1    86.7
          Age-adjusted Rate 27.1    45.7    67.4    78.1    95.8   103.7

 Table 8.6  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Black Females, United States, 1986-1989

 Age                         1986    1987    1988    1989

 0-34     Number               75      79      81      92
          Rate                7.8     8.2     8.3     9.4

 35-44    Number               94     116     109     159
          Rate               49.3    58.2    52.5    73.3

 45-54    Number              260     321     328     396
          Rate              192.9   233.5   232.3   273.5

 55-64    Number              512     623     599     692
          Rate              442.6   535.1   511.8   589.1

 65-74    Number              431     498     568     651
          Rate              502.5   571.5   641.5   722.9

 75+      Number              126     128     127     211
          Rate              218.9   215.8   207.8   335.7

 Total    Number             1498    1765    1812    2201
          Rate               97.1   112.8   114.1   136.6
          Age-adjusted Rate 116.1   134.9   136.4   162.2

 8.7 1,000,000 Pop., Age & Year,U.S.,80-89, Non-Black/White Males

 Table 8.7  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Other than White or Black Males, United States, 1980-1985

 Age                        1980    1981    1982    1983    1984    1985

 0-34     Number               1       5       3       3       4       8
          Rate               0.6     2.7     1.5     1.4     1.8     3.5

 35-44    Number               1       3      11       5      16      14
          Rate               3.0     8.4    28.3    12.0    35.6    29.1

 45-54    Number               0       2      23      27      23      39
          Rate               0.0     8.7    93.3   103.3    82.2   130.3

 55-64    Number               3      10      17      36      36      36
          Rate              20.0    62.2    98.8   197.7   186.1   177.2

 65-74    Number               1       6       9      22      16      29
          Rate              10.5    59.7    82.9   193.9   132.6   227.0

 75+      Number               0       0       4       6       9      13
          Rate               0.0     0.0    72.9   100.2   140.3   182.3

 Total    Number               6      26      67      99     104     139
          Rate               2.3     9.4    22.6    31.7    31.6    40.0
          Age-adjusted Rate  3.3    13.4    31.8    49.2    46.5    59.0

 Table 8.7  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Other than White or Black Males, United States, 1986-1989

 Age                          1986    1987    1988    1989

 0-34     Number                10       7       7       4
          Rate                 4.2     2.8     2.7     1.5

 35-44    Number                18      16      25      33
          Rate                34.6    28.7    42.0    51.8

 45-54    Number                38      43      55      71
          Rate               118.2   125.8   150.4   181.6

 55-64    Number                39      54      70      70
          Rate               181.4   240.7   297.7   284.9

 65-74    Number                29      49      51      56
          Rate               210.7   331.6   319.4   332.0

 75+      Number                15      11      21      27
          Rate               196.5   135.1   234.9   288.1

 Total    Number               149     180     229     261
          Rate                40.7    46.9    56.9    62.0
          Age-adjusted Rate   58.8    69.3    82.3    87.8

 8.8 1,000,000 Pop., Age/Year,U.S.,80-89, Non-White/Black Females

 Table 8.8  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Other than White or Black Females, United States, 1980-1985

 Age                        1980    1981    1982    1983    1984    1985

 0-34     Number               3       4       7       6       7       5
          Rate               1.7     2.1     3.5     2.9     3.2     2.2

 35-44    Number               2       2       7       8      10      14
          Rate               5.6     5.2    16.6    17.5    20.1    26.0

 45-54    Number               6       8      19      23      12      35
          Rate              23.8    30.0    67.6    77.7    38.6   106.1

 55-64    Number               1      15      41      40      55      50
          Rate               5.8    79.9   200.9   180.9   231.5   196.6

 65-74    Number               0       6      11      24      29      53
          Rate               0.0    54.3    89.8   181.0   202.9   341.8

 75+      Number               0       1       2       3       6      16
          Rate               0.0    15.7    29.1    39.7    73.4   176.2

 Total    Number              12      36      87     104     119     173
          Rate               4.5    12.5    28.3    32.0    34.7    47.8
          Age-adjusted Rate  4.6    16.9    37.4    43.0    47.4    65.0

 Table 8.8  Number of Persons Initiating Treatment for ESRD Related to
            Diabetes and Rate per 1,000,000 Population, by Age and Year,
            Other than White or Black Females, United States, 1986-1989

 Age                           1986    1987    1988    1989

 0-34     Number                  5       7      12      11
          Rate                  2.1     2.9     4.8     4.2

 35-44    Number                 14       5      16      21
          Rate                 24.1     8.1    24.2    29.8

 45-54    Number                 42      37      48      47
          Rate                119.8    99.4   120.6   110.4

 55-64    Number                 60      77      91     112
          Rate                221.1   266.6   298.7   353.7

 65-74    Number                 64      63      77      95
          Rate                376.6   344.0   387.0   444.6

 75+      Number                 15      19      24      32
          Rate                153.4   177.8   203.6   246.9

 Total    Number                200     208     268     318
          Rate                 52.4    51.9    63.7    72.2
          Age-adjusted Rate    69.8    69.6    81.8    92.3

 8.9-8.13 Rate Initiation of Treatment for ESRD Rel. to Diabetes

 8.9 100,000 Diabetic Pop., Age & Year, U.S., 80-89

 Table 8.9  Rate of Initiation of Treatment for ESRD Related to Diabetes
            per 100,000 Diabetic Population, by Age and Year, United
            States, 1980-1985

 Age                1980     1981     1982     1983     1984     1985

 0-44               74.19   119.52   149.51   162.83   193.99   204.13

 45-64              42.64    65.64    91.52   105.61   136.64   158.08

 65-74              24.63    49.75    59.20    89.57    82.88    96.11

 75+                 8.94    10.13    24.68    28.60    33.02    43.52

 Total              38.39    61.68    83.63   100.26   112.39   127.54

 Age-adjusted Rate  38.39    62.60    83.18    99.91   117.07   132.74

 Table 8.9  Rate of Initiation of Treatment for ESRD Related to Diabetes
            per 100,000 Diabetic Population, by Age and Year, United
            States, 1980-1989

 Age                 1986     1987     1988     1989


 0-44               217.68   169.37   213.73   220.91

 45-64              143.29   178.01   204.83   215.65

 65-74              139.41   147.53   174.59   221.76

 75+                 44.85    62.42    76.05   106.90

 Total              135.21   148.41   176.06   200.21

 Age-adjusted Rate  140.59   151.26   179.24   201.98

 8.10 100,000 Diabetic Pop., Age & Year, U.S., 80-89, White Males

 Table 8.10  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, White
             Males, United States, 1980-1985

 Age                1980     1981     1982     1983     1984     1985

 0-44              119.23   148.75   189.92   187.26   271.14   253.87

 45-64              38.15    50.14    73.69    94.22   129.69   137.41

 65-74              19.84    32.90    66.79    78.50    70.48    79.22

 75+                 9.78    12.27    17.62    25.59    35.50    38.53

 Total              41.56    58.54    85.56    98.51   122.24   124.98

 Age-adjusted Rate  43.26    57.18    83.81    96.10   124.77   127.69

 Table 8.10  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, White
             Males, United States, 1986-1989

 Age                    1986     1987     1988     1989

 0-44                  360.98   191.02   227.77   302.37

 45-64                 107.38   136.72   171.85   174.78

 65-74                 105.12   101.98   155.69   212.40

 75+                    43.95    53.81    69.47   136.78

 Total                 126.56   126.60   162.77   202.47

 Age-adjusted Rate     141.61   124.71   162.11   201.30

 8.11 100,000 Diabetic Pop., Age/Year, U.S., 80-89, White Females

 Table 8.11  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, White
             Females, United States, 1980-1985

 Age                1980     1981     1982     1983     1984     1985

 0-44              52.12    94.78   101.88   141.23   139.51   139.87

 45-64             28.27    52.83    76.09    77.16    95.61   116.50

 65-74             14.95    36.31    41.68    70.52    65.05    71.27

 75+                5.59     5.54    14.35    18.99    20.75    32.51

 Total             24.45    44.95    60.74    75.23    78.37    89.46

 Age-adjusted Rate 25.55    48.76    62.34    77.93    84.08    96.16

 Table 8.11  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, White
             Females, United States, 1980-1985

 Age                      1986     1987     1988     1989

 0-44                    130.35   149.50   206.39   155.64

 45-64                   114.95   137.99   163.84   165.42

 65-74                   119.86   125.71   136.85   169.58

 75+                      28.49    57.72    63.09    71.25

 Total                    99.56   121.15   141.39   144.78

 Age-adjusted Rate       106.05   124.81   149.16   150.78

 8.12 100,000 Diabetic Pop., Age & Year, U.S., 80-89, Black Males

 Table 8.12  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, Black
             Males, United States, 1980-1984

 Age                 1980     1981     1982     1983     1984     1985

 0-44                80.83   144.48   186.39   381.41   298.90   327.95

 45-64               67.71   112.15   161.66   169.88   177.36    229.66

 65-74               56.86   112.38   113.26   140.68   162.13    177.13

 75+                 10.23    47.76   108.10    73.71    94.12    136.85

 Total               63.72   113.95   152.08   178.22   183.58    224.39

 Age-adjusted Rate   58.58   108.26   145.26   184.80   182.17    219.17

 Table 8.12  Rate of Initiation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, Black
             Males, United States, 1980-1989

