MESSAGE FROM THE SECRETARY 

Currently, more than 18 million Americans have diabetes and are at risk for related 

complications like heart disease, stroke, blindness, amputations and kidney disease. On average, 

every 25 seconds, someone in the United States is diagnosed with diabetes. Diabetes rates are 

steadily increasing in America, and millions are unaware that they have the disease. 

Yet these facts do not tell the whole story of the true impact that diabetes has on Americans. 

Diabetes touches millions of Americans and their families and friends in ways that are difficult if 

not impossible to measure. Diabetes and its complications seriously diminish the quality of life 

for individuals suffering from this disease. In order to reverse these trends, the U.S. Department 

of Health and Human Services has increased its efforts to address this health crisis. 

I am proud to present our Diabetes: A National Plan for Action. This plan will help mobilize 

individuals, communities, businesses, and other organizations to address the rising rates of 

diabetes and its consequences. Many key stakeholders, such as government agencies, elected 

officials, public health experts, providers, professional organizations, and individuals impacted 

by diabetes, contributed to this document. 

The document provides up-to-date and accurate prevention, detection and treatment information, 

and includes simple action steps for individuals, families, health practitioners, policy-makers, 

government officials, employers, others in the medical community and members of the media to 

address this growing public health problem. It also provides screening tools, information on 

other federal diabetes programs, and listings of federally funded resources. We hope that this 

document not only will be informative, but also will encourage all interested persons to work 

together to reduce the burden that diabetes imposes on our nation. Only by joining together can 

we overcome this public health threat and secure a healthier future for our children. No effort is 

too small, and no specialized training is required, to begin to improve your health or the health of 

your family or community. 

I thank the many public and private health professionals who have pooled their talents to develop 

this document and for their tireless efforts in diabetes prevention, detection, and treatment. 

Tommy G. Thompson 

Acknowledgements: 

The Diabetes: A National Plan for Action is the result of the dedication and determination of 

many groups and individuals. The Department would like to thank all those who participated in 

creating this document. 

Special thanks to the American Diabetes Association, the Juvenile Diabetes Research Foundation 

International, the American Association of Diabetes Educators, and the American Dietetic 

Association for their participation at the town hall meetings. 

The Department would like to thank the following individuals for their participation on the 

expert panels at the town hall meetings: The Honorable Jennette Bradley, Lieutenant Governor 

and Director of Commerce for Ohio; J. Nick Baird, MD, Director, Ohio Department of Health; 

James Holsinger, PhD, Secretary of the Cabinet for Health Services, Kentucky; Steve Collier, 

Superintendent, Norwood City Schools; Jerry Mallicoat, Vice President of Midwest Marketing, 

Anthem Blue Cross/Blue Shield; Francine Kaufman, MD, Past President, American Diabetes 

Association; Nicole Johnson, Miss America 1999; The Honorable Mike Huckabee, Governor of 

Arkansas; Fay Boozman, MD, MPH, Director, Arkansas Department of Health; Virginia 

Zamudio, RN, MSN, CDE, Past President, American Association of Diabetes Educators; Victor 

H. Gonzalez, MD, National Board Member, American Diabetes Association; Simmie 

Armstrong, Jr., MD, Pine Bluff Family Medical Center, Arkansas; The Honorable George R. 

Nethercutt, Jr., JD, U.S. House of Representatives, Chairman of the Congressional Diabetes 

Caucus; Mary Selecky, Secretary, Washington Department of Health; Steven Kahn, MB, ChB, 

Director of Research and Development, VA Puget Sound Health Care System; Gerald Nepom, 

MD, PhD, Director, Benaroya Research Institute at Virginia Mason, Juvenile Diabetes Research 

Foundation International; Joe Finkbonner, R.Ph, MHA, Director of the Epidemiology Center, 

Northwest Portland Area Indian Health Board; Bradley J. Enegren, Vice President and General 

Manager, Research and Development, Medtronic, Inc.; Angela Bartels, RN, BSN, Diabetes 

Coordinator, 45th Street Medical Clinic, Seattle, Washington. 

The Department would also like to thank all of the agencies and offices of HHS for their 

contributions, especially: the Office of the Assistant Secretary for Planning and Evaluation, the 

Office of the Surgeon General, the Office of Intergovernmental Affairs, the Office of Minority 

Health, National Institutes of Health, the Centers for Disease Control and Prevention, the Health 

Resources and Services Administration, and the Administration on Aging. 

In addition, the Department would like to thank the Internal Advisory Committee: Kevin Keane, 

Assistant Secretary for Public Affairs; Howard Zucker, MD, JD, LLM, Acting Deputy Assistant 

Secretary for Health, Office of Public Health and Science; Garth Graham, MD, MPH, Acting 

Deputy Assistant Secretary for Minority Health, Office of Minority Health; Nathan Stinson, Jr., 

PhD, MD, MPH, formerly the Deputy Assistant Secretary for Minority Health, Office of 

Minority Health; Carolyn Clancy, MD, Director, Agency for Healthcare Research and Quality; 

John Wren, Director for Planning and Policy Development, Administration on Aging; Frank 

Vinicor, MD, Director, Division of Diabetes Translation, Centers for Disease Control and 

Prevention; Sean Tunis, MD, Chief Medical Officer/Director, Office of Clinical Standards and 

Quality, Centers for Medicare & Medicaid Services; Lester Crawford, DVM, PhD, Deputy 
Commissioner of Food and Drugs, Food and Drug Administration; Sam Shekar, MD, MPH, 

Associate Administrator, Bureau of Primary Health Care, Health Resources and Services 

Administration; Craig Vanderwagen, MD, Acting Chief Medical Officer, Indian Health Service; 

and Allen Spiegel, MD, Director, National Institute of Diabetes and Digestive and Kidney 

Diseases, National Institutes of Health. 

The Department extends additional thanks to Mary Mazanec, MD, JD, Wilma Tilson, MPH, and 

Ann Albright, PhD, RD, for their hard work in developing this document and acknowledges the 

work of the Research Triangle Institute International in this endeavor. 

Michael O’Grady, PhD 

Assistant Secretary of Planning and Evaluation 
CONTENTS

Section Page

Executive Summary................................................................................................................. iii 

Introduction................................................................................................................................1 

What Is Diabetes? .............................................................................................................4

Risk Factors for Diabetes..................................................................................................5 

Health Problems Related to Diabetes ...............................................................................7 

Diabetes: A National Plan for Action.............................................................................10 

Prevention ................................................................................................................................13 

Importance of Diabetes Prevention.................................................................................13 

Action Steps for Prevention............................................................................................14 

Detection..................................................................................................................................23 

The Importance of Early Diabetes Detection .................................................................23 

Action Steps for Detection..............................................................................................25 

Treatment .................................................................................................................................31 

The Importance of Diabetes Treatment and Management..............................................31 

Action Steps for Treatment.............................................................................................31 

List of Acronyms and Abbreviations......................................................................................43 

Appendices 

Appendix A: Steps to a HealthierUS.................................................................................45 

Appendix B: Medicare and Diabetes.................................................................................51 

Appendix C: Development of Diabetes: A National Plan for Action................................55 

Appendix D: Current Federal Diabetes Activities/Highlights...........................................63 

Appendix E: Are You at Risk for Diabetes?......................................................................75 

i 
FIGURES 

Number Page

1. Prevalence of Diagnosed and Projected Diagnosed Diabetes Cases in the United 

States, 1960- 2050 ............................................................................................................1

2. Age-Adjusted Total Prevalence of Diabetes in People Aged 20 Years or Older, by 

Race/Ethnicity: United States, 2002 ................................................................................2 

3. Body Mass Index ...................................................................................................................7 

4. Prevalence of diabetic retinopathy among adults 40 years and older (2000) ........................7 

5. Primary causes for kidney failure (1998)...............................................................................8 

6. Projected increase in total heart disease deaths related to increased diabetes 

prevalence .........................................................................................................................8 

7. Age-standardized Rate of Hospital Discharge for Non-traumatic Lower Extremity 

Amputation per 1,000 Diabetic Population, by Race, United States, 1980-2001.............9 

8. Vigorous physical activity in adolescents by grade level, 2001 ..........................................13 

TABLES 

Number Page

1. Risk Factors and Associated Medical Conditions for Diabetes.............................................6 

2. Signs and Symptoms of Diabetes ........................................................................................24 

3. Symptoms of Hypoglycemia and Hyperglycemia ...............................................................32 

4. Diabetes Care Checklist.......................................................................................................34 

5. Examples of Items to Include in Flow Chart for Patients with Diabetes.............................36 

ii
EXECUTIVE SUMMARY 

Currently, more than 18 million Americans have diabetes and projections show that the 

number of persons with the disease will continue to grow without public health intervention.1

