Diabetes & W
o
men’
s Health
&
Diabetes
Women’s Health
Across the Life Stages
Across the Life
Stages
A
Public
Health
Perspective
Beckles &
Thompson-Reid
U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION

---

---

&
Diabetes
Women’s Health
Across the Life
Stages
A
Public
Health
Perspective
Gloria L.A. Beckles, MBBS, MSc, and
Patricia E. Thompson-Reid, MAT, MPH
Editors
U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION

---

For more information, contact
CDC Division of Diabetes Translation
P. O. Box 8728
Silver Spring, MD 20910
Phone: Toll-free 1-877-CDC-DIAB (232-3422)
Fax: (301) 562-1050
E-Mail: diabetes@cdc.gov
Internet: http://www.cdc.gov/diabetes
Suggested citation:
Beckles GLA, Thompson-Reid PE, editors. Diabetes and Women’s Health Across the Life Stages: A
Public Health Perspective. Atlanta: U.S. Department of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division
of Diabetes Translation, 2001.

---

Message from Frank Vinicor, MD, MPH
Director, CDC Diabetes Program
Writing this monograph has been important for the diabetes program at the
Centers for Disease Control and Prevention (CDC). The monograph has
become much more than a “report” by CDC. It has become a model of
thought, interaction, and commitment to make a difference in the lives of
people—women or men—facing the daily challenges of diabetes.
We have come to better understand the impact of greater societal forces and
policies on the lives of people with diabetes, though individuals and health care
providers make their own essential contributions. Many cultural, social, organi-
zational, and environmental forces do and will facilitate or limit the impact of
our individual decisions, and the need to always coordinate science and clinical
medicine with programs and policies has become much more obvious to us.
We (at CDC), along with many partners, have the opportunity to convert the
ideas in this monograph into concrete action to assure that efforts to augment
programs directed to both the prevention of diabetes and the care of those with
the disease will occur. These efforts will synergistically blend clinical and public
health strategies. In the next 12 months, CDC and its primary cosponsors, the
American Diabetes Association, the Association of State and Territorial Health
Officials, and the American Public Health Association, will convene a national
call-to-action meeting to develop and then implement the National Public
Health Action Plan for Diabetes and Women. Much more effort is required, but
with this monograph, the process has begun.
Our clinical care systems have benefited many Americans. Now, with the blend-
ing of public health and medical approaches to the prevention of the disease
burden associated with diabetes—in this case in women—many more people
who face the daily challenges of diabetes can maintain hope.

---

---

Foreword
Diabetes has been a serious public health problem for many years. Currently an
estimated 16 million Americans have diabetes, more than half of them women.
Why, then, has so little progress been made in reducing the burden of this disabling
disease? This provocative question is explored by the authors of Diabetes and
Women’s Health Across the Life Stages: A Public Health Perspective. Throughout its
pages, editors Gloria L.A. Beckles and Patricia E. Thompson-Reid and their collab-
orators introduce us to some eye-opening issues and some serious, sobering implica-
tions for the health of women.
There is no better time for this in-depth look at diabetes as a women’s health issue
than now, as we begin a technologically advanced new century. Old or young, one-
third of American women are overweight, and more than one-fourth do not partici-
pate in any leisure-time physical activity, according to the Third National Health
and Nutrition Examination Survey (NHANES III 1988–1994). As a group,
American women are aging and growing more obese and less physically active; each
of these factors increases their risk for type 2 diabetes. Currently, about 20 million
are over age 65. By the year 2030, that number is expected to double to 40 million,
or roughly 1 in 4 American women. Astonishingly, more than 7 million women
will be past the age of 85, compared with 4 million men.
The face of the American population is also changing: by the year 2050, 1 in 4
American women will be of Hispanic heritage, 1 in 8 African American, 1 in 11
Asian American, and 1 in 100 American Indian. Non-Hispanic whites will repre-
sent barely half of the population of women. Currently, the prevalence of diabetes is
at least 2–4 times higher among women of color, and if this trend continues, the
burden of diabetes could reach unimaginable dimensions.
As the authors point out, the number of persons diagnosed with diabetes increased
fivefold between 1958 and 1997, at a direct cost of over $40 billion and an indirect
cost of another $50 billion annually from absenteeism, disability, and premature
death. These facts carry frustrating, even poignant overtones, because much of the
burden of diabetes associated with complications is potentially preventable.
Although we are well aware of the clinical risks and outcomes of diabetes, this
monograph adds a new and important public health dimension to diabetes research
by looking at the socioeconomic environment that has contributed to the increase
of this disease and the challenges we face as we seek to effectively educate women
iii

