Introduction and Methods
Women at High Risk for Diabetes: Access and Quality of Health Care, 2003-2006
Diabetes is a chronic disease that is very common, serious, and costly. Diabetes can lead to serious complications, such as heart disease and stroke, high blood pressure, blindness, and kidney disease. However, people with diabetes can control the disease and reduce their likelihood of developing complications.1 An estimated 24 million people in the United States, or 8% of those age 20 years and over, have diabetes; of those, almost half are women.1, 2
At least one-fourth of adults in the United States are also known to have prediabetes, a condition in which people have blood glucose levels higher than normal but not high enough to be diagnosed with diabetes. People with prediabetes have an increased risk of type 2 diabetes, heart disease, and stroke.1
Women are more likely than men to develop chronic diseases, such as diabetes, and to suffer disproportionately from disability compared to men.3 It is important to target women at high risk for diabetes for intervention to reduce their risk of diabetes. Evidence shows that people with prediabetes who lose 5 to 7% of their body weight and increase their physical activity can prevent or delay diabetes.4 Early interventions and access to preventive care services are important for women to reduce the risk of developing other diseases, such as cardiovascular disease.3 However, very few studies have examined preventive care measures for women at high risk for diabetes.
To address this gap, CDC collaborated with AHRQ to develop this report, which assesses and describes the quality of care that women at high risk for diabetes receive in the United States. This report can be used to identify areas in which intervention can help women at high risk for diabetes across the lifespan, and to focus attention on possible gaps in public health programs, policies, research, and surveillance.
Similar to the 2008 report, Women With Diabetes: Quality of Health Care, 2004-2005, this report analyzes a wide variety of measures selected by experts at CDC and AHRQ as highly relevant to an examination of the quality of health care for women at high risk for diabetes. Due to data availability and other constraining factors, the measures discussed in this report are not necessarily comprehensive. Still, they highlight important areas of health care quality of particular relevance to women at high risk for diabetes. Throughout the report, the comparison groups are:
- Women at high risk for diabetes.
- Women not at high risk for diabetes.
Women are defined as females age 18 years and older. Women at high risk for diabetes were identified by the following criteria5:
- Age 45 years and over with a body mass index (BMI) of 25 kg/m2 or greater, or
- Ages 18-44 years with a body mass index (BMI) of 25 kg/m2 or greater, and any of the following:
- Low physical activity (less than 150 minutes per week).
- Family history of diabetes.
- Racial or ethnic background in a high-risk group (African American, Hispanic or Latino, American Indian or Alaska Native, Asian American, or Native Hawaiian or Pacific Islander).
- History of gestational diabetes or baby with birth weight greater than 9 lb.
- Hypertension (blood pressure greater than or equal to 140/90 mm Hg [systolic] or 90 mm Hg [diastolic]).
- Dyslipidemia (low-density lipoprotein [LDL] greater than 130 mg/dL; high-density lipoprotein [HDL] less than 50 mg/dL, triglyceride level above 250 mg/dL).
- History of heart attack, stroke, or peripheral arterial disease.
Women not at high risk are defined as women who do not have diabetes and do not meet any of the above criteria for women at high risk for diabetes.
Data from the National Health and Nutrition Examination Survey (NHANES) were analyzed. NHANES is conducted by the National Center for Health Statistics, part of CDC, with data collection on an annual basis. Data are currently released in 2-year cycles. For this report, combined data from the 2003-2004 and 2005-2006 NHANES were analyzed.
The NHANES is a national survey of the U.S. civilian noninstitutionalized population. All ages are included in the survey population. The survey is designed to be nationally representative. Approximately 5,000 people are examined each year, with oversampling of African Americans, Mexican Americans, adolescents, older people, and low-income non-Hispanic whites.
In addition to in-person, in-home interviews, NHANES respondents are asked to participate in physical examinations and laboratory tests conducted in mobile examination centers (MECs). Tests include blood pressure readings, height and weight measurements (used for BMI calculation), and blood tests for cholesterol levels
Data Notes and Limitations
- Race and ethnicity categories are based on respondent self report.
- Two components of the definition above for being at high risk for diabetes (history of gestational diabetes or baby with birth weight greater than 9 lb, and history of peripheral arterial disease) were not included due to limitations of the source data.
- Low physical activity was defined as having less than 150 minutes of activity per week. Activities included walking, bicycling, and working in the home or yard where the activity required at least moderate physical effort.
- Family history of diabetes is based on respondent self report.
- Blood pressure was based on mean values of the second, third, and fourth readings. Hypertension was defined as a mean systolic reading greater than or equal to 140 mm Hg OR a mean diastolic reading greater than or equal to 90 mm Hg.
- Dyslipidemia was defined as having an LDL value greater than 130 mg/dL OR an HDL value less than 50mg/dL OR a triglyceride value greater than 250 mg/dL.
- Indicators of socioeconomic position used were education attained and family income, measured as poverty-income ratio (U.S. Census Bureau, poverty-income ratio). Poverty status was defined by categories of the poverty-income ratio. Negative/poor refers to household incomes below the Federal poverty line (FPL); near poor/low, over the poverty line to just below 200% of FPL; middle, 200% to just below 400% of FPL; and high, 400% of FPL and over. Self-reported education and income may be subject to recall and social desirability bias.
- Only differences with a two-tailed p-value <0.05 are considered statistically significant. All comparisons between groups are based on estimates age-standardized to the U.S. Census 2000 population. Estimates based on cell size less than 100 or a relative standard error greater than 30% do not meet the criteria for statistical reliability, data quality, or confidentiality and are not reported.