1 table omitted
Heart disease and stroke are the first and third leading causes of death
among U.S. adults.1 Adults with diabetes
have a twofold to fourfold greater risk for dying from cardiovascular diseases
than adults without diabetes.1 In addition,
although the annual incidence of deaths attributed to cardiovascular diseases
declined substantially among U.S. adults during 1970-1994, it decreased less
among those with diabetes.2 To compare the
prevalence of heart disease and stroke among adults with and without diabetes,
CDC analyzed data from the 1999-2001 National Health Interview Surveys (NHIS).
This report summarizes the results of that analysis, which indicate that the
age-adjusted prevalence of heart disease and stroke is approximately two to
three times greater among adults with diabetes than among adults without diabetes.
Increased efforts are needed to prevent diabetes and reduce the prevalence
of cardiovascular disease risk factors (e.g., hypertension and high cholesterol)
in the United States, particularly among adults with diabetes.
NHIS is a stratified, multistage probability sample survey representing
the U.S. civilian, noninstitutionalized population. In this analysis, only
data for respondents aged ≥35 years were analyzed because of the low prevalence
of cardiovascular disease among young adults and children. For 1999, 2000,
and 2001, response rates were 69.6%, 72.1%, and 73.8%, respectively. Respondents
were classified as having diabetes if they answered "yes" to the question,
"Have you ever been told by a doctor or health professional that you have
diabetes or sugar diabetes?" Women who had diabetes only during pregnancy
were classified as not having diabetes. Respondents were classified as having
a cardiovascular condition if they reported having a medical history of at
least one of the following: coronary heart disease (CHD) including angina
pectoris and myocardial infarction; stroke; or another type of heart condition
(other than CHD, angina pectoris, and myocardial infarction). The prevalence
of each condition was determined for the overall U.S. population with and
without diabetes and for specific demographic characteristics (i.e., age,
sex, race/ethnicity, and education level). Logistic regression analysis was
used to estimate the demographically adjusted probability of having heart
disease or stroke diagnosed. Because no substantial difference was observed
between the age-adjusted and adjusted prevalences for all demographic characteristics,
only the age-adjusted prevalences of heart disease and stroke are presented
for each population. Prevalence ratios were calculated by dividing the prevalence
of heart disease or stroke among adults with diabetes by the prevalence among
adults without diabetes. Chi square analysis was used to test for statistical
significance, and SUDAAN was used to calculate confidence intervals (CIs).
Data were weighted to reflect the age, sex, and racial/ethnic distribution
of the adult U.S. population.
During 1999-2001, adults with diabetes were significantly more likely
than adults without diabetes to report a history of CHD (24.5% versus 6.6%),
stroke (9.3% versus 2.6%), other heart condition (17.8% versus 8.1%), and
at least one of these conditions (37.2% versus 13.9) (Table). After data were
adjusted for age, adults with diabetes were 3.2 (95% CI = 2.9-3.4) times more
likely than those without diabetes to report a history of CHD, 2.9 (95% CI
= 2.5-3.2) times more likely to report a history of stroke, and 1.9 (95% CI
= 1.8-2.1) times more likely to report another heart condition (Figure). These
differences were greatest among adults aged 35-64 years with diabetes, who
were 5.1 times more likely to report a history of CHD, 4.9 times more likely
to report a history of stroke, 2.4 times more likely to report another heart
condition, and 3.1 times more likely to report at least one of these conditions
than adults of similar age without diabetes (Table). Overall, adults aged
≥35 years with diabetes were 2.3 (95% CI = 2.2-2.4) times more likely to
report having at least one condition, 3.3 (95% CI = 2.9-3.7) times more to
report at least two conditions, and 5.3 (95% CI = 3.6-7.1) times more likely
to report at least three conditions (Figure).
Among adults with and without diabetes, the prevalence of any cardiovascular
condition increased with age (p<0.05), the prevalence of CHD was higher
among men than women (p<0.05), non-Hispanic whites had the highest prevalence
of CHD and other heart conditions, and non-Hispanic blacks had the highest
prevalence of stroke (Table). Among those with diabetes, no significant correlation
was observed between education level and prevalence of heart disease or stroke.