---

about the behavioral changes necessary for prevention. As this document points
out, efforts to reach women with prevention messages will not work if their social
environment does not support the messages. The authors conclude that the same
social bias that resulted in women’s health historically being viewed primarily in the
context of their reproductive organs may still influence women’s health priorities.
The document’s uniqueness also lies in its visionary understanding of the changing
issues that affect women’s health through their life span. Because of this awareness,
the document is structured to reflect the different manifestations of diabetes at dif-
ferent stages of a woman’s life, including the threat of type 1 and the emergence of
type 2 diabetes in youth, gestational diabetes (seen in up to 5% of pregnancies)
among women of childbearing age, and type 2 diabetes as a disease of middle-aged
and older women.
The authors make a powerful argument that more information is needed on how
behavioral and social factors interact with biological factors to affect the health of
women, particularly those with diabetes or other chronic illnesses. Until such
research gives us a clearer picture of how diabetes develops over time, health care
systems should consider custom-designed prevention and control programs tailored
for women and based on local and regional attitudes about health care, differing
cultural health beliefs, and available social supports. Through the National Diabetes
Control Program, the Centers for Disease Control and Prevention collaborates with
all 50 states, the District of Columbia, and U.S. territories and jurisdictions to pro-
vide a mechanism for implementing such programs.
In the 21st century, the government cannot take on this health care burden
alone; diabetes will not receive the concerted effort it deserves without action
from both the public and private sectors. This monograph is lush with data and
easy to read and reference. It should quickly become a useful tool for health care
professionals, advocates, and educators seeking a leadership role in the fight
against diabetes.
Wanda K. Jones, DrPH
Deputy Assistant Secretary for Health (Women’s Health)
Director, U.S. Department of Health and Human Services
Office on Women’s Health
iv

---

Acknowledgments
This report was prepared by the Centers for
Contributing Authors
Disease Control and Prevention, National Center
for Chronic Disease Prevention and Health
Chapters
Promotion, Division of Diabetes Translation.
Gloria L.A. Beckles, MBBS, MSc, Medical
Epidemiologist/Senior Service Fellow, Division of
Jeffrey P. Koplan, MD, MPH, Director, Centers
Diabetes Translation, National Center for Chronic
for Disease Control and Prevention, Atlanta,
Disease Prevention and Health Promotion, Centers
Georgia.
for Disease Control and Prevention, Atlanta,
Georgia.
James S. Marks, MD, MPH, Director, National
Center for Chronic Disease Prevention and Health
Cynthia Berg, MD, MPH, Medical Officer,
Promotion, Centers for Disease Control and
Division of Reproductive Health, National Center
Prevention, Atlanta, Georgia.
for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and
Frank Vinicor, MD, MPH, Director, Division of
Prevention, Atlanta, Georgia.
Diabetes Translation, National Center for Chronic
Disease Prevention and Health Promotion, Centers
Isabella Danel, MD, MPH, Epidemiologist,
for Disease Control and Prevention, Atlanta,
Division of Reproductive Health, National Center
Georgia.
for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and
Kathy Rufo, MPH, Deputy Director, Division of
Prevention, Atlanta, Georgia.
Diabetes Translation, National Center for Chronic
Disease Prevention and Health Promotion, Centers
Kellie-Ann Ffrench, MA, Department of
for Disease Control and Prevention, Atlanta,
Psychology, University of Georgia, Athens, Georgia.
Georgia.
Catherine Hennessey, DrPh, Epidemiologist,
Editors
Division of Adult and Community Health,
Gloria L.A. Beckles, MBBS, MSc, Scientific
National Center for Chronic Disease Prevention
Editor, Medical Epidemiologist/Senior Service
and Health Promotion, Centers for Disease
Fellow, Division of Diabetes Translation, National
Control and Prevention, Atlanta, Georgia.
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and
Deanna Hill, MPH, Epidemiologist, Henry Ford
Prevention, Atlanta, Georgia.
Health System, Department of Biostatistics and
Research Epidemiology, Detroit, Michigan.
Patricia E. Thompson-Reid, MPH, MAT,
Managing Editor, Program Development
Georgeanna J. Klingensmith, MD, University of
Consultant, Division of Diabetes Translation,
Colorado Health Sciences Center, The Barbara
National Center for Chronic Disease Prevention
Davis Center for Childhood Diabetes, Denver,
and Health Promotion, Centers for Disease
Colorado.
Control and Prevention, Atlanta, Georgia.
v