Diabetes consists of a group of diseases in which the body is unable to produce insulin (type 1 

diabetes) or makes too little insulin and resists its action (type 2 diabetes). In addition to diabetes, 

an estimated 41 million Americans have pre-diabetes, a condition that puts them at high risk for 

developing type 2 diabetes.2 If current trends continue, one in every three children born in the 

year 2000 will develop diabetes within their lifetime.3 Diabetes often causes severe 

complications that can include heart disease and stroke, blindness, lower extremity amputations, 

kidney failure, dental disease, and increased susceptibility to infections.4 In addition to the 

personal and social costs resulting from impaired health and quality of life for people affected by 

diabetes, the disease also carries significant economic costs. Estimates suggest the cost of 

diabetes to be about $132 billion per year.5 

Diabetes is a serious public health problem, but the good news is that important advances 

are being made in prevention, detection, and treatment of diabetes. For example, the Diabetes 

Control and Complications Trial established that intensive control of blood glucose levels greatly 

reduces complications for people with type 1 diabetes, and the U.K. Prospective Diabetes Study 

has shown similar dramatic reductions in complications with control of blood glucose for 

persons with type 2 diabetes.6 In 2002, results from the Diabetes Prevention Program

demonstrated that type 2 diabetes can be prevented or delayed by weight loss and increased 

physical activity for many people at risk for the disease.7 These findings provide exciting 

evidence that the potentially devastating consequences of diabetes can be reduced dramatically. 

 

1 Centers for Disease Control and Prevention (CDC). (2003). Promising practices in chronic disease prevention and

control: A public health framework for action. Atlanta, GA: Department of Health and Human Services.

2 U.S. Department of Health and Human Services. Prevention: A blueprint for action. Available at: 

http://aspe.hhs.gov/health/blueprint/. 

3 Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. (2003). Lifetime risk for diabetes mellitus 

in the United States. Journal of the American Medical Association, 290(14), 1884-1890. 

4 CDC, op.cit. 

5 American Diabetes Association (ADA). (2003) Economic costs of diabetes in the U.S. in 2002. Diabetes Care, 26, 

917-932. 

6 The Diabetes Control and Complications Trial Research Group (1993). The effect of intensive treatment of 

diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. 

The New England Journal of Medicine, 329(14), 977-986; and Turner, RC. (1998). The U.K. prospective 

diabetes study: A review. Diabetes Care, 21(Suppl. 3), C35-C38.

7 Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle

intervention or Metformin. New England Journal of Medicine, 346(6), 393-403. 

iii
However, without significant action, the prevalence of diabetes, together with diabetes-related 

complications, will continue to increase. 

To help ensure that Americans take the steps needed to quell the growing diabetes 

problem, Secretary of Health and Human Services Tommy G. Thompson has identified diabetes 

prevention, detection, and treatment as one of the central components of his health agenda for the 

nation. Activities supporting the Secretary’s focus on diabetes include Steps to a HealthierUS: 

Putting Prevention First, the Diabetes Detection Initiative, and the Small Steps, Big Rewards, 

Prevent Type 2 Diabetes campaign. In addition, the Medicare Prescription Drug, Improvement, 

and Modernization Act (MMA) of 2003, establishes coverage of a one-time “Welcome to 

Medicare Physical Examination” within 6 months of a beneficiary’s first coverage under Part B 

to encourage health promotion and disease detection. The MMA also adds coverage for 

cardiovascular and diabetes screening for Medicare beneficiaries. Both benefits take effect 

January 1, 2005. More information on MMA and Medicare benefits in general can be found at 

http://www.medicare.gov/ or 1-800-Medicare (1-800-633-4227). Appendix B provides additional 

information on diabetes benefits offered through Medicare. 

The Diabetes: A National Plan for Action is the latest initiative sponsored by the U.S. 

Department of Health and Human Services to address diabetes prevention, detection, and 

treatment. Prompted by the Secretary’s commitment to disease prevention and health promotion, 

together with efforts of individuals and organizations—including the American Diabetes 

Association, Juvenile Diabetes Research Foundation International, American Association of 

Diabetes Educators, and other professional associations—the national action plan utilizes a 

comprehensive action-oriented approach to identify activities among relevant stakeholders to 

improve diabetes prevention, detection, and care. 

This document is designed to: 

1. Reduce the prevalence of diabetes and factors that increase the risk of diabetes; 

2. Promote improved diabetes detection, monitoring, and treatment; and 

3. Reduce the complications of diabetes. 

The plan seeks to raise national awareness of existing resources, facilitate and coordinate efforts, 

and leverage resources for the prevention, detection, and treatment of diabetes. In addition, the 

plan outlines steps individual Americans can take to help prevent or delay type 2 diabetes, 

together with recommendations persons already diagnosed with diabetes can use to prevent or 

iv
delay complications from the disease. However, individual action alone is not sufficient for 

addressing diabetes. Thus, the plan also recommends and outlines action steps for families, 

friends, health care providers, schools, the media, communities, health insurance providers, 

employers, researchers and professional educators, and tribal and other government agencies, to 

help mitigate the increase in the prevalence of diabetes and its complications. Additional 

information and resources about diabetes prevention, detection, and treatment are also provided. 

v
vi
INTRODUCTION 

Diabetes is approaching epidemic proportions in the United States. More than 18 million 

Americans today have diabetes. Approximately 41 million Americans have pre-diabetes,8 which 

means they are at high risk for developing type 2 diabetes.9 For people with diabetes, blood 

glucose (sugar) levels are elevated either because the body cannot make adequate amounts of the 

hormone insulin and/or its cells do not respond to insulin.10 

Figure 1. Prevalence of Diagnosed and Projected 

Diagnosed Diabetes Cases in the United States, 1960- 

2050 

SOURCE: Data for 1960–1998 from the National Health Interview 

Survey, National Center for Health Statistics (NCHS). Centers for 

Disease Control and Prevention (CDC) projected data for 2000–2050 

from the Behavioral Risk Factor Surveillance System, Division of 

Diabetes Translation, CDC. (Note: The “Diagnosed cases” arrow refers 

to the section of the figure that includes diagnosed cases of diabetes 

versus the section that includes projected cases. The line graph and not 

the line arrow indicate the number of diagnosed cases.) 

Over the past half century, 

there has been a four- to eight-fold 

increase in the prevalence of 

diagnosed cases of diabetes in the 

U.S.11 In 2002, the prevalence of 

diagnosed diabetes among people 

aged 20 years or older was 8.7 

percent and among 60 years or older 

was 18.3 percent.12 From 1997 

through 2002, the number of new 

cases of diagnosed diabetes per year 

increased from 878,000 to 1,291,000 

(a 47 percent increase).13 Projections 

of diabetes for future years are not 

encouraging (Figure 1). A 165 

percent increase in the number of 

persons with diabetes in the U.S. is 

 

8 Pre-diabetes is a condition defined by impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both. 

9 CDC, op.cit. 

10 ibid. 

11 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Atlanta, GA, U.S. Department

of Health and Human Services. Available at: http:www.cdc.gov/diabetes/statistics/index.htm; and Kenny SJ,

Aubert RE, Geiss LS. Prevalence and incidence of non-insulin-dependent diabetes, in Harris MI, Cowie CC, 

Stern MP, Boyko EJ, Reiber GE, Bennette Ph (eds). (1995). Diabetes in America, 2nd ed. Bethesda, MD: 

National Institutes of Health. 

12 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Atlanta, GA, U.S. Department

of Health and Human Services. Available at: http:www.cdc.gov/diabetes/statistics/index.htm.

13 Centers for Disease Control and Prevention (CDC). Diabetes Surveillance System. Incidence of diabetes. 

Available at: http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm. Accessed September 15, 2004.

1 
projected through 2050, with a rise from 11 million to 29 million diagnosed persons of all ages.14

Without preventive action, one in every three children born in the year 2000 will develop 

diabetes in their lifetime.15 

Figure 2. Age-Adjusted Total Prevalence of Diabetes in People Aged 20 Years or Older, by

Race/Ethnicity: United States, 2002 

SOURCE: 1999-2001 National Health Interview Survey and 1999-2000 National Health and Nutrition Examination Survey

estimates projected to year 2002. 2002 outpatient database of the Indian. (Note: Whites refers to non-Hispanic Whites, and

Blacks refers to non-Hispanic Blacks). 

*AI/AN who receive care from the IHS. 

In addition, minority populations are disproportionately affected by diabetes (Figure 2). 

On average Blacks, Hispanics, and American Indians and Alaska Natives are more likely (1.6 to 

2.3 times as likely) to have diabetes than non-Hispanic Whites.16 Rates of diabetes-related deaths 

 

14 Boyle JP, Honeycutt AA, Narayan KM, Hoerger TJ, Geiss LS, Chen H, Thompson TJ. (2001). Projection of

diabetes burden through 2050: Impact of changing demography and disease prevalence in the U.S. Diabetes 

Care, 24(11), 1936-1940. 