 Age                 1986     1987     1988     1989

 0-44              232.59   214.71   298.11   311.56

 45-64             265.43   281.95   277.53   286.57

 65-74             232.76   212.11   312.04   335.94

 75+               107.41   134.40   122.52   156.68

 Total             236.95   239.79   270.23   285.15

 Age-adjusted Rate 227.56   229.85   267.12   284.58

 8.13 100,000 Diabetic Pop., Age/Year, U.S., 80-89, Black Females

 Table 8.13  Rate of Invitation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, Black
             Females, United States, 1980-1989

 Age                  1980     1981     1982     1983     1984     1985

 0-44                30.33    67.20   130.55   113.75   141.39   182.83

 45-64               79.53   114.19   147.37   184.77   231.30   282.07

 65-74               68.65   102.96   113.82   113.57   173.88   189.22

 75+                 18.26    21.29    76.70    61.01    78.13    63.71

 Total               59.09    92.71   129.13   137.92   179.56   202.54

 Age-adjusted Rate   58.95    89.20   125.08   135.19   177.67   207.78

 Table 8.13  Rate of Invitation of Treatment for ESRD Related to Diabetes
             per 100,000 Diabetic Population, by Age and Year, Black
             Females, United States, 1980-1989

 Age                 1986     1987     1988     1989

 0-44               193.93   179.03   140.70   191.17

 45-64              275.29   337.51   381.03   481.14

 65-74              299.53   349.52   367.44   369.56

 75+                 99.65    87.31    90.33   156.38

 Total              234.83   260.44   269.04   329.24

 Age-adjusted Rate  241.31   275.74   292.20   352.77

 8.14 Undergoing Treatment for ESRD, State of Residence & Year

 Table 8.14  Number of People Undergoing Treatment for End-stage Renal
             Disease Related to Diabetes, by State of Residence and Year,
             1980-1985

                     1980     1981     1982     1983     1984     1985

   Alabama             74       93      127      187      258      316
   Alaska               4        4        6        8       13       15
   Arizona            123      144      198      280      354      417
   Arkansas            21       37       59       91      132      165
   California         506      875     1315     1791     2243     2805
   Colorado            67       76      101      149      187      233
   Connecticut        115      149      190      239      306      389
   Delaware            20       25       36       37       47       65
   Dist of Columbia    43       61       89      109      140      194
   Florida            188      360      557      737      947     1165

   Georgia            168      268      379      464      569      695
   Hawaii              74       95      108      109      106      137
   Idaho               16       19       30       43       51       55
   Illinois           327      458      623      799      952     1180
   Indiana            144      205      249      344      406      473
   Iowa                59       92      127      174      215      273
   Kansas              60       83      120      153      193      225
   Kentucky            70       96      135      184      249      296
   Louisian            84      127      182      227      310      389
   Maine               17       24       36       48       55       73

   Maryland            92      153      219      280      368      482
   Massachusetts      199      250      306      357      402      442
   Michigan           200      310      439      595      726      891
   Minnesota          144      197      267      342      429      496
   Mississippi         47       75      109      139      194      244
   Missouri            60      125      218      288      372      479
   Montana             16       25       27       35       53       65
   Nebraska            55       78       91      113      127      137
   Nevada              12       18       33       41       50       60
   New Hampshire       16       21       29       39       49       57

   New Jersey         233      325      452      615      738      869
   New Mexico          23       32       62      104      138      154
   New York           455      636      901     1140     1397     1635
   North Carolina     171      218      301      393      486      641
   North Dakota        20       21       26       41       55       57
   Ohio               378      496      645      800      953     1158
   Oklahoma            67       89      135      182      237      275
   Oregon              35       55      102      150      170      219
   Pennsylvania       457      535      672      832     1085     1288

   Rhode Island        20       32       36       44       55       70
   South Carolina      93      132      186      244      322      437
   South Dakota        14       27       35       44       62       81
   Tennessee           66      101      159      237      305      359
   Texas              415      601      892     1159     1447     1802
   Utah                55       72       83      106      157      186
   Vermont             13       20       34       31       36       46
   Virginia           156      201      289      396      521      660
   Washington         107      121      155      194      266      362
   West Virginia       42       56       78      119      144      170
   Wisconsin          196      226      300      360      446      499
   Wyoming              7       11       19       21       26       35

 Table 8.14  Number of People Undergoing Treatment for End-stage Renal
             Disease Related to Diabetes, by State of Residence and Year,
             1986-1989

                             1986     1987     1988     1989

   Alabama                    383      488      542      683
   Alaska                      20       26       29       39
   Arizona                    526      606      725      855
   Arkansas                   200      238      293      341
   California                3422     3836     4241     5056
   Colorado                   326      388      441      512
   Connecticut                430      491      512      571
   Delaware                    81       97      131      163
   Dist of Columbia           205      208      220      231
   Florida                   1440     1752     1945     2129

   Georgia                    818      970     1076     1256
   Hawaii                     178      246      293      330
   Idaho                       75       91      115      132
   Illinois                  1408     1598     1762     1953
   Indiana                    515      644      753      814
   Iowa                       318      336      369      427
   Kansas                     236      252      307      340
   Kentucky                   354      416      461      518
   Louisiana                  482      570      717      883
   Maine                       79      105      116      129

   Maryland                   544      623      693      839
   Massachusetts              507      551      604      726
   Michigan                  1086     1204     1378     1640
   Minnesota                  582      678      748      839
   Mississippi                278      319      396      475
   Missouri                   549      634      741      861
   Montana                     75       90      110      144
   Nebraska                   160      182      211      264
   Nevada                      84      113      122      157
   New Hampshire               68       89      101      128

   New Jersey                1029     1111     1222     1356
   New Mexico                 195      226      293      347
   New York                  1969     2257     2597     2907
   North Carolina             751      905     1012     1196
   North Dakota                70       88      103      132
   Ohio                      1365     1593     1841     2022
   Oklahoma                   346      402      516      591
   Oregon                     267      335      379      432
   Pennsylvania              1515     1756     2005     2254
   Rhode Island                72       96      116      136

   South Carolina             509      579      661      768
   South Dakota                89      105      128      136
   Tennessee                  436      527      612      751
   Texas                     2079     2450     2936     3568
   Utah                       220      242      277      303
   Vermont                     55       60       65       76
   Virginia                   732      808      919     1061
   Washington                 413      475      577      691
   West Virginia              206      244      280      311
   Wisconsin                  582      671      772      915
   Wyoming                     37       46       47       58

 8.15 Initiating Treatment for ESRD, State of Residence & Year

 Table 8.15  Number of Persons Initiating Treatment for End-stage Renal
             Disease Related to Diabetes and Rate per 100,000 Population,
             by State of Residence and Year, 1980-1983

 State                   1980         1981         1982         1983

                      No.   Rate   No.   Rate   No.   Rate   No.   Rate

 Alabama               23   0.59    38   0.97    59   1.50    85   2.14
 Alaska                 2   0.49     0   0.00     4   0.90     2   0.41
 Arizona               46   1.68    41   1.46    83   2.88   114   3.86
 Arkansas               6   0.26    21   0.91    28   1.21    46   1.98
 California           188   0.79   446   1.84   588   2.37   707   2.79
 Colorado              24   0.83    25   0.84    41   1.33    65   2.06
 Connecticut           26   0.84    61   1.95    62   1.98    94   2.99
 Delaware               7   1.18    12   2.01    14   2.33    10   1.65
 Dist of Columbia      11   1.72    23   3.63    43   6.86    38   6.09
 Florida               94   0.95   189   1.85   250   2.39   279   2.59

 Georgia               46   0.84   127   2.28   149   2.64   149   2.60
 Hawaii                23   2.35    36   3.67    32   3.21    31   3.04
 Idaho                  8   0.84     9   0.93    15   1.53    21   2.12
 Illinois             136   1.19   185   1.61   253   2.20   288   2.51
 Indiana               43   0.78    78   1.42    77   1.40   132   2.41
 Iowa                  26   0.89    48   1.64    50   1.72    69   2.38
 Kansas                19   0.80    32   1.34    52   2.16    50   2.06
 Kentucky              36   0.98    45   1.22    50   1.35    76   2.05
 Louisiana             32   0.76    57   1.33    76   1.73    72   1.62
 Maine                  7   0.62    11   0.97    15   1.32    17   1.48

 Maryland              33   0.78    74   1.74    93   2.18   113   2.63
 Massachusetts         61   1.06    78   1.36   101   1.76   104   1.81
 Michigan              71   0.77   149   1.62   181   1.98   233   2.57
 Minnesota             29   0.71    63   1.53    82   1.98   111   2.68
 Mississippi           23   0.91    34   1.34    44   1.71    46   1.78
 Missouri              16   0.33    72   1.46   116   2.35   101   2.03
 Montana                4   0.51    14   1.76     4   0.50    12   1.47
 Nebraska              14   0.89    32   2.02    27   1.70    35   2.19
 Nevada                 3   0.37     9   1.06    15   1.71    14   1.56
 New Hampshire          6   0.65     8   0.85    10   1.05    14   1.46

 New Jersey            87   1.18   133   1.80   200   2.69   233   3.12
 New Mexico            10   0.76    13   0.97    36   2.63    51   3.64
 New York             189   1.08   273   1.55   382   2.17   434   2.46
 North Carolina        68   1.15    79   1.33   123   2.04   147   2.42
 North Dakota           4   0.61     5   0.76     7   1.04    15   2.20
 Ohio                 143   1.32   198   1.83   254   2.36   278   2.59
 Oklahoma              26   0.85    39   1.25    64   1.98    77   2.32
 Oregon                18   0.68    24   0.90    55   2.06    57   2.14
 Pennsylvania         176   1.48   184   1.55   253   2.13   305   2.56
 Rhode Island           9   0.95    13   1.37    13   1.36    15   1.57