However, among those without diabetes, the prevalence of CHD and stroke was
associated inversely with education level (p<0.05).
SM Benjamin, PhD, LS Geiss, MA, L Pan, MPH, MM Engelgau, MD, Div of
Diabetes Translation; KJ Greenlund, PhD, Div of Adult and Community Health,
National Center for Chronic Disease Prevention and Health Promotion, CDC.
The findings in this report indicate that the age-adjusted prevalence
of reported heart disease and stroke is approximately two to three times greater
among persons with diabetes than among persons without diabetes. These results
are consistent with mortality data, which indicate that cardiovascular disease
death rates are two to four times higher for adults with diabetes than for
adults without diabetes.
Antihypertensive treatment, aspirin use, lipid-lowering medication,
and promotion of healthy lifestyles reduce the risk for heart disease and
stroke in persons with and without diabetes.3,4 However,
a substantial proportion of persons with diabetes have uncontrolled blood
pressure and dyslipidemia and do not take aspirin.5 Persons
with diabetes and those with heart disease also are both more likely than
those without diabetes to have other risk factors associated with ill health
(e.g., overweight/obesity, physical inactivity, and poor diet).
In 2001, the National Diabetes Education Program (NDEP), cosponsored
by CDC and the National Institutes of Health, started the "Be Smart About
Your Heart: Control the ABCs of Diabetes" campaign to educate persons with
diabetes about their high risk for heart disease and stroke and what they
can do to lower that risk. Information about the campaign is available from
NDEP at http://ndep.nih.gov/campaigns/BeSmart/BeSmart_index.htm.
In addition, CDC and the Health Resources and Service Administration established
the National Diabetes Collaborative, a partnership of public and private agencies,
to increase access to and improve the quality of diabetes care in approximately
395 health centers.
The findings of this survey identified various demographic characteristics
associated with an increased prevalence of heart disease and stroke among
adults with and without diabetes. For both populations, prevalences were higher
among men than among women. Non-Hispanic blacks were more likely than non-Hispanic
whites or Hispanics to report having had a stroke, probably because of the
high prevalence of hypertension among blacks.6
Prevention of diabetes can decrease the prevalence of heart disease
and stroke. Improved diet, weight loss, and increased physical activity can
prevent or delay the onset of diabetes among adults with impaired glucose
tolerance.7 In 2003, the U.S. Department
of Health and Human Services initiated the "Steps to a HealthierUS" program
to reduce the prevalence of diabetes, overweight, obesity, and asthma and
address physical inactivity, poor nutrition, and tobacco use.
The findings in this report are subject to at least five limitations.
First, NHIS data on history of diabetes, heart disease, and stroke are based
on self-reports. However, rates of these conditions based on self-reports
have been shown to be highly accurate and only slightly higher than those
based on physician reports8; such rates
have a high validity among adults with diagnosed diabetes.9 Second,
because approximately one third of U.S. adults have undiagnosed diabetes,10 the results might underestimate the difference
in heart disease or stroke prevalence between adults with and without diabetes.
Third, because NHIS excludes institutionalized persons, a population at high
risk for illness, the results might underestimate the prevalence of heart
disease and stroke. Fourth, differences in prevalence of heart disease and
stroke between persons with and without diabetes in part might be due to differences
in how the groups were screened for those conditions. Finally, because only
survivors of heart disease and stroke were studied, the prevalence estimates
might not reflect the true burden of disease in the U.S. population or in
any of the demographic groups studied.
Heart diseases and stroke impose a substantially greater burden on persons
with diabetes than on persons without diabetes. To reduce the incidence of
heart disease and stroke, a concerted effort is needed among health-care providers,
public health officials, members of community-based organizations, patients,
and their families.
Self-Reported Heart Disease and Stroke Among Adults With and Without Diabetes—United States, 1999-2001. JAMA. 2003;290(23):3060-3063. doi:10.1001/jama.290.23.3060