---

Diabetes and Women’s Health Across the Life Stages: A Public Health Perspective
JoAnn E. Manson, MD, DrPH, Associate
Dawn L. Satterfield, RN, MSN, Health Education
Professor, Department of Epidemiology, Harvard
Specialist, Division of Diabetes Translation,
School of Public Health, Harvard University,
National Center for Chronic Disease Prevention
Boston, Massachusetts.
and Health Promotion, Centers for Disease Control
and Prevention, Atlanta, Georgia.
Lily D. McNair, PhD, Assistant Professor,
Department of Psychology, University of Georgia,
Angela Green-Phillips, MPA, Chief, Office of
Athens, Georgia.
Policy and Program Information, Division of
Diabetes Translation, National Center for Chronic
Jill M. Norris, MPH, PhD, Assistant Professor,
Disease Prevention and Health Promotion, Centers
Department of Preventive Medicine and
for Disease Control and Prevention, Atlanta,
Biometrics, University of Colorado School of
Georgia.
Medicine, Denver, Colorado.
Senior Reviewers
Diane Rowley, MD, MPH, Associate Director for
Barbara A. Bowman, PhD, Associate Director for
Science, National Center for Chronic Disease
Policy Studies, Division of Diabetes Translation,
Prevention and Health Promotion, Centers for
National Center for Chronic Disease Prevention
Disease Control and Prevention, Atlanta, Georgia.
and Health Promotion, Centers for Disease Control
and Prevention, Atlanta, Georgia.
Mary Sabolsi, MD, MPH, Brigham and Women’s
Hospital, Harvard University, Boston,
Carl Caspersen, PhD, Associate Director for
Massachusetts.
Science, Division of Diabetes Translation, National
Center for Chronic Disease Prevention and Health
Patricia E. Thompson-Reid, MPH, MAT, Program
Promotion, Centers for Disease Control and
Development Consultant, Division of Diabetes
Prevention, Atlanta, Georgia.
Translation, National Center for Chronic Disease
Prevention and Health Promotion, Centers for
Michael M. Engelgau, MD, Chief, Epidemiology
Disease Control and Prevention, Atlanta, Georgia.
and Statistics Branch, Division of Diabetes
Translation, National Center for Chronic Disease
Frank Vinicor, MD, MPH, Director, Division of
Prevention and Health Promotion, Centers for
Diabetes Translation, National Center for Chronic
Disease Control and Prevention, Atlanta, Georgia.
Disease Prevention and Health Promotion, Centers
for Disease Control and Prevention, Atlanta,
Anne Fagot-Campagna, MD, PhD, Visiting
Georgia.
Scientist, Division of Diabetes Translation, National
Center for Chronic Disease Prevention and Health
Case Studies
Promotion, Centers or Disease Control and
Ann Albright, PhD, RD, Director, California
Prevention, Atlanta, Georgia.
Diabetes Control Program, California Department
of Health, Sacramento, California.
H. Wayne Giles, MD, PhD, Associate Director for
Science, Division of Adult and Community Health,
Ann Kollmeyer, RD, MPH, Chief, Office of Policy
National Center for Chronic Disease Prevention
and Program Information, Wolf Project, Minnesota
and Health Promotion, Centers for Disease Control
Department of Health, Minneapolis, Minnesota.
and Prevention, Atlanta, Georgia.
vi