 South Carolina        42   1.34    52   1.63    76   2.36    88   2.70
 South Dakota           1   0.14    15   2.17     9   1.30    18   2.58
 Tennessee             33   0.72    45   0.97    74   1.59    93   1.98
 Texas                131   0.91   252   1.71   388   2.52   414   2.62
 Utah                  31   2.11    32   2.11    26   1.67    41   2.57
 Vermont                5   0.98     7   1.36    15   2.88     4   0.76
 Virginia              59   1.10    73   1.34   120   2.19   167   3.00
 Washington            44   1.06    39   0.92    58   1.36    71   1.65
 West Virginia         19   0.97    22   1.12    33   1.68    54   2.75
 Wisconsin             61   1.30    63   1.33   113   2.38   101   2.13
 Wyoming                1   0.21     5   1.01    10   1.96     5   0.97

 Table 8.15  Number of Persons Initiating Treatment for End-stage Renal
             Disease Related to Diabetes and Rate per 100,000 Population,
             by State of Residence and Year, 1984-1986

 State                 1984         1985         1986

                     No.   Rate   No.   Rate   No.   Rate

 Alabama             100   2.50   110   2.74   131   3.23
 Alaska                6   1.19     3   0.57    11   2.07
 Arizona             122   4.01   135   4.28   182   5.55
 Arkansas             61   2.60    63   2.67    71   3.00
 California          790   3.06  1010   3.83  1164   4.31
 Colorado             70   2.19    79   2.44   128   3.92
 Connecticut         106   3.36   150   4.73   130   4.07
 Delaware             18   2.93    24   3.86    30   4.74
 Dist of Columbia     46   7.37    70  11.23    53   8.48
 Florida             348   3.15   409   3.60   539   4.61

 Georgia             189   3.23   216   3.62   256   4.20
 Hawaii               27   2.61    57   5.42    75   7.04
 Idaho                18   1.80    16   1.59    28   2.79
 Illinois            329   2.86   433   3.75   458   3.97
 Indiana             126   2.29   150   2.73   153   2.78
 Iowa                 65   2.24    86   2.98   101   3.54
 Kansas               67   2.74    64   2.61    51   2.07
 Kentucky            107   2.87    95   2.55   112   3.01
 Louisiana           132   2.96   120   2.68   175   3.89
 Maine                20   1.73    23   1.97    25   2.13

 Maryland            136   3.13   179   4.07   160   3.59
 Massachusetts       113   1.95   118   2.03   154   2.64
 Michigan            268   2.96   306   3.37   371   4.06
 Minnesota           134   3.22   128   3.05   147   3.49
 Mississippi          74   2.85    80   3.06    86   3.28
 Missouri            135   2.70   172   3.42   166   3.28
 Montana              19   2.31    20   2.42    19   2.33
 Nebraska             33   2.06    39   2.43    45   2.82
 Nevada               18   1.96    23   2.46    35   3.62
 New Hampshire        15   1.53    21   2.10    18   1.75

 New Jersey          249   3.32   303   4.01   345   4.52
 New Mexico           46   3.22    45   3.10    74   5.00
 New York            509   2.87   517   2.91   666   3.74
 North Carolina      173   2.80   232   3.70   228   3.60
 North Dakota         17   2.48    11   1.61    22   3.24
 Ohio                337   3.14   388   3.61   437   4.07
 Oklahoma             89   2.69    95   2.87   126   3.81
 Oregon               51   1.91    74   2.76    84   3.11
 Pennsylvania        424   3.57   425   3.58   504   4.24
 Rhode Island         20   2.08    23   2.38    20   2.05

 South Carolina      123   3.73   163   4.89   151   4.47
 South Dakota         23   3.26    31   4.38    21   2.97
 Tennessee           112   2.37   119   2.50   135   2.81
 Texas               529   3.29   609   3.72   638   3.82
 Utah                 60   3.69    50   3.04    61   3.67
 Vermont              10   1.89    16   2.99    11   2.03
 Virginia            202   3.58   233   4.09   197   3.40
 Washington           98   2.25   134   3.04   110   2.46
 West Virginia        55   2.82    55   2.84    83   4.33
 Wisconsin           141   2.96   123   2.58   162   3.39
 Wyoming               8   1.56    15   2.94     7   1.38

 Table 8.15  Number of Persons Initiating Treatment for End-stage Renal
             Disease Related to Diabetes and Rate per 100,000 Population,
             by State of Residence and Year, 1987-1989

 State                  1987         1988         1989

                     No.   Rate   No.   Rate   No.   Rate

 Alabama              169   4.14   167   4.05   234   5.68
 Alaska                 9   1.71     8   1.48    17   3.22
 Arizona              184   5.43   222   6.31   271   7.62
 Arkansas             104   4.35   100   4.16   115   4.78
 California          1190   4.30  1239   4.39  1696   5.83
 Colorado             117   3.55   131   3.92   159   4.79
 Connecticut          149   4.64   125   3.86   166   5.13
 Delaware              29   4.50    44   6.75    53   7.88
 Dist of Columbia      42   6.75    42   6.78    59   9.76
 Florida              584   4.86   575   4.68   605   4.78

 Georgia              308   4.95   290   4.55   390   6.06
 Hawaii               103   9.52    97   8.81    98   8.79
 Idaho                 31   3.11    36   3.58    44   4.34
 Illinois             490   4.23   496   4.27   548   4.70
 Indiana              224   4.05   238   4.29   219   3.92
 Iowa                  72   2.54    98   3.49   124   4.37
 Kansas                76   3.07    90   3.62   100   3.98
 Kentucky             140   3.76   134   3.59   142   3.81
 Louisiana            187   4.19   247   5.51   317   7.23
 Maine                 39   3.29    29   2.42    33   2.70

 Maryland             192   4.23   195   4.24   270   5.75
 Massachusetts        146   2.49   161   2.74   245   4.14
 Michigan             345   3.75   444   4.80   548   5.91
 Minnesota            182   4.29   170   3.98   198   4.55
 Mississippi           98   3.73   125   4.72   147   5.61
 Missouri             207   4.06   222   4.32   263   5.10
 Montana               26   3.21    29   3.59    49   6.08
 Nebraska              52   3.26    64   4.02    83   5.15
 Nevada                43   4.27    38   3.69    55   4.95
 New Hampshire         30   2.84    29   2.67    39   3.52

 New Jersey           338   4.41   394   5.09   425   5.49
 New Mexico            64   4.27   115   7.46   102   6.67
 New York             688   3.86   811   4.55   866   4.82
 North Carolina       295   4.60   285   4.38   383   5.83
 North Dakota          26   3.87    32   4.78    47   7.12
 Ohio                 496   4.60   540   5.00   550   5.04
 Oklahoma             129   3.94   193   5.89   179   5.55
 Oregon               105   3.86   107   3.91   126   4.47
 Pennsylvania         536   4.49   581   4.87   659   5.47
 Rhode Island          39   3.96    45   4.56    42   4.21

 South Carolina       180   5.26   192   5.54   241   6.86
 South Dakota          34   4.79    39   5.49    28   3.92
 Tennessee            178   3.67   189   3.86   254   5.14
 Texas                756   4.50   930   5.44  1169   6.88
 Utah                  61   3.63    71   4.15    62   3.63
 Vermont               15   2.74    15   2.71    22   3.88
 Virginia             209   3.54   272   4.54   315   5.17
 Washington           124   2.73   179   3.90   213   4.47
 West Virginia         75   3.95    88   4.67    90   4.85
 Wisconsin            179   3.72   206   4.28   253   5.20
 Wyoming               14   2.86    11   2.23    19   4.00
DISABILITY

 Introduction

 Disability, an important component of the morbidity associated
 with diabetes, reflects the inability of persons to perform their
 social roles and to function independently.  The disruption of social
 functioning caused by disability has profound social and economic
 costs for both society and the afflicted individuals.  Measuring
 disability among people with diabetes provides another means of
 assessing the health burden of the disease.

 In this chapter, we present data on the prevalence of disability among
 non-institutionalized persons with diagnosed diabetes.  Using National
 Health Interview Survey (NHIS) data, we examine trends from 1983 through
 1989, and where possible, we present data categorized by age, race, and
 sex.  Data for the non-institutionalized population of the U.S. have
 been published in Current Estimates from the National Health Interview
 Survey, a series of publications of the National Center for Health
 Statistics (Vital and Health Statistics, Series 13).

 Methods

 Disability indicators were derived from the 1983-1989 NHIS.  (See
 Chapter 2, Prevalence and Incidence, for a description of NHIS
 methodology.)  In 1982, the core of the NHIS interview underwent
 substantial changes in the measurement of several health-related
 variables, including changes in disability indicators. Since disability
 indicator data prior to these changes are not comparable to data
 collected after these changes, the present analysis begins with 1983
 NHIS data. Although the NHIS provides a stable source of annual
 estimates of disability, it does not sample the institutionalized U.S.
 population, which accounts for a significant proportion of all
 disability.  Therefore, estimates of disability derived from NHIS
 underestimate the total amount of disability.

