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### Agent Orange Brief

**Prepared by the Environmental Agents Service (131)**

D12 VA Central Office, Washington, DC 20420 August 2005

# 

##  AGENT ORANGE AND DIABETES

> **What is diabetes?**
>
> High blood sugar levels that result from defects in the body's ability
> to produce and/or resistance to the actions of the hormone insulin
> characterize diabetes. There are two major types of diabetes: type 1
> and type 2. Type 1 occurs most commonly among juveniles but
> occasionally among adults. Type 2 occurs primarily in adults and only
> occasionally in juveniles.
>
> More than 90 percent of the diabetics in the United States are type 2
> diabetics. Many of these patients initially exhibit few or no
> symptoms, although increased urination and excessive thirst may be
> present. Diabetes is associated with high levels of glucose in the
> blood. The presence of obesity or a strongly positive family history
> for mild diabetes suggests a high risk for the development of type II
> diabetes.
>
> Diabetes is the Nation's sixth-leading cause of death and the leading
> cause of blindness in the United States. It can also lead to heart
> disease, stroke, kidney failure, and amputation. Approximately 15
> percent of veterans receiving care in VA medical facilities have been
> diagnosed with diabetes. VA diabetes patients require an estimated
> \$2.5 billion dollars annually for their treatment and healthcare,
> including more than 200,000 bed-days per year.
>
> Nationally, more than 17 million people are estimated to be diabetic.
> More than \$100 billion are spent for their treatment and care
> annually. More than 650,000 additional diabetics are newly diagnosed
> each year.
>
> **Why are some Vietnam veterans worried about their risk of developing
> diabetes?**
>
> Many animal studies provide potential biological mechanisms for an
> association between herbicide exposure and diabetes risk. Although
> earlier reports on humans suggest little association, the potentially
> more definitive 1997 report from the Ranch Hand Study (the Air Force
> Health Study of the unit responsible for most of the herbicide aerial
> spraying in Vietnam) raises the possibility that veterans in the
> highest herbicide exposure category may be at increased risk.
>
> **What did the National Academy of Sciences (NAS) conclude about the
> relationship between exposure to herbicides and the development of
> diabetes in its 1993 report, entitled [Veterans and Agent Orange --
> Health Effects of Herbicides Used in Vietnam]{.underline}?**
>
> The NAS reviewers noted that there was "limited" information
> suggesting the possibility of diabetes in chemical production workers
> and Ranch Hand veterans exposed to TCDD or dioxin (the contaminant
> produced during the manufacture of one of the ingredients of Agent
> Orange), but that the data were "inconclusive." In the 1993 report,
> the NAS found that there is "inadequate or insufficient" evidence to
> determine whether an association exists between exposure to herbicides
> and diabetes mellitus.
>
> **What was VA's reaction to this NAS finding?**
>
> After careful review, Secretary Brown concluded that the credible
> evidence for an association does not equal or outweigh the credible
> evidence against an association between exposure to herbicides used in
> Vietnam and the development of metabolic and digestive disorders,
> including diabetes mellitus.
>
> In January 1994, VA published a notice in the [Federal
> Register]{.underline} that Secretary Brown has determined that a
> presumption of service connection based on exposure to herbicides in
> Vietnam is not warranted for a long list of conditions identified in
> the NAS report. A metabolic and digestive disorder, including diabetes
> mellitus, was included in this list. (See 59 [Fed. Reg.]{.underline}
> 341, January 4, 1994).
>
> **What did the 1996 NAS update conclude about diabetes?**
>
> The 1996 report again concluded that there is "inadequate or
> insufficient" evidence to determine whether an association exists
> between exposure to herbicides and diabetes mellitus.
>
> **What was VA's response to the NAS 1996 finding regarding diabetes?**
>
> After careful review, VA's Secretary Brown concluded that the credible
> evidence for an association does not equal or outweigh the credible
> evidence against an association between exposure to herbicides used in
> Vietnam and the development of metabolic and digestive disorders,
> including diabetes mellitus.
>
> In August 1996, VA published a notice in the [Federal
> Register]{.underline} that Secretary Brown has determined that a
> presumption of service connection based on exposure to herbicides in
> Vietnam is not warranted for a long list of conditions identified in
> the NAS report. Metabolic and digestive disorders, including diabetes
> mellitus was included in this list. (See 61 [Fed. Reg.]{.underline}
> 41442, August 8, 1996).
>
> **What did the 1998 NAS update conclude about diabetes?**
>
> Like the two earlier NAS reports, the 1998 report again concluded that
> there is "inadequate or insufficient" evidence to determine whether an
> association exists between exposure to herbicides and diabetes
> mellitus. The 1998 update "strongly" urged that the National Institute
> for Safety and Health (NIOSH) study be documented more completely and
> published in the peer-review literature of dioxin-exposed workers, so
> that its potentially important findings can be fully evaluated. The