15 Narayan, op.cit. 

16 Centers for Disease Control and Prevention (CDC). (2003). National diabetes fact sheet: General information

and national estimates on diabetes in the United States. Atlanta, GA: U.S. Department of Health and Human 

2
are higher among Blacks, American Indians, and Hispanics than for Whites,17 and diabetes is the 

5th leading cause of death for Asian and Pacific Islanders.18 Certain minority groups also have 

much higher rates of diabetes-related complications, in some cases as much as 50 percent more 

than the diabetes population. For example, Blacks are more likely to have serious complications 

from diabetes, such as end-stage renal disease and lower extremity amputations.19

Costs of diabetes are high in both human and economic terms. While estimating the 

national costs for diabetes over time is difficult because of changes in the U.S. population and 

changes in the cost of health care services, evidence suggests that these costs are high and rising. 

The American Diabetes Association (ADA) estimated the national cost of diabetes for 2002 to be 

approximately $132 billion: $92 billion for direct medical expenditures and $40 billion for 

indirect costs, such as lost work days, restricted activity days, and mortality and permanent 

disability due to diabetes.20 Research from the Centers for Disease Control and Prevention 

(CDC) indicates that people with diabetes miss 8.3 days per year from work, compared to 1.7 

days for people without diabetes.21 In the same ADA study, it is projected that the annual costs 

of diabetes (in 2002 dollars) could rise to $156 billion by 2010 and to $192 billion in 2020. By 

2020, direct medical costs are estimated to increase to $138 billion and indirect costs from lost 

productivity could increase to $54 billion.22

 Services, Centers for Disease Control and Prevention. Available at: 

http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf. 

17 ibid. 

18 National Center for Health Statistics. (2003). 15 Leading causes of death for Asian and Pacific Islanders, 2001

Chart, Health, United States, 2003. Atlanta, GA: U.S. Department of Health and Human Services, Centers for 

Disease Control and Prevention. Available at http://www.omhrc.gov/healthgap/datastats_aapi1.pdf. 

19 World Health Organization. Global strategy on diet, physical activity and health. Available at: 

http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf. Accessed May 28, 2004; Centers for Disease

Control and Prevention (CDC). (2003). Diabetes surveillance, 2003. [Statistics. 2003 surveillance report]. 

Atlanta: National Center for Chronic Disease and Prevention and Health Promotion, Centers for Disease Control

and Prevention. Available at: http://www.cdc.gov/diabetes/statistics/esrd/Fig5.htm; Agency for Healthcare 

Research and Quality (AHRQ). (2001). Diabetes disparities among racial and ethnic minorities. (AHRQ Pub.

NO. 02-P007). Rockville, MD: AHRQ. Available at http://www.ahrq.gov/research/diabdisp.htm; and Gornic, 

ME, Eggers P.W, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC. (1996). Effects of race 

and income on mortality and use of services among Medicare beneficiaries. New England Journal of Medicine, 

335(11), 791-799. 

20American Diabetes Association (ADA). Direct and indirect costs of Diabetes in the United States. (2003). 

Available at: http://www.diabetes.org/diabetes-statistics/cost-of-diabetes-in-us.jsp. Accessed September 15, 

2004; and ADA, op.cit., Economic costs of diabetes. 

21 Centers for Disease Control and Prevention (CDC). Fact sheet,Diabetesatwork.org. Available at: 

http://www.cdc.gov/diabetes/pubs/factsheets/atwork.htm. 2004.

22 ADA, op.cit., Economic costs of diabetes. 

3
What Is Diabetes? 

Diabetes is typically classified according to three main types—type 1 diabetes, type 2

diabetes including a related condition called pre-diabetes, and gestational diabetes. 

Type 1 diabetes (previously called “juvenile diabetes”) is an autoimmune disorder in

which the insulin producing beta cells are destroyed by the body’s immune system. As a 

result the body is unable to produce insulin. Without insulin, the body is unable to use 

glucose (sugar) as energy for everyday activities. Individuals with type 1 diabetes must 

take insulin by injection or pump every day to survive. This type of diabetes occurs in 5 

percent to 10 percent of Americans who are diagnosed with diabetes. Children and 

adolescents are most often diagnosed with type 1 diabetes although a significant portion 

of those with type 1 diabetes are diagnosed as adults. 

Type 2 diabetes (previously called “adult onset diabetes”) is the most common form of 

diabetes, accounting for about 90 percent to 95 percent of all diabetes cases. In this type of 

diabetes, the body does not produce enough insulin and/or the body’s cells become

resistant to insulin. Insulin resistance occurs when the body’s muscle, fat, and liver cells 

do not respond to insulin. The pancreas tries to keep up with the demand for insulin by 

producing more. Since insulin helps to mobilize glucose from the blood stream into cells, 

excess glucose builds up in the blood stream. Many people with insulin resistance have 

high levels of blood glucose and high levels of insulin circulating in their blood at the 

same time indicating that the cells are not responding properly to insulin. 

A related condition, called pre-diabetes, occurs when a person’s blood sugar levels are 

higher than normal, but not high enough for a diagnosis of diabetes. People with prediabetes have impaired fasting glucose (fasting blood sugar level is 100 to 125 milligrams

per deciliter [mg/dl]) or impaired glucose tolerance (blood sugar level is 140 to 199 mg/dl 

after a 2-hour oral glucose tolerance test).23 

People with pre-diabetes and type 2 diabetes often do not show symptoms and they do 

not know that they have the conditions. The Diabetes Prevention Program—a major 

clinical trial in 3,234 people with impaired glucose tolerance—showed that in some

individuals the loss of 5 percent to 7 percent of body weight reduced their risk of 

 

23 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Insulin resistance and pre-diabetes. 

NIH Publication No. 04-4893. Available at: http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/index.htm.

2004. 

4
developing type 2 diabetes by 58 percent.24 This study also suggested that people with 

pre-diabetes can prevent or delay the development of type 2 diabetes through lifestyle 

changes that include eating a low-calorie, low-fat diet to lose weight and getting 150 

minutes of physical activity a week.25 

Gestational diabetes is a form of diabetes that occurs in some women who have high 

blood glucose levels during pregnancy but have never had diabetes before. This type of 

diabetes may disappear after the pregnancy ends, but women who have had gestational 

diabetes have a 20 percent to 50 percent chance of developing type 2 diabetes in the next 

5 to 10 years.26 

 Risk Factors for Diabetes 

Diabetes occurs in people of all ages and racial and ethnic groups. Researchers do not 

fully understand the cause of type 1 diabetes or what can be done to prevent it. Research suggests 

that type 1 diabetes has a strong genetic basis that is modified by environmental factors. Certain 

viruses are among the factors that have been suggested, but the definitive factors have yet to be 

determined.27 Having a family member with type 1 diabetes puts one at higher risk for 

developing the disease.28 However, most type 1 diabetes patients do not have a family history of 

the disease. Research is currently being done to learn more about the genetic and environmental 

factors important in type 1 diabetes. 

 

24 Diabetes Prevention Program Research Group, op.cit. 

25 ibid. 

26 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). What I need to know about

gestational diabetes. NIH Pub No. 04-5129. Available at: http://diabetes.niddk.nih.gov/dm/pubs/gestational/#3. 

Accessed May 28, 2004. 

27 Graves PM, Norris JM, Pallansch MA, Gerling IC, Rewers M. (1997). The role of enterviral infections in the 

development of IDDM: Limitations of current approaches. Diabetes, 46: 161-168; and Salminen KK, Vuorinen

T, Oikarinen S, Helminen M, Simell S, Knip M, Ilonen J, Simell O, and Hyöty H. (2004). Isolation of

enterovirus strains from children with preclinical type 1 diabetes. Diabetes Medicine, 21:156-164. 

28 Diabetes Research Working Group. Conquering Diabetes: Highlights of program efforts, research advances and 

opportunities. Available at: http://www.niddk.nih.gov/federal/dwg/2002/3summary.pdf. 2002. 

5
Table 1. Risk Factors and Associated Medical Conditions for Diabetes 

Risk Factor 

Type 1

Diabetes

Type 2

Diabetes Pre-diabetes

Gestational 

Diabetes

Family History 

Family member with diabetes X X X X 

Lifestyle 

Overweight or obesity X X X 

Sedentary lifestyle (exercise fewer than three times per week) X X X 

Associated Medical Conditions or Events

Impaired glucose tolerance or impaired fasting glucose X X X 

High blood pressure X X 

Low HDL cholesterol and/or high triglycerides X X 

History of gestational diabetes X X X 

Delivered baby 9 lbs. or heavier X X X 

Race/Ethnicity

Black X X X

Hispanic/Latino American X X X

Native American X X X

Asian American X X X

Native Hawaiian or Pacific Islander ancestry X X X

SOURCES: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Am I at risk for type 2 diabetes? NIH Publication No. 04-

4805. Available at: http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/. Insulin resistance and pre-diabetes. Available at: 

http://diabetes.niddk.nih.gov/dm/pubs/insulinresistance/. What I need to know about gestational diabetes. NIH Pub No. 04-5129. Available at: 

http://diabetes.niddk.nih.gov/dm/pubs/gestational/#3. Accessed May 28, 2004. 