 This chapter analyzes four disability indicators used in the NHIS:
 activity limitation, work limitation, need for assistance in personal
 care and other routine activities, and activity restriction.  These
 indicators are defined below.  For the analyses of the first three
 indicators, we pooled three years of data to develop more precise
 estimates.  These estimates were obtained by calculating three-year
 moving averages among the one-sixth subsamples asked about diabetes.
 For analyses of activity restriction, we also pooled three years of data
 to develop more precise estimates, but used the full rather than the
 one- sixth samples.  This decision resulted in more conservative
 estimates of the number of persons with restricted activity (i.e., full
 sample estimates were roughly 10% lower than one-sixth sample
 estimates).

 Calculation of rates and their relative standard errors were performed
 using the SESUDAAN computer software package (Shah, 1981).  Rates were
 age-adjusted by direct standardization, using estimates of the 1980
 diabetic population as the standard.

 Definitions of the major disability indicators examined in this chapter
 are as follows and are briefly repeated in the results section.

 Activity Limitation

      In the NHIS, activity limitation reflects a long-term reduction in
 activity resulting from one or more chronic diseases or impairments.
 Persons reporting more than one cause of activity limitation are asked
 to indicate the primary cause of the limitation.  Activity limitation
 reflects a person's capacity to perform activities normal for a person's
 age-sex group.  Major activities normal for a person's age-sex group are
 defined as (1) "ordinary play" for children under 5 years of age, (2)
 "going to school" for children 5 to 17 years of age, (3) "working at a
 job or business" or "keeping house" for persons 18-69 years of age, and
 (4) independent performance of basic life activities (e.g., bathing,
 eating, shopping) for persons 70 years of age and older.  In terms of
 these activities, persons can be categorized as being (1) unable to
 perform their major activity, (2) able to perform their major activity
 but limited in the kind or amount of this activity, (3) not limited in
 major activity but limited in other activities, and (4) not limited in
 activity.  Using these categories, our analysis of activity limitation
 examines persons limited in activity (categories 1-3), limited in major
 activity (categories 1-2), and unable to perform major activity
 (category 1).  Our analysis also examines the proportion of respondents
 who attribute activity limitation to their having diabetes.

 Work Limitation

      Persons between the ages of 18 and 69 are asked about their ability
 to work at a job or business.  Responses can classify persons into four
 work limitation categories (which parallel the four activity limitation
 categories described in the preceding paragraph): (1) persons unable to
 work, (2) persons limited in kind or amount of work, (3) persons limited
 in other activities, and (4) persons not limited.  Our analysis examines
 persons limited in work (categories 1-2) and persons unable to work
 (category 1).  Our analysis also examines the proportion of respondents
 who attribute work limitation to their having diabetes.

 Need for Assistance in Personal Care and Other Routine Activities
      Beginning with the 1984 NHIS, persons between the ages of 5 and 59
 who report an activity limitation and persons between the ages of 60 and
 69 (regardless of activity limitation) are asked whether they need help
 in performing personal care (e.g., eating, bathing, dressing) or are
 limited in performing other routine activities (e.g., shopping, doing
 household chores). Responses to these questions are combined as a
 measure of the need for personal assistance in personal care and other
 routine activities.  Because of sample size limitations, we only present
 crude rates of this measure.

 Activity Restriction

      Activity restriction refers to a reduction in activity due to
 either short-term or long-term conditions.  It is measured in NHIS as
 school-loss days (among children between the ages of 5 and 17),
 work-loss days (among the currently employed between the ages of 18 and
 69), cut-down days (days in which persons reduce or cut down on the
 things they usually do), and bed days.  The total number of restricted
 activity days is the total number of days that a person experiences at
 least one of the above types of days.  Because of small sample sizes, we
 only present data on total restricted activity days and bed days.

 Results

  Activity Limitation

   Limited in Activity
     Unable to perform major activity, or limited in the kind or amount
     of major activity, or limited in other activities normal for a
     person's age-sex group

 In the United States, approximately half of all persons with diabetes
 reported that they were limited in activity (Table 9.1).  Among persons
 with diabetes, the number increased from 3.1 million in 1983 to 3.3
 million in 1989, but the proportion decreased from 53% to 50% (Figure
 9.1, Table 9.1).  This decline over time occurred primarily among
 persons 65 years of age and older.  In each year, the proportion
 reporting that they were limited in activity increased with increasing
 age, with a tendency to level off after age 64.

 In general, rates of being limited in activity were greater among blacks
 than among whites, and among females than among males (Figure 9.2,
 Tables 9.2- 9.5).  Rates among black males averaged 1.3 times that of
 white males, and rates among black females averaged 1.2 times that of
 white females.  From 1983 to 1989, rates were relatively stable among
 white males and decreased 7% among white females.  Rates decreased 10%
 among black males and 12% among black females. Marked decreases were
 noted for white males over 74 years of age, for black males under 45
 years of age and between the ages of 65 and 74 years, and for females
 between 65 and 74 years of age.

 Between 1983 and 1989, the proportion of persons with diabetes reporting
 being limited in activity due to diabetes averaged 34% percent (Table
 9.6). Thus, 60% of all those limited in activity attribute it to
 diabetes.  This attribution of being limited in activity due to diabetes
 was more common among blacks than whites and among females than males
 (Table 9.7).  Between 1983 and 1989, the age-adjusted prevalence of
 those limited in activity due to diabetes decreased modestly, largely
 because of a 27% decrease in rates among black males and an 21% decrease
 in rates among black females.

   Limited in Major Activity

     Unable to perform major activity or limited in the kind or amount
     of major activity normal for a person's age-sex group

 Almost 40% of all persons with diabetes (approximately 75% of those
 limited in activity) reported being limited in their major activity
 (Table 9.8).  The age-adjusted prevalence decreased slightly over the
 seven-year period, primarily because of decreases among persons 75 years
 of age and older.  Being limited in major activity was most often
 reported by those 45 to 74 years of age.  Although no clear temporal
 trends among age-specific rates were evident for whites, dramatic
 decreases were noted for blacks under the age of 45 years and over the
 age of 74 (Tables 9.9-9.10).

 The prevalence of being limited in major activity varied by race and sex
 (Figure 9.3, Table 9.11).  The age-adjusted prevalence was higher among
 blacks than whites.  Over the seven-year period, age-adjusted rates
 decreased 19% among black females.  By 1988, the rate among black
 females approached that of white females, but the rate among black males
 in 1989 was 1.3 times that of white males.

   Unable to Perform Major Activity

     Unable to perform the major activity normal for a person's age-sex
     group

 About 20% of persons with diabetes reported that they are unable to
 perform their major activity (Table 9.12).  This proportion fluctuated
 very little over the seven-year period but varied by age.  It increased
 considerably from persons younger than 45 years of age to persons
 between 45 and 64 years, and then leveled off or declined for persons 65
 years of age or older.

 Age-specific trends differed by race (Tables 9.13-9.14).  The only
 temporal trend evident among whites was an increase in rates among those
 under 45 years of age.  Among blacks, rates increased for those under 75
 years of age, particularly for those between the ages of 65 and 74.
 These increases were offset by dramatic decreases for blacks older than
 74 years of age.

 Race-sex differences were also noted (Figure 9.4, Table 9.15).  In
 general, rates among males were greater than rates among females, and
 rates among blacks were greater than rates among whites.  For the
 seven-year period, the age-adjusted rate averaged 35.5% for black males,
 26.8% for black females, 20.4% for white males, and 16.4% for white
 females.

Work Limitation

 Work Limitation Among Persons Between the Ages of 18 and 69

   Limited in Work
     Unable to work, or limited in kind or amount of work

 Among persons with diabetes between the ages of 18 and 69, the
 prevalence of being limited in work was high (averaging 43%) but
 decreased modestly over the seven-year period (Table 9.16).  The rate
 was greatest among black females, followed in descending order by black
 males, white females, and white males. Over half of those limited in
 work attributed their limitation to having diabetes (Table 9.17).

   Unable to Work

     Unable to work at a job or business

 Persons unable to work accounted for over 70% of all those limited in
 work (Table 9.18).  As with the prevalence of being limited in work, the
 prevalence of being unable to work was greatest among black females,
 followed in descending order by black males, white females, and white
 males.  With the exception of white males, the prevalence was lower in
 1989 than in 1983 for all race-sex groups (Figure 9.5).

 Need for Assistance in Personal Care and Other Routine Activitie

     Unable to perform personal care needs (e.g., eating, bathing,
     dressing) or limited in performing other routine activities (e.g.,
     shopping, housekeeping)

 Approximately 13% of persons with diabetes between the ages of 5 and 69
 required help with personal care or other routine activities.  Rates
 were similar for black males and white males, but were somewhat greater
 for black females than white females (Table 9.19).  Rates for black
 females and white females averaged, respectively, 2.8 and 1.6 times that
 of their male counterparts.

 Activity Restriction

   Total Restricted Activity Days

     Number of days a person experiences at least one the of four types
     of restricted activity days (i.e., bed days, work-loss days,
     school-loss days, and cut-down days)

 The total number of restricted activity days due to both acute and
 chronic conditions among people with diabetes increased from 199 million
 days in 1983 to 233 million days in 1989 (Figure 9.6, Table 9.20).
 Between 1983 and 1989, the age-adjusted rate was relatively stable,
 averaged 34 days, and generally increased with increasing age.  In this
 time period, the number of restricted activity days was 1.4 times
 greater among blacks than among whites (Figure 9.7, Tables 9.21-9.22).
 Among blacks, the number of days per person decreased markedly for those
 under 45 years of age and over 74 years of age, but increased for those
 between the ages of 65 and 74.