---

Document Outline

• Diabetes & Womens Health Across the Life Stages„Cover Page
  • For more information
  • Suggested citation
  • Message from Frank Vinicor, MD, MPH, Director, CDC Diabetes Program
  • Foreword
  • Acknowledgments
  • Contents
    • List of Tables and Figures
      • Table 2-1. Expectation of life, by age and sex„United States, 1979…81, 1990, 1995
      • Table 2-2. Age-specific female-male ratios, by race/Hispanic origin„United States, 1995
      • Table 2-3. Median annual income of persons aged 15 years or older, by age and sex„United States, 1995
      • Table 2-4. Percentage of persons who lived below the poverty level, by age, sex, and race/ Hispanic* origin„United States, 1995
      • Table 2-5. Percentage of adolescent females and women who were overweight in various national surveys, by age and race/Hispanic origin„United States, 1988…96
      • Table 2-6. Percentage of female high school and college students who participated in vigorous* or moderate physical activity, were enrolled in a physical education class, and played on an intramural sports team, by age, race/Hispanic origin, and grade„U
      • Table 2-7. Percentage of adolescent females and women who were overweight* or did not exercise, by race/Hispanic origin, generation, and duration of residence„United States, 1995
      • Figure 2-1. Percentage of women who lived alone, by age„United States, 1970, 1980, 1995
      • Figure 2-2. Percentage distribution of female population, by race/Hispanic* origin„United States, 1995 and 2010 (projected)
      • Figure 2-3. Projected percentage change in the number of females, by age and race/Hispanic origin„United States, 1995…2010
      • Figure 2-4. Population age structures: minority and non-Hispanic white females„United States, 1995
      • Figure 2-5. Percentage of females who lived in central cities, by age and race/Hispanic* origin„United States, 1995
      • Figure 2-6. Percentage of women completing high school and college, by race/Hispanic* origin„United States, 1970, 1985, 1995
      • Figure 2-7. Median annual income of adults aged 25 years or older, by sex and educational attainment„United States, 1995
      • Figure 2-8. Median annual earnings of women who worked full-time year round, by race/Hispanic* origin„United States, 1970…95
      • Figure 2-9. Percentage of females who lived below the federal poverty level, by age and race/Hispanic* origin„United States, 1995
      • Figure 2-10. Health insurance coverage among all females and poor* females, by race/Hispanic origin„United States, 1996
      • Figure 2-11. Type of health care insurance coverage among all females and poor* females, by race/Hispanic origin„United States, 1996
      • Table 4-1. Prevalence of diagnosed diabetes among reproductive-aged women, by race/Hispanic origin„United States, 1965…97
      • Table 4-2. Crude and age-adjusted* prevalence of diabetes during pregnancy, by race/Hispanic origin„United States, 1993…95
      • Table 4-3. Prevalence (%) of sociodemographic characteristics of women aged 18…44 years with and without type 2 diabetes, by race/Hispanic origin„United States, 1989
      • Figure 4-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults, by age and sex„NHANES III, 1988…94
      • Figure 4-2. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, by age and race/Hispanic origin„NHANES III, 1988…94
      • Figure 4-3. All-cause mortality rates for U.S. adults aged 25…44 years, by diabetes status, sex, and race/Hispanic origin, 1971…93
      • Table 5-1. Prevalence (%) of diagnosed and undiagnosed diabetes among adults aged 45…64 years, by race/Hispanic origin„United States, 1986…97
      • Table 5-2. Prevalence (%) of sociodemographic characteristics of women aged 45…64 years with and without type 2 diabetes, by race/Hispanic origin„United States, 1989
      • Table 5-3. Prevalence (%) of hypertension among adults aged 45…64 years with and without type 2 diabetes, by sex and race/Hispanic origin„United States, 1976…84