Research conducted to date has identified specific risk factors related to the development 

of type 2 diabetes, pre-diabetes, and gestational diabetes, including family history, a sedentary 

lifestyle, and overweight or obesity (Table 1). Maintaining a healthy weight as measured by 

body mass index (BMI) reduces one’s risk for developing type 2 diabetes, pre-diabetes, or 

gestational diabetes.29 BMI is a measure of weight in relation to height (see Figure 3). Studies 

have shown that BMI is significantly correlated with body fat content for most adults. For adults, 

a BMI less than 25 is considered a healthy weight. Regular physical activity and eating a healthy 

diet can help attain and maintain a healthy weight. 

 

29National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). National diabetes statistics. NIH 

Publication No. 04-3892. Available at: http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm. 2004; and 

Diabetes Prevention Program Research Group, op.cit. 

6
Figure 3. Body Mass Index 

SOURCE: The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001

Health Problems Related to Diabetes 

Diabetes can have a significant impact on quality of life by increasing risk for a variety of 

complications. These include: 

Figure 4. Prevalence of diabetic retinopathy 

among adults 40 years and older (2000)

SOURCE: National Institutes of Health, National Eye Institute

data from Prevalence and Causes of Visual Impairment and

Blindness Among Adults 40 Years and Older in the United 

States, http://www.nei.nih.gov/eyedata/. 

 Blindness—Diabetes is the 

leading cause of new cases 

of blindness among adults 

aged 20 to 74 years, with 

the greatest number in 

adults 65 years and older 

(Figure 4). Retinopathy 

causes 12,000 to 24,000 

new cases of blindness each 

year in people with 

diabetes.30

 

30 CDC, National diabetes fact sheet, op.cit. 

7
 Kidney Disease—Diabetes 

is the leading cause of endstage kidney disease, 

accounting for 43 percent 

of new cases each year 

(Figure 5).31 In 2001, 

nearly 43,000 people with 

diabetes began treatment 

for end-stage kidney 

disease and approximately 

143,000 people with endstage kidney disease were 

living on chronic dialysis 

or with a kidney transplant 

due to diabetes.32 The rate of diabetic end-stage kidney disease is 2.6 times higher 

among Blacks than among Whites.33

Figure 5. Primary causes for kidney failure (1998) 

SOURCE: National Institute of Diabetes and Digestive Kidney Diseases

(1998). Accessed at 

http://kidney.niddk.nih.gov/kudiseases/pubs/kdd/index.htm. 

Glomerulonephritis is a variety of kidney disease characterized by

inflammation of the capillaries. 

 High Blood Pressure—About 73 percent of adults with diabetes have blood pressure 

greater than or equal to 140/90 mm Hg or use prescription medications for 

hypertension.34

Figure 6. Projected increase in total heart 

disease deaths related to increased diabetes 

prevalence

SOURCE: Unpublished estimates from the National 

Heart, Lung and Blood Institute, October 18, 2002. 

 Heart Disease and Stroke—About 

65 percent of deaths among people 

with diabetes are due to heart 

disease and stroke.35 Adults with 

diabetes have heart disease death 

rates about two to four times 

higher than adults without 

diabetes. It is projected that in the 

year 2025, twenty-nine percent of 

all heart disease deaths will be due 

 

31 ibid. 

32 ibid. 

33 AHRQ, op.cit

34 CDC, National diabetes fact sheet, op.cit. 

35 ibid. 

8
to diabetes (Figure 6). The risk for stroke is two to four times higher among people 

with diabetes. 

 Nervous System Disease—About 60 to 70 percent of people with diabetes have mild 

to severe forms of nervous system damage including impaired sensation or pain in the 

feet or hands, carpal tunnel syndrome, slowed digestion of food in the stomach, and 

other nerve problems.36 Severe forms of nerve disease are a major contributing cause 

of lower-extremity amputations for people with diabetes. 

 Dental Disease—Gum disease is more common among people with diabetes. Among 

young adults, those with diabetes have about twice the risk of developing gum disease 

as those without diabetes. Almost one third of people with diabetes have severe gum

diseases. 

 Amputations—More 

than 60 percent of 

nontraumatic lowerlimb amputations occur 

among people with 

diabetes.37 In 2000–

2001, about 82,000 

nontraumatic lowerlimb amputations were 

performed annually 

among people with 

diabetes.38 Blacks have 

higher rates of lower 

extremity amputations 

than Whites (see Figure 

7).39

 Pregnancy 

Complications—Poorly controlled diabetes before conception and during the first 

Figure 7. Age-standardized Rate of Hospital Discharge for 

Non-traumatic Lower Extremity Amputation per 1,000 

Diabetic Population, by Race, United States, 1980-2001

SOURCE: Centers for Disease Control and Prevention, National Center for 

Health Statistics, Division of Health Care Statistics, data from the National 

Hospital Discharge Survey and Division of Health Interview Statistics, data

from the National Health Interview Survey. 

U.S. Bureau of the Census, census of the population and population estimates 

and Centers for Disease Control and Prevention, National Center for Health 

Statistics, bridged-race population estimates. 

 

36 ibid. 

37 ibid. 

38 ibid. 

39 AHRQ, op.cit.

9
trimester of pregnancy can cause major birth defects in 5 percent to 10 percent of 

pregnancies and spontaneous abortions in 15 percent to 20 percent of pregnancies.40

Poorly controlled diabetes during the second and third trimesters of pregnancy can 

result in very large babies, posing a risk to the mother and the child during delivery. 

 Other Complications—People with diabetes are more susceptible to many other 

illnesses and often have worse outcomes. For example, people with diabetes are more 

likely to die from pneumonia or the flu than people who do not have diabetes.41

Early and optimal treatment is key to prevent or delay such complications.

Diabetes: A National Plan for Action 

Secretary of Health and Human Services (HHS) Tommy G. Thompson has identified 

diabetes prevention, detection, and treatment as important components of his health agenda. 

Activities supporting the Secretary’s focus on diabetes include Steps to a HealthierUS: Putting 

Prevention First (Appendix A), the Diabetes Detection Initiative, and the Small Steps, Big 

Rewards, Prevent Type 2 Diabetes campaign. In addition, the Medicare Prescription Drug, 

Improvement, and Modernization Act (MMA) of 2003, establishes coverage of a one-time 

“Welcome to Medicare Physical Examination” within 6 months of a beneficiary’s first coverage

under Part B to encourage health promotion and disease detection. The MMA also adds coverage 

for cardiovascular and diabetes screening for Medicare beneficiaries. Both benefits take effect 

January 1, 2005. More information on MMA and Medicare benefits in general can be found at 

http://www.medicare.gov/ or 1-800-Medicare (1-800-633-4227). Appendix B provides additional 

information on diabetes benefits offered through Medicare. 

Diabetes: A National Plan for Action (hereby referred to as the National Diabetes Action 

Plan—NDAP) is the latest initiative to address diabetes. This action plan was prompted by the 

Secretary’s commitment to disease prevention and health promotion. It utilizes a comprehensive 

action-oriented approach to identify activities to improve diabetes prevention, detection, and 

care. 

The goals of the NDAP are to: 

 Increase national awareness of diabetes, its impact, and what various stakeholders can 

do to prevent or manage the disease; 

 

40 CDC, National diabetes fact sheet, op.cit. 

41 ibid. 

10
 Reduce the prevalence of diabetes and factors that increase the risk of diabetes; 

 Promote improved detection, monitoring, and treatment of the disease; and 

 Identify existing public and private efforts to facilitate coordination and to leverage 

existing resources for detection, prevention, and treatment of diabetes. 

An advisory committee composed of senior officials within the U.S. Department of 

Health and Human Services (HHS) was named to direct the development of the NDAP. This 

committee provided recommendations to reduce the prevalence and burden of diabetes. In 

addition, the Secretary and his senior staff hosted several town hall “listening sessions” in 

different parts of the country to highlight the important steps that individuals, health care 

practitioners and providers, businesses, and communities can and are taking to prevent, detect, 

and treat diabetes and educate patients, their families, and other Americans. The first town hall 

meeting focused on prevention of diabetes and was held in Cincinnati, Ohio, on March 29, 2004. 