   Bed Days

     Inpatient hospital days or days in which a person stayed in bed for
     more than half a day because of illness or injury

 About half of all restricted activity days among persons with diabetes
 were bed days (Figure 9.6, Table 9.23).  Between 1983 and 1989, the
 number of bed days was 1.5 times greater among blacks than among whites
 (Figure 9.7, Tables 9.24-9.25).  Age-specific trends over time were not
 observed among whites, but increases among blacks between 45 and 74
 years of age were partially offset by decreases among those younger than
 45 years and older than 74 years.
 Discussion

 For the period 1983-1989, the prevalence of disability among
 non-institutionalized people with diabetes was high.  About 50% of
 persons with diabetes reported being limited in activity; about 40% of
 persons with diabetes reported being limited in their major activity;
 and about 20% reported being unable to perform their major activity.
 The prevalence of work limitation was of similar magnitude.  Forty-three
 percent reported being limited in work and 30% reported being unable to
 work.  In addition, 13% of persons with diabetes between the ages of 5
 and 69 required help with personal care or other routine activities.

 More than 60% of respondents attribute being limited in activity and in
 work to their diabetes.  Since diabetes-related disability is often due
 to complications that may not be perceived as diabetes-related, however,
 this proportion is likely to be underestimated.   Regardless of type of
 limitation, the prevalence of disability was greater among blacks than
 whites.  This disparity may reflect greater severity of disease among
 blacks, poorer access to health care, greater likelihood of types of
 work or activity that do not accommodate physical disability, fewer work
 options based on skills, training, or opportunity, or some combination
 of these factors.

 With the exception of inability to perform major activity, measures of
 activity limitation were higher among females than males.  The higher
 prevalence of these types of disability among females may be due to the
 same factors suggested above to explain the higher prevalence among
 blacks.  Females may have a lower prevalence of inability to perform
 their major activity because they have changed their major activity from
 work at a job or business to managing a household or other activities
 that may be more accommodating or less physically demanding.

 Inability to perform major activity and inability to work are two of the
 most severe forms of disability examined.  Examination of temporal
 trends of inability to perform major activity suggests that this type of
 disability is increasing for persons with diabetes under the age of 45.
 In contrast, for persons over 74 years of age, the prevalence of
 inability to perform major activity decreased (due primarily to a
 dramatic decrease among blacks).  This finding might be explained by
 improved health status or increased institutional care and increased
 mortality among diabetic persons.  Although the prevalence of inability
 to work could not be examined by age, there was a paradoxical trend
 toward decreasing prevalence among those aged 18-69.

 Restricted activity days, because they measure both acute and chronic
 disability, provide the most inclusive but least descriptive disability
 information.  Between 1983 and 1989, persons with diabetes averaged 34
 restricted activity days per year.  Half of these days were bed days.
 In all age categories, blacks averaged a greater number of restricted
 activity days than whites.  This disparity could be explained by poorer
 health among blacks with diabetes or by more difficult daily activities
 for blacks, with a resulting increase in the need to restrict activity.

 In general, the prevalence of disability among non-institutionalized
 persons with diabetes is very high but appears to be declining among the
 elderly, blacks, and white females.  Despite these declines, the actual
 number of persons reporting disability is increasing, because of the
 increasing prevalence of diabetes.  Although some measures of disability
 show evidence of improvement, decreasing the net burden of disability
 presented by diabetes will remain a challenge.

 Detailed Tables

 9.1-9.5 Limited in Activity, Persons with Diabetes
 
 9.1 Limited in Activity, by Age & Year

 Table 9.1   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             United States, 1983-1986

 Age                           1983       1984      1985      1986

 0-44        Number (a)         368        363       387       351
             Rate              36.7       36.5      37.3      33.6

 45-64       Number            1327       1232      1244      1512
             Rate              51.1       52.2      53.4      53.1

 65-74       Number             805       1068      1089       934
             Rate              61.7       60.8      58.8      58.7

 75+         Number             564        690       684       727
             Rate              64.5       63.3      62.1      56.6

 Total       Number            3065       3354      3403      3525
             Rate              53.0       54.1      53.9      52.1
             Adjusted Rate (b) 53.4       53.4      53.3      51.7

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.1   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             United States, 1987-1989

 Age                           1987       1988      1989

 0-44        Number (a)         461        352       432
             Rate              33.8       32.2      35.3

 45-64       Number            1329       1252      1383
             Rate              52.1       50.9      51.1

 65-74       Number             952        927       854
             Rate              55.9       54.4      52.3

 75+         Number              654       609       663
             Rate              54.8       55.7      60.4

 Total       Number            3397       3140      3332
             Rate              49.9       49.4      50.0
             Adjusted Rate (b) 50.3       49.3      50.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.2 Limited in Activity, by Age & Year, White Males

 Table 9.2   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             White Males, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)         129        115       120        93
             Rate              31.7       32.4      30.5      31.0

 45-64       Number             387        358       429       612
             Rate              42.1       44.0      49.1      49.5

 65-74       Number             207        316       360       341
             Rate              49.8       53.4      53.1      54.5

 75+         Number             197        195       205       203
             Rate              60.1       60.3      58.5      50.1

 Total       Number             921        985      1114      1249
             Adjusted Rate (b) 44.4       47.3      48.5      48.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.2   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             White Males, United States, 1983-1989

 Age                             1987     1988      1989

 0-44        Number (a)           193      160       156
             Rate                33.4     33.2      37.5

 45-64       Number               498      428       478
             Rate                47.3     45.8      44.3

 65-74       Number               383      320       317
             Rate                54.3     57.5      59.1

 75+         Number               187      171       115
             Rate                44.6     44.4      44.7

 Total       Number              1261     1080      1066
             Adjusted Rate (b)   45.8     45.7      46.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.3 Limited in Activity, by Age & Year, White Females

 Table 9.3   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             White Females, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number  (a)        145        154       180       180
             Rate              36.0       35.1      36.0      30.5

 45-64       Number             585        590       501       596
             Rate              54.1       56.5      54.9      55.6

 65-74       Number             399        488       516       399
             Rate              63.4       60.8      58.3      59.0

 75+         Number             302        375       364       393
             Rate              65.9       63.2      61.3      57.7

 Total       Number            1432       1607      1561      1568
             Rate              55.7       55.8      54.0      51.9
             Adjusted Rate (b) 55.2       54.9      53.4      52.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.3   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             White Females, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)         159        112       198
             Rate              31.1       31.5      36.1

 45-64       Number             516        510       585
             Rate              54.0       55.3      56.0

 65-74       Number             398        424       371
             Rate              53.5       51.2      46.4

 75+         Number             309        311       430
             Rate              57.6       60.7      66.7

 Total       Number            1382       1357      1584
             Rate              50.3       51.8      52.2
             Adjusted Rate (b) 50.4       50.9      51.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.4 Limited in Activity, by Age & Year, Black Males

 Table 9.4   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             Black Males, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          19         29        30        44
             Rate              51.5       51.7      47.9      52.5

 45-64       Number             121        113       122       102
             Rate              59.5       52.3      54.8      50.2

 65-74       Number              79         75        76        63
             Rate              92.4       85.4      77.1      69.7

 75+         Number              11         14        13        24
             Rate              47.0       39.8      38.6      62.4

 Total       Number             231        230       241       234
             Rate              65.8       58.5      57.7      56.1
             Adjusted Rate (b) 64.9       59.0      57.0      57.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.4   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             Black Males, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)          41         29        24
             Rate              44.8       36.0      28.8

 45-64       Number             121        145       183
             Rate              58.0       58.7      66.3

 65-74       Number              70         56        57
             Rate              67.0       66.2      66.3

 75+         Number              24         31        31
             Rate              67.2       61.1      57.1

 Total       Number             255        261       295
             Rate              58.1       56.4      59.1
             Adjusted Rate (b) 59.4       57.1      58.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.5 Limited in Activity, by Age & Year, Black Females

 Table 9.5   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             Black Females, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          52         50        56        43
             Rate              45.2       46.2      61.8      49.3

 45-64       Number             195        177       173       179
             Rate              64.9       62.9      66.7      63.8

 65-74       Number             142        136       132       102
             Rate              71.2       72.9      72.0      71.0

 75+         Number              65         75        94        79
             Rate              78.2       81.4      79.5      62.6

 Total       Number             455        438       454       403
             Rate              65.0       65.5      69.8      63.2
             Adjusted Rate (b) 65.1       65.4      69.2      63.0

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.5   Prevalence of Being Limited in Activity Among Persons with
             Diabetes, per 100 Diabetic Population, by Age and Year,
             Black Females, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)          46         46        48
             Rate              42.3       34.4      36.6

 45-64       Number             190        147       133
             Rate              67.8       60.3      58.7

 65-74       Number              97         91       105
             Rate              67.8       58.6      59.5

 75+         Number              95         86       101
             Rate              64.6       61.2      74.5

 Total       Number             427        370       386
             Rate              63.0       54.9      57.8
             Adjusted Rate (b) 62.9       55.5      57.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.6-9.7 Limited in Activity Attributed to Diabetes

 9.6 Limited in Activity, by Age & Year

 Table 9.6   Prevalence of Being Limited in Activity Attributed to
             Diabetes, per 100 Diabetic Population, by Age and Year,
             United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)         240        243       240       236
             Rate              23.9       24.4      23.2      22.5

 45-64       Number             900        854       890      1116
             Rate              34.6       36.2      38.2      39.2

 65-74       Number             512        677       622       548
             Rate              39.2       38.6      33.6      34.4