      • Figure 5-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults, by age and sex„NHANES III,* 1988…94
      • Figure 5-2. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, by age and race/Hispanic origin„NHANES III,* 1988…94
      • Figure 5-3. All-cause mortality rates for U.S. adults aged 45…64 years, by diabetes status, sex, and race/Hispanic origin, 1971…93
      • Figure 5-4a. Survival of diabetic and nondiabetic U.S. adults aged 45…54 years, by years of follow-up, 1971…93
      • Figure 5-4b. Survival of diabetic and nondiabetic U.S. adults aged 55…64 years, by years of follow-up, 1971…93
      • Table 6-1. Prevalence (%) of sociodemographic characteristics of women aged 65 years or older with and without type 2 diabetes, by race/Hispanic origin„United States, 1989
      • Table 6-2. Percentage of beneficiaries with diabetes who received recommended preventive and monitoring services in fee-for-service Medicare, by sex„United States, 1994
      • Table 6-3. Age-associated factors affecting diabetes management in older women
      • Figure 6-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults, by age and sex„NHANES III,* 1988…94
      • Figure 6-2. Number of new cases and incidence rate of diagnosed diabetes among women aged 65 years or older„NHIS,* 1980…94
      • Figure 6-3. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, by age and race/Hispanic origin„NHANES III,* 1988…94
      • Figure 6-4. All-cause mortality rates for U.S. adults aged 65…74 years, by diabetes status, sex, and race/Hispanic origin„1971…93
      • Appendix A
      • Appendix B
      • Appendix C
      • Appendix D
    • Chapter 1: Introduction
      • References
    • Chapter 2: A Profile of Women in the United States
      • 2.1. Population Size and Growth
      • 2.2. Population Composition
      • 2.3. Psychosocial Determinants of Health Behaviors and Health Outcomes
      • 2.4. Public Health Implications
      • References
    • Chapter 3: The Adolescent Years
      • 3.1. Prevalence, Incidence, and Trends
      • 3.2. Sociodemographic Characteristics
      • 3.3. Impact of Diabetes on Health Status
      • 3.4. Health-Related Behaviors
      • 3.5. Psychosocial Determinants of Health Behaviors and Health Outcomes
      • 3.6. Concurrent Illness as a Determinant of Health Behaviors and Health Outcomes
      • 3.7. Public Health Implications
      • References
    • Chapter 4: The Reproductive Years
      • 4.1. Prevalence, Incidence, and Trends
      • 4.2. Sociodemographic Characteristics
      • 4.3. Impact of Diabetes on Health Status
      • 4.4. Health-Related Behaviors
      • 4.5. Psychosocial Determinants of Health Behaviors and Health Outcomes
      • 4.6. Concurrent Illness as a Determinant of Health Behaviors and Health Outcomes
      • 4.7. Public Health Implications
      • References
    • Chapter 5: The Middle Years
      • 5.1. Prevalence, Incidence, and Trends
      • 5.2. Sociodemographic Characteristics
      • 5.3. Impact of Diabetes on Health Status
      • 5.4. Health-Related Behaviors
      • 5.5. Psychosocial Determinants of Health Behaviors and Health Outcomes
      • 5.6. Concurrent Illnesses as Determinants of Health Behaviors and Health Outcomes
      • 5.7. Public Health Implications
      • References
    • Chapter 6: The Older Years
      • 6.1. Prevalence, Incidence, and Trends
      • 6.2. Sociodemographic Characteristics
      • 6.3. Impact of Diabetes on Illness and Death
      • 6.4. Health-Related Behaviors
      • 6.5. Psychosocial Determinants of Health Behaviors and Health Outcomes
      • 6.6. Concurrent Illnesses as Determinants ofHealth Behaviors and Health Outcomes
      • 6.7. Public Health Implications
      • References
    • Chapter 7: Major Findings, Public Health Implications, and Conclusions
      • 7.1 Major Findings
      • 7.2 Public Health Implications
      • References
    • Epilogue
    • Appendix A
    • Appendix B
    • Appendix C
    • Appendix D
    • Appendix E
    • List of Abbreviations
    • Glossary

---