The second town hall focused on diabetes detection and education and was held in Little Rock, 

Arkansas, on June 18, 2004. The third town hall focused on diabetes treatment and was held in 

Seattle, Washington, on July 26, 2004. In all, more than 1,200 people attended the three town 

halls. 

During the public comment period at these town hall meetings, individuals and those 

representing organizations were able to ask questions, express their views, and provide input to 

the national diabetes action plan. Hundreds of people shared their thoughts about the burden of 

diabetes and solutions for preventing or delaying the disease and its complications. The public 

comment period identified issues of concern to the diabetes community. These included: 

 The key role that schools and teachers can play in educating students and parents 

about the importance of healthy behaviors (i.e. physical activity, nutrition) to reduce 

their risk for diabetes; 

 The important role health insurance plays in the ability of people with diabetes to 

manage their diabetes and the need for policymakers to continue to strive to improve 

the health insurance system for people with diabetes and other chronic conditions; 

 The need to educate and train healthcare providers in state-of-the art diabetes 

prevention, detection, and management strategies; 

 The importance of continued research into effective and innovative prevention 

strategies and treatments for diabetes; and 

11
 The need for focused prevention, detection, and treatment efforts targeted specifically 

to individuals at higher risk for diabetes, including Blacks, Hispanics, American 

Indians, Alaskan Natives, Asians and Pacific Islanders using culturally sensitive 

materials and messages emphasizing the importance of early detection and optimal 

treatment. 

See Appendix C for more information on the development of the NDAP. 

The remainder of this document is organized around three key components: prevention, 

detection, and treatment of diabetes. Within each component, action steps are provided for 

individuals, friends and family, health care providers, schools, the media, community 

organizations, health insurance providers, employers, and government agencies to improve the 

quality of life for people living with diabetes and reduce the burden of diabetes on the nation. 

12
PREVENTION 

Importance of Diabetes Prevention

The causes of type 1 diabetes are under investigation, and researchers are working to 

learn how to prevent the disease. While the causes of type 2 diabetes are not well understood, 

recent research has demonstrated that it often can be prevented or delayed through lifestyle 

changes in at risk persons.42 This section focuses on the prevention of type 2 diabetes. The 

“Treatment” section within this document addresses the prevention of medical complications 

caused by diabetes. 

The prevalence 

of diagnosed type 2 

diabetes increased sixfold in the latter half of

the past century.43

Obesity and physical 

inactivity have played a 

major role in this 

dramatic increase in rates 

of type 2 diabetes.44 For 

example, until recently 

type 2 diabetes was not 

frequently seen in 

school-aged children and 

adolescents. Now the 

prevalence of type 2 

diabetes for persons 20 and under appears to be rising considerably, and this rise can be 

attributed to increases in physical inactivity and excess weight gain.45 More than one-third of 

young people in grades 9-12 do not regularly engage in vigorous activity (Figure 8).46 

Figure 8. Vigorous physical activity in adolescents by grade 

level, 2001 

SOURCE: Kann L, et al. (2000). Youth Risk Behavior Surveillance Survey – US 1999, in

CDC Surveillance Survey. MMWR, 49(SS-5), 1-96. 

 

42 Diabetes Prevention Program Research Group, op.cit. 

43 Centers for Disease Control and Prevention (CDC). (2001). Diabetes: A serious public health problem. Atlanta, 

GA: Department of Health and Human Services. 

44 CDC, op.cit., Promising practices in Chronic Disease. 

45 ibid. 

46 Kann L, et al. (2000). Youth Risk Behavior Surveillance Survey – US 1999, in CDC surveillance survey. 

MMWR, 49(SS-5), 1-96. 

13
Vigorous activity is defined as sustained activity that results in a significant increase in heart and 

breathing rate.47

The Diabetes Prevention Program (DPP)—a major clinical trial involving 3,234 people 

with impaired glucose tolerance, a condition that often precedes diabetes—demonstrated that 

some people at high risk for type 2 diabetes can prevent or delay the onset of the disease by 

losing 5 percent to 7 percent of their body weight and getting 30 minutes or more of physical 

activity at least 5 days per week.48 In this study, the development of type 2 diabetes was reduced 

by 58 percent over a three-year period. This benefit was seen in participants of all ages and racial 

and ethnic backgrounds. The very encouraging results of this trial show that it is possible to 

prevent or delay type 2 diabetes in high-risk persons. 

It is not easy for many people to lose weight and increase their physical activity. 

However, it is imperative to build upon the results of the DPP and encourage people to take the 

necessary steps to prevent type 2 diabetes. This not only will help many Americans live 

healthier, more productive lives, but it also has the potential to save billions of dollars in health 

care costs associated with hospitalizations for diabetes and its complications. Friends, families, 

schools, health care providers, work sites and communities all can contribute in important ways 

to support healthier lifestyles. 

Action Steps for Prevention 

Individuals 

Americans at risk for type 2 diabetes (please see Appendix D—Are You At Risk For 

Diabetes?) can take important steps to prevent or delay the disease by losing a small amount of 

weight by eating a reduced fat, low-calorie diet and increasing their physical activity. The goal is 

to eat fewer calories and increase physical activity to lose a small amount of weight.49 The 

following action steps help people lower their risk for type 2 diabetes and other chronic diseases. 

Other helpful tips can be found at http://www.smallstep.gov/ and 

http://www.nal.usda.gov/fnic/dga/dguide95.html. 

 Eat a variety of foods within the basic food groups (fruits, vegetables, grains, milk, 

and meat and beans). 

 

47 Centers for Disease Control and Prevention (CDC). Physical Activity Terms. Available at: 

http://www.cdc.gov/nccdphp/dnpa/physical/terms/index.htm#Vigorous. Accessed September 15, 2004. 

48 Diabetes Prevention Program Research Group, op.cit. 

49 U.S. Department of Agriculture and U.S. Department of Health and Human Services. (1995). 4th ed. Nutrition for 

your health: dietary guidelines for Americans. Available at: http://www.nal.usda.gov/fnic/dga/dguide95.html. 

14
 Choose a diet low in fats (not recommended for children 2 years old and under), 

saturated fats, and cholesterol; and use sugar and alcohol in moderation.50 

 Order healthier food choices or split a meal with a friend or ask the server to put half 

of it in a take home box when dining out. 

 Use a salad plate for meals, rather than a full-size dinner plate, to make the meal 

appear larger. 

 Learn to use the food label to determine the size or amount of a portion or serving of 

foods and beverages. Consume appropriate portions of foods and beverages. 

 Drink a big glass of water or low-calorie beverage before a meal to help curb your 

hunger. 

 Drink plenty of water throughout the day. 

 Bake or broil foods rather than fry. 

 Drink 2 percent or 1 percent milk rather than whole milk. 

 Request a low-fat dressing for your salad. 

 Keep a daily record of eating habits, noting type of food, amount, and time of day. 

Determine times where overeating occurs and develop a plan to help avoid these 

situations in the future. 

 Find ways other than eating to deal with stress. Take a walk, stretch or take slow deep 

breaths. 

 Be “snackwise.” Have a piece of fruit or some reduced-fat popcorn instead of 

reaching for a piece of cake. 

 Make small nutritional changes. Some people find they are able to lose weight by 

simply eliminating sugary drinks. 

 Try some new recipes for healthier foods, such as those suggested by the American 

Diabetes Association (http://www.diabetes.org) or the American Heart Association 

(http://www.americanheart.org). 

 Make regular physical activity an essential part of daily activities. 

 Exercise while watching TV by running or marching in place to avoid being a “couch 

potato.” Put away the remote and get up to change the channel on the TV. 

 Find an enjoyable exercise or physical activity and get active. For example, for those 

who enjoy dancing, put on some music and dance each day. 

 Take the stairs instead of elevators and escalators.

 Park farther away from stores, or ride a bicycle or walk to stores. 

 Walk inside a mall as an inexpensive way to exercise in a sheltered space. 

 Volunteer to walk dogs at the local animal shelter or for an elderly neighbor. 

 

50 ibid. 

15
 Ask friends or use the Internet to find out about local parks or other facilities where 

you can exercise. 

 Set personal goals for exercise and track progress. For example, if a goal is to walk at 

least 30 minutes five times a week, keep a record of how many times the goal was 

met. If a day is missed, record it and indicate why it was missed. At the end of the 

week, consider what changes to make so that the goals for the following week will be

met. Some people find it helpful to begin with smaller, easier-to-reach goals. 

Families and Friends 

One of the best ways to build exercise and healthy eating into daily activities is to do it 

with others, including family and friends. Here are some suggestions: 

 Parents can exercise with their children. Be a role model for them. Walking together 

has the added benefit of providing a regular opportunity to talk with them. 