 75+         Number             305        431       475       531
             Rate              34.9       39.6      43.2      41.4

 Total       Number            1957       2205      2227      2432
             Rate              33.9       35.6      35.2      35.9
             Adjusted Rate (b) 34.0       35.3      35.1      35.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.6   Prevalence of Being Limited in Activity Attributed to
             Diabetes, per 100 Diabetic Population, by Age and Year,
             United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)          299       232       287
             Rate               21.9      21.3      23.5

 45-64       Number              947       882       923
             Rate              37.1       35.9      34.1

 65-74       Number              567       605       549
             Rate               33.3      35.5      33.7

 75+         Number              434       319       321
             Rate               36.4      29.2      29.3

 Total       Number             2247      2039      2081
             Rate               33.0      32.1      31.2
             Adjusted Rate (b)  33.3      32.2      31.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.7 Limited in Activity, by Race, Sex, & Year

 Table 9.7   Prevalence of Being Limited in Activity Attributed to
             Diabetes, per 100 Diabetic Population, By Race, Sex, and
             Year, United States, 1983-1989

 Race and Sex                             1983      1984      1985     1986

 White Males    Number (a)                566        612       696      797
                Rate                      27.3      29.4      30.3     31.1
                Adjusted Rate (b)         27.4      29.3      30.6     30.2

 White Females  Number                    838        995      1014     1076
                Rate                      32.6      34.6      35.0     35.6
                Adjusted Rate (b)         32.6      34.1      34.6     35.8

 Black Males    Number                    187        179       166      177
                Rate                      53.2      45.4      39.6     42.6
                Adjusted Rate (b)         53.7      44.8      38.0     41.9

 Black Females  Number                    358        355       327      312
                Rate                      51.1      53.0      50.2     49.0
                Adjusted Rate (b)         51.2      52.9      49.8     49.2

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.7   Prevalence of Being Limited in Activity Attributed to
             Diabetes, per 100 Diabetic Population, By Race, Sex, and
             Year, United States, 1983-1989

 Race and Sex                             1987      1988      1989


 White Males    Number (a)                 808       676       691
                Rate                      29.3      28.6      30.2
                Adjusted Rate (b)         29.6      29.2      29.5

 White Females  Number                     894       853       932
                Rate                      32.5      32.6      30.7
                Adjusted Rate (b)         32.9      32.3      30.6

 Black Males    Number                     191       188       201
                Rate                      43.4      40.6      40.3
                Adjusted Rate (b)         44.8      41.1      39.4

 Black Females  Number                     298       277       271
                Rate                      44.0      41.1      40.5
                Adjusted Rate (b)         44.1      41.9      40.2

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.8-9.11 Limited in Major Activity

 9.8 By Age & Year

 Table 9.8   Prevalence of Being Limited in Major Activity Among People
             with Diabetes, per 100 Diabetic Population, by Age and
             Year, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)         287        280       262       238
             Rate              28.6       28.2      25.2      22.7

 45-64       Number            1111       1042      1104      1314
             Rate              42.8       44.2      47.4      46.1

 65-74       Number             535        737       772       688
             Rate              41.0       42.0      41.7      43.2

 75+         Number             395        470       448       459
             Rate              45.2       43.1      40.7      35.7

 Total       Number            2328       2529      2586      2698
             Rate              40.3       40.8      40.9      39.8
             Adjusted Rate (b) 40.2       40.6      41.0      39.7

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.8   Prevalence of Being Limited in Major Activity Among People
             with Diabetes, per 100 Diabetic Population, by Age and
             Year, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)          321       283       350
             Rate               23.5      25.9      28.6

 45-64       Number             1115       999      1099
             Rate               43.7      40.6      40.6

 65-74       Number              726       737       676
             Rate               42.6      43.3      41.4

 75+         Number              408       366       400
             Rate               34.2      33.4      36.5

 Total       Number             2570      2384      2525
             Rate               37.7      37.5      37.9
             Adjusted Rate (b)  38.5      37.7      38.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.9 By Age & Year, Whites

 Table 9.9   Prevalence of Being Limited in Major Activity Among People
             with Diabetes, per 100 Diabetic Population, by Age and
             Year, Whites, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)         214        212       202       180
             Rate              26.4       26.7      22.6      20.1

 45-64       Number             829        801       814      1032
             Rate              41.4       43.1      45.6      44.7

 65-74       Number             408        552       599       527
             Rate              39.0       39.6      38.3      40.5

 75+         Number             326        371       360       358
             Rate              41.3       40.5      38.1      32.9

 Total       Number            1778       1936      1975      2097
             Rate              38.2       39.0      38.1      37.5
             Adjusted Rate (b) 38.2       38.9      38.5      37.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.9   Prevalence of Being Limited in Major Activity Among People
             with Diabetes, per 100 Diabetic Population, by Age and
             Year, Whites, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)          231       219       294
             Rate               21.2      26.1      30.5

 45-64       Number              853       744       845
             Rate               42.5      40.1      39.8

 65-74       Number              577       582       533
             Rate               39.8      42.0      39.9

 75+         Number              299       292       336
             Rate               31.0      32.4      37.4

 Total       Number             1960      1838      2009
             Rate               35.6      36.9      37.7
             Adjusted Rate (b)  36.4      37.0      37.9

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.10 By Age & Year, Blacks

 Table 9.10   Prevalence of Being Limited in Major Activity Among
               People with Diabetes, per 100 Diabetic Population, by
               Age and Year, Blacks, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          54         54        60        64
             Rate              35.2       32.6      39.0      37.4

 45-64       Number             256        244       273       261
             Rate              50.6       49.1      56.7      53.8

 65-74       Number             140        148       163       138
             Rate              49.0       53.8      57.8      58.7

 75+         Number              76         80        83        77
             Rate              70.2       62.6      54.4      46.4

 Total       Number             527        526       579       539
             Rate              49.9       49.4      54.1      51.1
             Adjusted Rate (b) 50.4       49.5      53.6      51.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.10   Prevalence of Being Limited in Major Activity Among
               People with Diabetes, per 100 Diabetic Population, by
               Age and Year, Blacks, United States, 1983-1989

 Age                            1987      1988      1989

 0-44        Number (a)           71        58        51
             Rate               35.3      26.6      23.9

 45-64       Number              260       236       253
             Rate               53.2      48.2      50.4

 65-74       Number              140       126       137
             Rate               56.7      52.5      52.2

 75+         Number              80         69        61
             Rate               44.4      35.8      32.3

 Total       Number              551       488       502
             Rate               49.3      42.9      43.0
             Adjusted Rate (b)  49.7      43.7      43.5

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.11 By Race, Sex, & Year

 Table 9.11   Prevalence of Being Limited in Major Activity Among
              People with Diabetes, per 100 Diabetic Population, by
              Race, Sex, and Year, United States, 1983-1989

 Race and Sex                    1983     1984      1985      1986


 White Males   Number (a)         711      728       781       904
               Rate              34.3     35.0      34.0      35.2
               Adjusted Rate (b) 34.1     35.1      34.3      34.0

 White Females Number            1065     1213      1194      1200
               Rate              41.4     42.1      41.3      39.8
               Adjusted Rate     41.1     41.8      41.7      40.5

 Black Males   Number             196      192       205       207
               Rate              55.8     48.7      49.1      49.6
               Adjusted Rate     55.5     48.3      46.2      49.9

 Black Females Number             332      333       373       332
               Rate              47.4     49.8      57.3      52.1
               Adjusted Rate     48.3     49.8      56.7      51.7

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.11   Prevalence of Being Limited in Major Activity Among
              People with Diabetes, per 100 Diabetic Population, by
              Race, Sex, and Year, United States, 1983-1989

 Race and Sex                             1987      1988      1989

 White Males   Number (a)                  920       840       855
               Rate                       33.4      35.5      37.4
               Adjusted Rate (b)          34.2      36.4      37.2

 White Females Number                     1036       989      1174
               Rate                       37.7      37.8      38.6
               Adjusted Rate              38.3      37.5      38.4

 Black Males   Number                      222       229       246
               Rate                       50.5      49.4      49.2
               Adjusted Rate              50.5      49.6      47.8

 Black Females Number                      329       260       257
               Rate                       48.6      38.5      38.4
               Adjusted Rate              48.8      39.8      39.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.12-9.15 Unable to Perform Major Activity

 9.12 By Age & Year

 Table 9.12  Prevalence of Being Unable to Perform Major Activity Among
             People with Diabetes, per 100 Diabetic Population, By Age
             and Year, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          88         84        74        79
             Rate               8.8        8.4       7.1       7.5

 45-64       Number             594        561       623       739
             Rate              22.8       23.8      26.7      26.0

 65-74       Number             245        355       380       383
             Rate              18.8       20.2      20.5      24.0

 75+         Number             198        203       234       234
             Rate              22.6       18.7      21.2      18.2

 Total       Number            1125       1204      1311      1435
             Rate              19.5       19.4      20.7      21.2
             Adjusted Rate (b) 19.3       19.4      20.9      21.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.12  Prevalence of Being Unable to Perform Major Activity Among
             People with Diabetes, per 100 Diabetic Population, By Age
             and Year, United States, 1983-1989

 Age                           1987       1988      1989

 0-44        Number (a)         139        125       165
             Rate              10.2       11.5      13.5

 45-64       Number             617        541       586
             Rate              24.2       22.0      21.7

 65-74       Number             414        424      371
             Rate              24.3       24.9      22.7

 75+         Number             245        183      203
             Rate              20.5       16.8      18.5