> NAS report "strongly" recommended that the Ranch Hand study develop a
> fully adjusted multivariate model, fully controlling for baseline age
> and obesity and, if possible, for family history of diabetes, central
> fat distribution, diabetogenic drug exposure, and a measure of obesity
> at the time of Vietnam service.
>
> The NAS reviewers also recommended that consideration be given to a
> combined analysis of Ranch Hand and NIOSH studies to further examine
> the possibility that herbicide or dioxin exposure leads to an
> increased risk of diabetes. The NAS added that using the "new"
> American Diabetes Association (ADA) definition of diabetes, outcome
> data from both studies could be made comparable.
>
> **What was VA's response to the NAS 1998 report regarding diabetes?**
>
> Shortly after the NAS report was released, one additional important
> study was published (Calvert GM, Sweeney MH, Deddens J, Wall DK. 1999.
> An evaluation of Diabetes Mellitus, Serum Glucose, and Thyroid
> Function Among U.S. Workers Exposed to
> 2,3,7,8-tetrachlorodibenzo-p-dioxon. [Occupational and Environmental
> Medicine]{.underline} 56:270-276). This led Secretary West to request
> that the NAS review its previous finding in light of this recent
> paper. This special, expedited review was completed in May 2000 but
> was delayed, at VA request, to allow for consideration of a Ranch Hand
> report which included important findings regarding diabetes. On
> October 11, 2000, NAS released its report, which noted that diabetes
> should be included in category two (limited/suggestive evidence of an
> association). On November 9, 2000, Acting Secretary Gober announced
> that VA would presumptively recognize diabetes for service connection.
> Implementing proposed regulations were published in the federal
> register in January 2001 (See 66 [Fed. Reg]{.underline}. 2376 January
> 2001.) The final rule was published in May 2001 See 66 [Fed.
> Reg]{.underline}. 2316 May 8, 2001.
>
> **What did the NAS conclude regarding diabetes in subsequent
> updates?**
>
> In the 2000, 2002, and 2004 updates the NAS concluded that there is
> limited/suggestive evidence of an association between exposure to
> herbicides and diabetes.
>
> **What about type 1 diabetes**?
>
> The NAS conclusions were limited to type 2 diabetes. Consequently, VA
> presumptive service -- connection was restricted to type 2 diabetes.
>
> **What is VA doing with the American Diabetes Association (ADA) on
> behalf of veterans with diabetes?**
>
> On March 3, 1998, VA and the ADA signed a Memorandum of Understanding
> and announced that they would collaborate in determining the most
> effective ways to treat diabetes. This includes assessing blood
> monitoring devices and other technology; sharing information to guide
> research and further collaboration; and exploring the exchange of
> benchmarking information on quality cost, and productivity.
>
> The ADA is the largest voluntary health organization dedicated to
> diabetes research. It operates programs in all 50 States and in more
> than 800 communities.
>
> **Where can a veteran get additional information about diabetes?**
>
> For additional information please see, our Web site at
> [www.va.gov/diabetes](http://www.va.gov/diabetes).
>
> Information regarding diabetes and related matters can be obtained at
> public libraries. Information about diabetes an Agent Orange exposure
> can be obtained from the Environmental Health Clinicians at every VA
> medical center, from the Environmental Agents Service (131),
> Department of Veterans Affairs, 810 Vermont Avenue, N.W., Washington,
> DC 20420. Private health organizations, such as the JDF the ADA, also
> may be helpful.
>
> **Where can a veteran get additional information regarding Agent
> Orange - related issues?**
>
> The following Agent Orange fact sheets (including the one you are
> reading) are available on the World Wide Web at
> [www.va.gov/AgentOrange](http://www.va.gov/AgentOrange): **A1**.Agent
> Orange - General Information; **A2**.Agent Orange Class Action
> Lawsuit; **B1**.Agent Orange Registry Program; **B2**.Agent Orange --
> Health Care Eligibility; **B3**.Agent Orange and VA Disability
> Compensation; **B4**.VA Information Resources on Agent Orange and
> Related Matters; **C1**.Agent Orange -- The Problem Encountered in
> Research; **C2**.Agent Orange and Vietnam Related Research -- VA
> Projects; **C3**.Agent Orange and Vietnam Related Research -- Non-VA
> Projects; **D1**.Agent Orange and Birth Defects; **D2**.Agent Orange
> and Chloracne; **D3**.Agent Orange and Non-Hodgkin's Lymphoma;
> **D4**.Agent Orange and Soft Tissue Sarcomas; **D5**.Agent Orange and
> Peripheral Neuropathy; **D6**.Agent Orange and Hodgkin's Disease;
> **D7**.Agent Orange and Porphyria Cutanea Tarda; **D8**.Agent Orange
> and Multiple Myeloma; **D9**.Agent Orange and Respiratory Cancers;
> **D10**.Agent Orange and Prostate Cancer; **D11**.Agent Orange and
> Spina Bifida; **D12.**Agent Orange and Diabetes; and **D13**.Agent
> Orange and Chronic Lymphocytic Leukemia. Hard copies can be obtained
> from local VA medical centers or from the VA Central Office at the
> Environmental Agents Service (131) Department of Veterans Affairs, 810
> Vermont Avenue, N.W., Washington, DC 20420.
>
> At the same Web site you will find copies of past and current issues
> of the "Agent Orange Review" newsletter and other items of interest.
>
> **This fact sheet was updated in August 2005 and does not include
> subsequent developments**.