 Parents can model good eating habits for their children by eating a diet that includes 

plenty of whole grain products, vegetables, and fruits, and is low in fats, saturated 

fats, and cholesterol, and limiting portion sizes.

 Caregivers should promote physical activity and good eating habits for older family 

members.

 Walk the dog. Make walking the dog a regular family activity. The dog will 

appreciate it. 

 Give pedometers to family or friends to help make exercise fun. 

 Support the exercise habits of family members, including older adults. Look for ways 

to help them fit exercise into their schedules. 

 Offer to bring fresh fruit as a dessert rather than cake or cookies when going to a 

friend or family’s house for a meal. 

Schools 

The increase in type 2 diabetes among children makes schools essential partners in 

preventing the disease. Some specific activities for schools and teachers to consider include: 

 Educate and share health promotion messages about sound nutrition and regular 

physical activity with teachers, school nurses, students, and parents. 

 Educate children about the importance of balanced nutrition and regular exercise in 

preventing diabetes. 

 Encourage children to develop plans for better nutrition and exercise and ways to 

measure their progress. 

 Engage parents to increase their understanding of the importance of healthier diets 

and the benefits of exercise. 

 Offer regular physical education/gym classes. 

16
 Provide opportunities for unstructured activities for all ages at lunch and during 

breaks. For elementary school children, this might include actively participating in 

physical activities on the playground. For older students, sports equipment can be 

provided (e.g., basketballs, tennis rackets, etc.), with coaches encouraging 

participation in activities.

 Provide opportunities for nontraditional sports and alternatives to team sports for 

students who may not have the same physical talents as their peers. 

 Provide after-school activities through the school or in partnership with other 

organizations, such as city parks and recreation leagues, religious organizations, 

community YMCAs, or Boys and Girls Clubs. 

 Provide tasty food options that are low in saturated fats and include fruits, vegetables, 

nuts, and whole grains for cafeteria and food cart choices. 

 Provide healthy alternatives, such as milk, low-calorie beverages, or water in vending 

machines and in the cafeteria. 

 Solicit help from school staff in setting examples for healthier eating and increased 

exercise. 

 Foster the benefits of exercise through fun competitions and activities. For example, 

sponsor contests among teacher and student groups to register the most steps on their 

pedometers. 

 Encourage all students to participate in exercise and support each other regardless of 

different abilities. 

 Partner with State Diabetes Prevention and Control Programs run by the State Health

Department. 

Health Care Providers 

Health care providers play a key role in the prevention of type 2 diabetes. Research 

shows that medical providers are among the most important health messengers and that patients 

are more likely to adopt new behaviors when instructed to do so by their health practitioners.51

Providers can take the following steps to encourage healthy behaviors among their patients: 

 Counsel patients with pre-diabetes about their risk of developing diabetes and 

develop a concrete plan for patients to help them decrease the likelihood of 

developing the disease.

 Refer high-risk individuals to appropriate resources for nutrition counseling and prediabetes education.

 Screen for overweight and obesity. Counsel patients who are overweight to lose 

weight. Set reasonable weight loss goals to avoid failure and frustration. 

 

51 Logsdon DN, Lazaro CM, Meier RV. (1998). The feasibility of behavioral risk reduction in primary medical care. 

Am J Prev Med, 5(5), 249-256; and Inui TS, Yourtee EL, Williamson JW. (1976). Improved outcomes in

hypertension after physician tutorials: A controlled trial. Ann Intern Med, 84(6), 646-651.

17
 Refer patients to local resources or services that offer weight loss and physical 

activity programs and/or provide tools to help patients make lifestyle changes, 

activity logs, or meal plan guides.52

 Provide information (e.g., handouts) on safe approaches to weight loss. Ready-to-use 

materials are available free of charge for providers through resources such as “Your 

Game Plan for Preventing Type 2 Diabetes: Health Care Provider’s Toolkit” 

(http://www.ndep.nih.gov/diabetes/pubs/GP_Toolkit.pdf). 

 Encourage patients whose health permits to begin an exercise plan. Emphasize that 

even small steps can produce big rewards. 

 Help patients set reasonable and realistic long-term and short-term exercise goals that 

can be measured over time so that they can see their successes.

 Build in accountability for patients. For example, after delivering the initial 

prevention messages and working with patients to set realistic goals, set up a 

reminder or follow-up system with patients who have been counseled to lose weight 

to assess progress and offer motivational messages. 

 Acknowledge patients’ efforts to adopt healthier behaviors, even if the initial changes 

reflect only part of the change needed. 

 Encourage lifestyle changes for youth and counsel their parents on the importance of 

exercise and healthy eating to help prevent type 2 diabetes.53

 Work with State Diabetes Prevention and Control Programs run by the State Health 

Department.

Employers 

Healthy employees are more productive and can be cost beneficial to companies. For 

example, a research study conducted on the return on investment (ROI) for worksite health 

promotion and disease prevention programs in nine companies, found significant ROI with the 

benefit to cost ratio ranging from $1.49 to $4.91 in benefits per dollar spent on the program.

54

The following are some suggested worksite actions for employers that can encourage healthy 

behaviors in their employees: 

 Be creative about developing exercise options. For example, think outside the 

“conference room box” by encouraging employees to hold discussions while walking 

with their colleagues rather than sitting in a conference room. 

 

52 The National Diabetes Education Program has developed tools to support providers in their efforts to encourage

healthier lifestyle choices among their patients. These tools are available free of charge at 

http://www.ndep.nih.gov/resources/health.htm. 

53 Sinha R, Fisch G, Teague B, et al. (2002). Prevalence of impaired glucose tolerance among children and

adolescents with marked obesity. New England Journal of Medicine, 346(11), 802-810. 

54 U.S. Department of Health and Human Services. Prevention makes common cents. (2003). Available at: 

http://aspe.hhs.gov/health/prevention/. 

18
 Provide exercise space. For example, a conference room with a VCR player, a couple 

of low-impact aerobics tapes, and some low-cost mats made available at lunch time 

can serve as an exercise space for employees as well as a valuable networking activity

that can improve morale and productivity. 

 Provide healthy food options in cafeterias and vending machines to employees. 

 Encourage employees to adopt healthy behaviors. For example, offer “contests” with 

prizes to encourage exercise for employees. 

 Consider providing health promotion or wellness programs and disease management

programs for employees as part of their health benefits.

 Provide on-site education about diabetes prevention to employees. 

 Utilize resources that are readily available at no cost to employers, such as Diabetes 

at Work (http://www.diabetesatwork.org/). 

 Consider partnering with the local YMCA or community health club to offer 

discounted memberships to employees and their families.

 Partner with community organizations to develop and implement community health 

promotion and disease prevention initiatives. 

 Request health insurers to provide appropriate information for employees to educate 

them on their health and diabetes prevention. 

 Provide employees information about local parks and walking trails.

Health Insurance Providers 

Successful prevention initiatives can reduce the need for some costly medical services

and treatment. Therefore, health insurance providers can also assist prevention efforts as follows: 

 Educate patients and purchasers on the importance of prevention to reduce the risk for 

diabetes.

 Review preventive health benefits offered to purchasers.

 Partner with others working in diabetes prevention such as State Diabetes Prevention 

and Control Programs in State Health Departments.

 Develop creative prevention messages and programs that encourage patients to adopt 

healthy behaviors (i.e., eating healthy, regular exercise).

 Participate in research into effective preventive services and practices.

Communities

Local communities also play an important role in preventing or delaying type 2 diabetes 

by providing environments that promote healthier lifestyles through improved nutrition and 

increased physical activity. Civic and community organizations can partner with business 

groups, government agencies and others to encourage healthier eating and increased physical 

19
activity for the community. Some actions communities can take to help prevent type 2 diabetes 

for their citizens include: 

 Promote environments that foster fitness, such as walking trails. Marking sidewalks 

with distance markers and messages can help encourage exercise. 

 Encourage a community culture that promotes healthier eating habits. For example, 

community groups can sponsor “cook-offs” to create healthy culinary options among 

local chefs. 

 Create community vegetable gardens. 

 Organize community activities, such as community block parties with dancing and 

healthy food choices. 

Media 

The media serve as important partners in promoting diabetes prevention messages. The 

following are steps that members of the media can take to help spread the word about how to 

prevent type 2 diabetes: 

 Promote public awareness about the importance of diabetes prevention and the 

benefits of maintaining a healthy weight with regular physical activity and a healthy 

diet.

 Disseminate credible and accurate messages that encourage healthy habits and 

discourage risky behaviors. Media staff can help tailor messages to target specific 

audiences.

 Partner with medical professionals, federal, state, and local governments, and privatesector community entities to help the public understand the importance of preventing 

diabetes. Publicize providers who are doing a particularly good job in facilitating 

behavior change or a hospital that has opened its doors to run a no-cost exercise 

program in a low-income area.