 Total       Number            1414       1274      1326
             Rate              20.8       20.1      19.9
             Adjusted Rate (b) 21.2       20.1      20.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.13 By Age & Year, Whites

 Table 9.13   Prevalence of Being Unable to Perform Major Activity
              Among People with Diabetes, per 100 Diabetic Population,
              by Age and Year, Whites, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          67         63        53        56
             Rate               8.3        7.9       5.9       6.3

 45-64       Number             432        404       425       541
             Rate              21.6       21.7      23.8      23.5

 65-74       Number             192        259       279       277
             Rate              18.3       18.6      17.8      21.2

 75+         Number             136        141       189       194
             Rate              17.2       15.3      20.1      17.8

 Total       Number             826        867       946      1068
             Rate              17.8       17.5      18.2      19.1
             Adjusted Rate (b) 17.7       17.5      18.5      19.0

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.13   Prevalence of Being Unable to Perform Major Activity
              Among People with Diabetes, per 100 Diabetic Population,
              by Age and Year, Whites, United States, 1983-1989

 Age                           1987       1988      1989

 0-44        Number (a)         95          84       120
             Rate               8.8       10.1      12.4

 45-64       Number             461        377       417
             Rate              23.0       20.3      19.6

 65-74       Number             309        319       269
             Rate              21.3       23.0      20.1

 75+         Number             185        131       150
             Rate              19.2       14.5      16.7

 Total       Number            1050        912       956
             Rate              19.1       18.3      18.0
             Adjusted Rate (b) 19.5       18.4      18.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.14 By Age & Year, Blacks

 Table 9.14   Prevalence of Being Unable to Perform Major Activity
              Among People with Diabetes, per 100 Diabetic Population,
              by Age and Year, Blacks, United States, 1983-1989

 Age                           1983       1984      1985      1986

 0-44        Number (a)          18         19        22        22
             Rate              11.9       11.7      14.1      12.9

 45-64       Number             149        160       194       180
             Rate              29.4       32.3      40.3      37.3

 65-74       Number              64         80        92        94
             Rate              22.4       29.2      32.5      40.0

 75+         Number              63         52        46        38
             Rate              58.3       41.2      30.6      23.0

 Total       Number             294        313       354       334
             Rate              27.9       29.4      33.1      31.7
             Adjusted Rate (b) 28.8       29.2      32.2      31.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.14   Prevalence of Being Unable to Perform Major Activity
              Among People with Diabetes, per 100 Diabetic Population,
              by Age and Year, Blacks, United States, 1983-1989

 Age                           1987       1988      1989

 0-44        Number (a)          32         36        39
             Rate              16.2       16.7      18.4

 45-64       Number             155        157       170
             Rate              31.7       32.0      34.0

 65-74       Number              98         89        95
             Rate              39.8       37.2      36.0

 75+         Number              52         53        51
             Rate              28.9       27.6      26.7

 Total       Number             338        335       355
             Rate              30.3       29.4      30.4
             Adjusted Rate (b) 30.7       30.0      30.7

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.15 By Race, Sex, & Year

 Table 9.15   Prevalence of Being Unable to Perform Major Activity
              Among People with Diabetes, per 100 Diabetic Population,
              By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                  1983       1984      1985      1986

 White Males   Number (a)         364      393       455       594
               Rate              17.5     18.8      19.8      23.2
               Adjusted Rate (b) 17.7     18.9      20.1      21.7

 White Females Number             462      473       490       489
               Rate              18.0     16.4      16.9      16.2
               Adjusted Rate     17.7     16.4      16.6      15.9

 Black Males   Number             133      142       143       152
               Rate              37.9     35.9      34.2      36.6
               Adjusted Rate     35.1     34.1      31.2      38.0

 Black Females Number             160      172       211       182
               Rate              22.9     25.7      32.4      28.5
               Adjusted Rate     24.3     25.7      32.1      28.3

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Tables 9.15   Prevalence of Being Unable to Perform Major Activity
               Among People with Diabetes, per 100 Diabetic Population,
               By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                    1987     1988      1989

 White Males   Number (a)         585      493       475
               Rate              21.2     20.9      20.7
               Adjusted Rate (b) 21.9     21.7      20.7

 White Females Number             468      410       485
               Rate              17.0     15.7      16.0
               Adjusted Rate     16.8     15.4      16.0

 Black Males   Number             152      179       180
               Rate              34.6     38.5      36.0
               Adjusted Rate     36.2     38.9      34.7

 Black Females Number             186      157       176
               Rate              27.5     23.3      26.3
               Adjusted Rate     27.6     23.7      26.2

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.16-9.17 Limited in Work Between 18 & 69 Years of Age
 
 9.16 Persons with Diabetes, By Race, Sex, & Year

 Table 9.16  Prevalence of Being Limited in Work Among Persons with
             Diabetes Between 18 and 69 Years of age, per 100 Diabetic
             Population, By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                  1983       1984      1985      1986

 White Males   Rate (a)        36.5       38.3      40.3      40.4

 White Females Rate            45.8       47.1      43.6      42.8

 Black Males   Rate            58.8       48.9      49.0      46.9

 Black Females Rate            52.6       54.2      61.0      58.3

 Total         Rate            43.9       44.8      44.2      43.4

             (a) Three-year moving average.

 Table 9.16  Prevalence of Being Limited in Work Among Persons with
             Diabetes Between 18 and 69 Years of age, per 100 Diabetic
             Population, By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                   1987      1988      1989

 White Males   Rate (a)         39.2      39.1      38.4

 White Females Rate             39.9      41.0      40.3

 Black Males   Rate             49.9      50.2      52.1

 Black Females Rate             56.3      48.2      46.8

 Total         Rate             41.5      41.0      40.5

             (a) Three-year moving average.

 9.17 Attributed to Diabetes, By Race, Sex, & Year

 Table 9.17  Prevalence of Being Limited in Work Attributed to Diabetes
             Among Persons with Diabetes Between 18 and 69 Years of Age,
             per 100 Diabetic Population, by Race, Sex, and Year, United
             States, 1983-1989

 Race and Sex                  1983       1984      1985      1986

 White Males   Rate (a)        23.1       25.5      28.3      27.5

 White Females Rate            26.7       28.5      25.2      27.1

 Black Males   Rate            50.4       44.0      42.2      42.4

 Black Females Rate            36.5       39.4      41.8      43.9

 Total         Rate            27.9       29.8      29.2      29.9

             (a) Three-year moving average.

 Table 9.17  Prevalence of Being Limited in Work Attributed to Diabetes
             Among Persons with Diabetes Between 18 and 69 Years of Age,
             per 100 Diabetic Population, by Race, Sex, and Year, United
             States, 1983-1989

 Race and Sex                   1987      1988      1989

 White Males   Rate (a)         26.7      26.7      27.2

 White Females Rate             24.0      25.2      22.1

 Black Males   Rate             35.6      35.0      33.8

 Black Females Rate             37.7      32.9      29.7

 Total         Rate             27.1      26.8      25.3

             (a) Three-year moving average.

 9.18 Unable to Work, Ages 18-69

 Table 9.18  Prevalence of Being Unable to Work Among Persons with
             Diabetes Between 18 and 69 Years of Age, per 100 Diabetic
             Population, By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                  1983       1984      1985      1986

 White Males   Rate (a)        21.4       23.4      25.9      26.9

 White Females Rate            33.7       33.7      29.9      31.3

 Black Males   Rate            48.0       37.7      34.9      31.2

 Black Females Rate            45.8       48.8      52.2      48.4

 Total         Rate            31.4       31.8      30.8      31.0

             (a) Three-year moving average.

 Table 9.18  Prevalence of Being Unable to Work Among Persons with
             Diabetes Between 18 and 69 Years of Age, per 100 Diabetic
             Population, By Race, Sex, and Year, United States, 1983-1989

 Race and Sex                   1987      1988      1989

 White Males   Rate (a)         26.0      24.8      23.3

 White Females Rate             30.1      28.9      26.7

 Black Males   Rate             34.4      39.1      38.9

 Black Females Rate             44.2      38.4      39.0

 Total         Rate             29.8      28.6      27.3

             (a) Three-year moving average.

 9.19 Needing Help with Personal Care, Ages 5-69

 Table 9.19  Prevalence of Needing Help with Personal Care or Limited
             in Performing Other Routine Activities Among Persons with
             Diabetes Between 5 and 69 Years of Age, per 100 Diabetic
             Persons, by Race, Sex, and Year, United States, 1984-1989

 Race and Sex              1984     1985    1986    1987     1988    1989

 White Males   Rate (a)     8.2      9.6     9.5     9.9      9.2     9.8

 White Females Rate        17.2     15.2    15.0    13.3     14.6    15.1

 Black Males   Rate         6.0      7.9     4.8     7.1      8.7    11.6

 Black Females Rate        20.8     26.3    25.8    21.4     16.6    16.4

 Total         Rate        13.4     13.6    13.1    12.1     12.0    12.7

             (a) Three-year moving average.

 9.20-9.22 Total Number of Restricted Activity Days

 9.20 By Age & Year

 Table 9.20  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People with Diabetes, by Age and Year, United States,
             1983-1989

 Age                              1983     1984      1985      1986


 0-44        Number (a)           24183    20034     17457     16900
             Average               24.1     20.1      16.8      16.1

 45-64       Number               83860    79898     78594     97646
             Average               32.3     33.9      33.7      34.3

 65-74       Number               48300    61025     61454     57268
             Average               37.0     34.7      33.2      35.9

 75+         Number               42752    49041     46983     51225
             Average               48.9     45.0      42.7      39.9

 Total       Number              199095   209998    204488    223039
             Average               34.4     33.9      32.4      32.9
             Adjusted Average (b)  34.6     33.4      32.0      32.4

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.20  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People with Diabetes, by Age and Year, United States,
             1983-1989

 Age                                      1987       1988      1989

 0-44        Number (a)                   24717     22495      27520
             Average                       18.1      20.6       22.5

 45-64       Number                       87668     82516      90119
             Average                       34.4      33.5       33.3

 65-74       Number                       66655     70747      68099
             Average                       39.1      41.5       41.7

 75+         Number                       48708     46135      47072
             Average                       40.8      42.2       42.9

 Total       Number                      227747     221893    232811
             Average                       33.4       34.9      35.0
             Adjusted Average (b)          33.7       34.7      35.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.21 By Age & Year, Whites

 Table 9.21  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People With Diabetes, by Age and Year, Whites,
             United States, 1983-1989

 Age                            1983        1984     1985       1986

 0-44        Number (a)         16468      13792     12279     11695
             Average             20.3       17.4      13.7      13.1

 45-64       Number             59083      56364     52798     69812
             Average             29.5       30.3      29.6      30.3

 65-74       Number             39051      47737     51459     44831
             Average             37.3       34.2      32.9      34.4

 75+         Number             36386      39538     40614     44336
             Average             46.1       43.1      43.0      40.8

 Total       Number            150988     157430    157150    170675
             Average             32.5       31.7      30.3      30.5
             Adjusted Rate (b)   32.4       31.0      29.7      29.9

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.21  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People With Diabetes, by Age and Year, Whites,
             United States, 1983-1989

 Age                                        1987      1988     1989

 0-44        Number (a)                    17202     15752     21272
             Average                        15.8      18.8      22.1

 45-64       Number                        62289     57106     65150
             Average                        31.0      30.7      30.7

 65-74       Number                        54947     54912     53549
             Average                        37.9      39.6      40.1

 75+         Number                        40020     37179     36037
             Average                        41.6      41.2      40.1

 Total       Number                       174457    164948    176007
             Average                        31.7      33.1      33.1
             Adjusted Rate (b)              31.8      32.5      33.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.22 By Age & Year, Blacks

 Table 9.22  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People with Diabetes, by Age and Year, Blacks,
             United States, 1983-1989

 Age                            1983       1984      1985      1986

 0-44        Number (a)         6104       5330      4884      5203
             Average            39.6       32.3      31.6      30.6

 45-64       Number            22765      24086     24834     24684
             Average            45.0       48.5      51.7      51.0

 65-74       Number             9956      10511      9239     11009
             Average            34.8       38.1      32.7      46.9

 75+         Number             6940       7282      6155      6148
             Average            64.3       57.3      40.5      37.2

 Total       Number            45766      47209     45111     47043
             Average            43.4       44.3      42.2      44.6
             Adjusted Rate (b)  44.2       44.2      41.5      44.3

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.22  Total Number of Restricted Activity Days Due to Acute and
             Chronic Conditions and Average Number of Days per Person
             Among People with Diabetes, by Age and Year, Blacks,
             United States, 1983-1989

 Age                                      1987       1988      1989

 0-44        Number (a)                   5497       5985      5615
             Average                      27.5       27.6      26.2

 45-64       Number                       23905     23010     23550
             Average                      48.8       47.0      47.0

 65-74       Number                       11433     13485     13940
             Average                      46.4       56.3      53.0

 75+         Number                       6374       8319      9223
             Average                      35.2       43.4      48.8

 Total       Number                       47208     50798     52329
             Average                      42.3       44.7      44.8
             Adjusted Rate (b)            42.5       45.5      45.2


             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.23-9.25 Total Number of Bed Days

 9.23 By Age & Year

 Table 9.23  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Bed Days per Person
             Among People with Diabetes, by Age and Year, United
             States, 1983-1989

 Age                             1983       1984      1985      1986

 0-44        Number (a)         13896      10878      9014      7960
             Average             13.9       10.9       8.7       7.6

 45-64       Number             39851      35580     33607     43473
             Average             15.3       15.1      14.4      15.3

 65-74       Number             24731      30801     29748     28953
             Average             19.0       17.5      16.1      18.2

 75+         Number             26539      27271     27681     27900
             Average             30.4       25.0      25.1      21.7

 Total       Number            105017     104531    100050    108286
             Average             18.2       16.9      15.8      16.0
             Adjusted Rate (b)   18.3       16.5      15.5      15.7

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.23  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Bed Days per Person
             Among People with Diabetes, by Age and Year, United
             States, 1983-1989

 Age                                      1987       1988      1989

 0-44        Number (a)                   12559     11784     14918
             Average                       9.2       10.8      12.2

 45-64       Number                       43790     43349     47081
             Average                       17.2      17.6      17.4

 65-74       Number                       35092     36821     35229
             Average                       20.6      21.6      21.6

 75+         Number                       27525     23087     23137
             Average                       23.1      21.1      21.1

 Total       Number                       118966    115041    120366
             Average                        17.5      18.1      18.1
             Adjusted Rate (b)              17.6      18.0      18.1

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.24 By Age & Year, Whites

 Table 9.24  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Days per Person Among
             People with Diabetes, by Age and Year, Whites, United
             States, 1983-1989

 Age                            1983       1984      1985      1986

 0-44        Number (a)         8968       6981      5578      4884
             Average            11.0        8.8       6.2       5.5

 45-64       Number            28854      24217     21414     28688
             Average            14.4       13.0      12.0      12.4

 65-74       Number            20161      23040     24053     21716
             Average            19.3       16.5      15.4      16.7

 75+         Number            23599      22867     24787     24571
             Average            29.9       24.9      26.2      22.6

 Total       Number            81582      77106     75832     79859
             Average            17.5       15.5      14.6      14.3
             Adjusted Rate (b)  17.4       15.0      14.0      13.8

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.24  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Days per Person Among
             People with Diabetes, by Age and Year, Whites, United
             States, 1983-1989

 Age                            1987       1988      1989

 0-44        Number (a)         8345       8321     11693
             Average             7.7        9.9      12.1

 45-64       Number            30446      28914     33436
             Average            15.2       15.6      15.7

 65-74       Number            29370      28851     27968
             Average            20.3       20.8      20.9

 75+         Number            22701      18360     17462
             Average            23.6       20.3      19.4

 Total       Number            90863      84446     90559
             Average            16.5       16.9      17.0
             Adjusted Rate (b)  16.5       16.7      17.0

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 9.25 By Age & Year, Blacks

 Table 9.25  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Days per Person Among
             People with Diabetes, by Age and Year, Blacks, United
             States, 1983-1989

 Age                            1983       1984      1985      1986

 0-44        Number (a)         3663       3194      3012      3070
             Average            23.8       19.3      19.5      18.0

 45-64       Number             9781      11336     11694     13031
             Average            19.3       22.8      24.3      26.9

 65-74       Number             4710       6204      5243      6756
             Average            16.4       22.5      18.6      28.8

 75+         Number             3283       3139      2719      2969
             Average            30.4       24.7      17.9      18.0

 Total       Number            21437      23872     22668     25825
             Average            20.3       22.4      21.2      24.5
             Adjusted Rate (b)  21.0       22.4      21.0      24.5

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

 Table 9.25  Total Number of Bed Days Due to Acute and Chronic
             Conditions and Average Number of Days per Person Among
             People with Diabetes, by Age and Year, Blacks, United
             States, 1983-1989

 Age                           1987        1988      1989

 0-44        Number (a)         3118       3179      3106
             Average            15.6       14.7      14.5

 45-64       Number            13033      13714     13333
             Average            26.6       28.0      26.6

 65-74       Number             5925       7178      7605
             Average            24.1       30.0      28.9

 75+         Number             3575       4174      4470
             Average            19.8       21.8      23.7

 Total       Number            25650      28245     28514
             Average            23.0       24.8      24.4
             Adjusted Rate (b)  23.0       25.3      24.6

             (a) In thousands; three-year moving average.
             (b) Adjusted for age.

CONCLUSIONS

        Diabetes mellitus is a major cause of morbidity and premature mortality
 in the United States.  Surveillance data describing the magnitude of the
 disease burden of diabetes and its complications can be used to help formulate
 health care policy, target high-risk groups, develop strategies to reduce the
 burden associated with diabetes, and evaluate progress in disease prevention
 and control.  We have established a diabetes surveillance system to serve such
 purposes.  This system compiles and analyzes periodic and representative data
 on the disease burden associated with diabetes and its complications in the
 United States.  The results of these analyzes have been summarized in Chapters
 2 through 9.
       Although national data are available for many of the complications of
 diabetes, there are some important gaps.  Diabetes is the leading cause of new
 cases of blindness among adults in the United States, but recent national data
 are not available on eye disease and blindness related to diabetes.  And
 although women with diabetes are known to be at increased risk for adverse
 outcomes of pregnancy, national data are not available for monitoring
 pregnancy outcomes among these women.  Nor are periodic, national data
 available on health care practices and behaviors that could prevent many of
 the complications of diabetes.  Data are also lacking on minority groups, such
 as Hispanics and Native Americans, who are at increased risk for both diabetes
 and its complications.  In the future, we will build upon our diabetes
 surveillance system by identifying and analyzing additional data sources and
 topics that describe the disease burden of diabetes and its complications.


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