 Conduct or participate in research to study the effectiveness of media messages 

promoting healthy lifestyles. 

 Use public access networks to broadcast local conferences or training videos on 

diabetes prevention. 

Researchers and Professional Educators 

Researchers and professional educators also play important roles in diabetes prevention. 

The following are some general diabetes prevention steps these groups can take:

 Continue research into the causes of type 1 and type 2 diabetes.

 Continue applied research into the prevention of diabetes and other relevant issues 

such as cost benefit analysis and evidence-based prevention strategies for combating 

the disease. 

20
 Continue to conduct clinical trials like the DPP to prevent the onset of type 2 diabetes 

in individuals at high risk for developing the disease, such as minority populations.

 Continue to develop effective methods to translate research findings into clinical 

practice to prevent diabetes.

 Develop useful outcome measures for health promotion and diabetes prevention 

activities, services, and practices to assess progress in these areas, and provide 

information to inform program improvement. 

 Develop and evaluate innovative methods to inform people about the importance of 

diabetes prevention and the link between the risk for diabetes and personal behaviors 

and choices, such as physical activity and dietary choices. 

 Develop partnerships with community organizations to promote research and 

educational initiatives regarding diabetes prevention. 

State and Local, Federal, and Tribal Governments 

The public sector plays an important role in (a) supporting healthy lifestyles among 

Americans that may prevent type 2 diabetes, (b) advancing research on how to prevent diabetes, 

and (c) supporting efforts to translate research to practice. Action steps that can be taken by state, 

federal, and tribal governments include the following: 

 Review and design policies that optimize strategies to address diabetes at all stages. 

 Partner with communities and other entities to create environments that encourage 

healthy lifestyles and habits (e.g., collaborate with communities to develop walking 

trails and parks where people can exercise safely) and implement initiatives. 

 Disseminate information about the importance of healthy lifestyles to prevent 

diabetes. Tailor these messages to be meaningful to people of all ages, and cultural, 

socio-economic, ethnic, and racial backgrounds. 

 Support research on the effectiveness of different interventions to prevent diabetes. 

 Conduct surveillance activities to measure progress toward achieving public health 

goals. 

 Create an evidence base of effective strategies for preventing diabetes. 

 Intensify prevention efforts among Blacks, Hispanics, American Indians and Alaskan 

Natives, and other population groups who disproportionately suffer diabetes and its 

complications.55

 Motivate government employees to adopt healthy lifestyles, thereby serving as a 

model to other employers. 

 Foster interagency collaboration at federal, state, and tribal levels to promote healthy 

lifestyles in order to reduce the risks for diabetes. 

 

55 Centers for Disease Control and Prevention. (1991) Diabetes surveillance system Atlanta: US Department of

Health and Human Services. Available at: http://www.cdc.gov/diabetes/statistics/survl99/chap1/conclusion.htm. 

21
22
DETECTION 

The Importance of Early Diabetes Detection 

Approximately 5 million of the 18 million people with diabetes in the U.S. do not know 

they have it.56 Early detection and treatment of diabetes is an important step toward keeping 

people with diabetes healthy. It can help to reduce the risk of serious complications such as 

premature heart disease and stroke, blindness, limb amputations, and kidney failure.57 

Some of the important signs and symptoms of diabetes are shown in Table 2. Many 

people with type 2 diabetes have no signs or symptoms, but do have risk factors (see Table 1). 

For persons at increased risk or those experiencing these signs and symptoms, several tests are 

used to diagnose diabetes: 

 A fasting plasma glucose test measures blood glucose after not eating for at least 8 

hours. This test is used to detect diabetes (126 mg/dl and above) or pre-diabetes 

(between 100 mg/dl and 125 mg/dl).58 

 An oral glucose tolerance test measures blood glucose after not eating for at least 8 

hours and 2 hours after drinking a glucose-containing beverage. This test is used to 

diagnose diabetes (200 mg/dl and above) or pre-diabetes (between 140 mg/dl and 

199 mg/dl).59 

 In a random plasma glucose test, blood glucose is checked without regard to when 

food is consumed. Values of 200 mg/dl or greater in the presence of specific 

symptoms, such as increased urination or thirst and unexplained weight loss, indicate 

a diagnosis of diabetes.60

Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral 

glucose tolerance test on a different day. 

Type 1 diabetes is typically detected much sooner after onset than type 2 disease because 

the symptoms are dramatic and the need for medical care is immediate and obvious. In contrast, 

the signs and symptoms of type 2 diabetes can be absent or so mild that the disease may not be 

 

56 Williamson DF, Vinicor F, Bowman BA. (2004). Centers For Disease Control and Prevention Primary 

Prevention Working Group: Primary prevention of type 2 diabetes mellitus by lifestyle intervention: implications

for health policy. Ann Int Med, 140(11), 951-957. 

57 U.S. Department of Health and Human Services (DHHS). Diabetes detection initiative: Finding the undiagnosed. 

Available at: http://www.ndep.nih.gov/ddi/about/index.htm. 

58 National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2003). Diagnosis of diabetes. NIH 

Pub No. 04-4642. Available at: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/index.htm.

59 ibid. 

60 ibid. 

23 
diagnosed for 7 to 10 years after the onset resulting in increased risk for complications, such as 

nerve, eye, and kidney disease, when the disease is finally detected.61

Table 2. Signs and Symptoms of Diabetes 

Symptoms Type 1 Diabetes Type 2 Diabetes 

Frequent urination X X 

Unusual thirst X X 

Extreme hunger X X 

Unusual weight loss X 

Extreme fatigue X X 

Sudden vision changes X X 

Fruity, sweet, or wine-like odor on breath X 

Heavy, labored breathing X 

Stupor, unconsciousness X 

Irritability X X

Frequent infections X X 

Blurred vision X X 

Cuts/bruises that are slow to heal X X 

Recurring skin, gum, or bladder infections X 

SOURCES: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2004). Am I at risk for type 2 

diabetes? NIH Publication No. 04-4805. Available at http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/. Accessed May

28, 2004. 

Juvenile Diabetes Research Foundation. Knowing the warning signs for type 1 diabetes could save a child’s life. Available at 

http://www.jdrf.org/index.cfm?fuseaction=home.viewPageandpage_id=117E31FB-001E-A85D-3C71EBB8B19732AC. 

Accessed May 28, 2004. 

In the past, type 2 diabetes was a disease seen primarily in adults over age 45 with the 

highest percentage occurring in adults 60 years and older.62 It is now being seen at increasingly 

younger ages, including children and adolescents.63 As with adults, identifying type 2 diabetes in 

children is challenging because children may not have any symptoms or show only very mild 

symptoms. Diagnosis of type 2 diabetes in young people means that they may have the disease 

for a longer period time than if they developed diabetes as adults. The longer duration of the 

 

61 DHHS, op.cit.

62 ibid. 

63 Centers for Disease Control and Prevention (CDC). (2000). CDC funds registries for childhood diabetes. Press 

release, November 21. Available at http://www.cdc.gov/od/oc/media/pressrel/r2k1226.htm. 

24 
disease increases the rate of severe complications such as blindness, renal failure, and 

amputations.64 

Early diagnosis of diabetes and pre-diabetes is important so that patients can begin to 

manage the disease early and potentially prevent or delay the serious disease complications that 

can decrease quality of life. Recognizing the importance of identifying the more than 5 million 

Americans with undiagnosed diabetes, Secretary Tommy G. Thompson launched the Diabetes 

Detection Initiative (DDI) in November 2003. The DDI is a new community-based effort to 

identify persons with undiagnosed type 2 diabetes and refer them for follow-up blood testing and 

treatment, if appropriate. The pilot program was evaluated in 10 locations throughout the U.S. 

(see Appendix C for more information on the DDI). 

Action Steps for Detection 

Knowledge of the risk factors, and signs and symptoms of diabetes and pre-diabetes may 

help increase awareness about the need to be tested for diabetes. Individuals, family members, 

friends, health care providers, schools, the media, community organizations, health insurance 

providers, employers, as well as local, state, and federal governments all play important roles in 

helping to ensure that at-risk or asymptomatic individuals are screened for diabetes.65 

Individuals and Family and Friends 

People at risk for diabetes and their family and friends can be actively involved in 

ensuring that diabetes is diagnosed early. Individuals may be able to recognize diabetes 

symptoms for themselves, or a friend or family member may recognize these symptoms in a 

loved one and encourage that person to get tested for diabetes. The following are some steps that 

can help to identify people at risk for diabetes: 

 Take a self-administered type 2 diabetes risk assessment test (see Appendix D) to 

determine individual risk for diabetes and important next steps. Discuss the results 

with a health care provider. 

 Pregnant women should ask their health care provider if a diabetes test is needed. 

 Individuals with pre-diabetes should work with their health care provider to develop a 

plan to help delay or prevent the onset of type 2 diabetes. Even if blood glucose levels 

do not indicate diabetes, pre-diabetes is a risk factor for developing diabetes. Losing a 

 

64 ibid. 

65The USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening 

asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose. The USPSTF

does recommend screening for type 2 diabetes in adults with hypertension or hyperlipidemia (see 

http://www.ahrq.gov/clinic/uspstf/uspsdiab.htm. for more information). The generally accepted standards of care 

for diabetes screening can be found at: http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s11#SEC3

25 
small amount of weight by eating a healthier diet and getting regular exercise may 

prevent or delay the onset of type 2 diabetes. 

 Encourage family members and friends with diabetes symptoms to seek medical help. 

Talk with a health care provider or local office of the American Diabetes Association 

to learn how to support someone who may be at risk for diabetes. 

Schools 

School personnel play an important role in identifying children with type 1 and type 2 

diabetes. Specific actions schools can take to help in diabetes detection include: 

 Educate teachers and school nurses about the signs, symptoms, and risk factors of 

diabetes and encourage them to report concerns about students to parents or the 

appropriate school officials. Diabetes education information can be found at 

http://www.ndep.nih.gov. 

 Educate parents and children about diabetes, for example, by sending information 

home with report cards about how the number of children with type 2 diabetes is 

increasing, and providing information about diabetes risk factors and signs and 

symptoms to look for in children or by providing diabetes and health education 

information during parent teacher meetings. 

 Partner with local and state health departments and/or organizations, such as the 

American Diabetes Association, to support diabetes awareness activities in schools.

Health Care Providers 

Different types of medical providers, such as doctors, physicians’ assistants, nurse 

practitioners, nurses, diabetes educators, registered dietitians, and pharmacists can play critical 

roles in helping to detect diabetes. Here are some things providers can do: 

 Gain and maintain state-of-the-art knowledge about the risk factors for diabetes and 

pre-diabetes and effective strategies related to testing for and diagnosing the disease. 

For example, the diagnostic glucose numbers for diabetes and pre-diabetes have been 

revised in the past few years (See “The Importance of Early Diabetes Detection” in 

this section for current diagnostic glucose numbers). 

 Create opportunities within the health care setting to identify persons at high risk for 

diabetes, such as asking patients to provide information about diabetes symptoms and 

risk factors on a pre-visit questionnaire. Knowing a patient has symptoms or risk 

factors for diabetes can serve as an important prompt for diagnostic testing. 

 Assess risk for gestational diabetes. The American College of Obstetricians and 

Gynecologists (ACOG) advises that it is appropriate to screen all pregnant women for 

gestational diabetes, whether by patient history, clinical risk factors for gestational 

diabetes, or a laboratory test to determine blood glucose levels. However, ACOG 

acknowledges that more research is needed before it can be determined what 

26 
screening method is best and when it should occur.66 The U.S. Preventive Services 

Task Force concludes that evidence is insufficient for or against routine screening for 

gestational diabetes.67

 Establish and implement protocols to ensure that newly diagnosed patients with 

diabetes are (1) promptly educated about lifestyle changes and diabetes selfmanagement techniques that can delay or prevent complications of diabetes; (2) 

tested when appropriate for comorbid conditions, such as eye or cardiovascular 

disease; and (3) involved in developing a plan to control HbA1c, blood pressure, and 

cholesterol, the “ABCs of diabetes.”68 

 Refer patients and provide contact information as needed to additional health care 

providers to address specific or urgent problems. 

 Be a diabetes messenger and help to educate patients and community members about 

the risk factors and signs and symptoms of diabetes and encourage behavior change. 

Share information about diabetes detection with community leaders. 

 Become involved in research aimed at identifying effective approaches to detect 

diabetes in various populations, such as children, older persons, and members of 

specific racial/ethnic groups. 

Employers 

Employers can play a key role in educating their employees about the risk for diabetes 

and encouraging them to be screened and/or tested for the disease. By working with the National 

Diabetes Education Program,69 some employers have become the central nexus for improved 

detection: 

 Distribute information about diabetes and its risk factors and signs and symptoms to 

employees and their families. 

 Partner with the health department or other local organizations to provide work-site 

diabetes screening and strongly encourage individuals who indicate a high risk for 

diabetes to be tested for the disease. 

 

66 American College of Gynecologists. (2001). Pregnant women should be screened for gestational diabetes: 

Though no one test is ideal. Press release, August 31. Available at: 

http://www.acog.org/from_home/publications/press_releases/nr08-31-01.cfm. August 31, 2001. 

67 U.S. Preventive Services Task Force. Screening for gestational diabetes mellitus: Recommendations and 

rationale. (February 2003). Agency for Healthcare Research and Quality, Rockville, MD. Available at 

http://www.ahrq.gov/clinic/3rduspstf/gdm/gdmrr.htm.

68 National Diabetes Education Program. Guiding principles for diabetes care: For health care providers. NIH 

Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf. 

69 The National Diabetes Education Program is a jointly funded program by the National Institutes of Health and the 

Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, 

working together to reduce morbidity and mortality associated with diabetes.

27 
Health Insurance Providers 

Health insurance organizations can also support early detection of diabetes through 

education and outreach efforts to their members. Early identification of diabetes can help 

improve quality of life and avoid costly complications. Health plans may also consider giving 

diabetes screening and testing guidelines to providers. Potential steps health insurance providers 

can take include: 

 Educate members about the risk factors and signs and symptoms for diabetes and 

offer incentives to at-risk patients to be tested for diabetes. 

 Inform pregnant women about the potential value of screening for gestational 

diabetes. 

 Consider offering incentives to health care providers to follow evidence-based 

diabetes diagnostic guidelines. 

 Provide information to assist providers in reaching racial and ethnic groups that are 

disproportionately affected by diabetes. 

 Provide culturally sensitive messages that are targeted to racial and ethnic populations 

at higher risk for diabetes. 

Communities and Local Health Departments 

Community organizations and local health departments can play an important role in 

diabetes education and detection. Various local organizations (e.g., federally supported health 

centers, the local chapter of the American Diabetes Association, faith-based organizations, etc.) 

along with the local health department may be valuable resources to help develop and/or 

distribute information on the importance of early diabetes detection and the risk factors for and 

signs and symptoms of diabetes. Some action steps for community organizations include: 

 Encourage local organizations to disseminate information, such as copies of diabetes 

risk assessment tests, through their various communication channels. Examples of 

potential partnerships include vendors placing diabetes information on shopping bags; 

local utility companies including inserts into mailings; and churches, synagogues, and 

other faith-based organizations placing diabetes risk assessment tests in their 

newsletters, bulletins, or other mailings. 

 Organize outreach sessions at community venues such as libraries that can provide 

space, equipment, and other resources for community-wide presentations on diabetes 

detection, including risk factors, signs and symptoms, and action steps for individuals 

who think they might have the disease. 

 Develop a directory of community resources for diabetes screening, testing, and 

treatment that can be distributed to people at high risk for diabetes. 

28 
Media 

The media can make an important contribution to early detection of diabetes by helping 

to educate the public about the risk factors and signs and symptoms of diabetes and encouraging 

those with risk factors and signs and symptoms to discuss testing with their health care providers. 

Specific functions the media can perform to enhance diabetes detection include: 

 Increase diabetes awareness through responsible reporting about the risk factors and 

signs and symptoms of diabetes. 

 Provide information about the risk factors for diabetes and make people aware that 

many people with diabetes may not have signs or symptoms. 

 Promote health messages that emphasize the importance of early diabetes detection to 

improve health outcomes and avoid diabetes complications. 

 Promote National Diabetes Alert Day (the fourth Thursday in March) on national, 

state, and local levels. 

 Utilize resources that are readily available at no cost, such as information about the 

Diabetes Detection Initiative (http://www.ndep.nih.gov/ddi/index.htm). 

 Partner with medical professionals, federal, state, and local governments, and privatesector community entities to develop effective health messages that will generate 

public interest and increase public understanding of the importance of detecting 

diabetes. 

 Participate with public health researchers to develop appropriate, targeted, and 

effective media messages to reach people at risk for diabetes, particularly older adults 

and at-risk racial and ethnic populations. 

 Provide tailored messages targeting specific racial and ethnic populations at higher 

risk for diabetes. 

 Work with officials to encourage public access networks to broadcast local 

conferences or training videos on diabetes detection. 

 Work with local professional organizations to identify and acknowledge health care 

providers who have excelled in diabetes detection efforts. 

 Recognize local, state, and national programs that have been successful in detecting 

diabetes and decreasing the proportion of Americans with undiagnosed diabetes. 

State, Tribal, and Federal Governments 

At the state and national levels, government organizations and others are working to 

improve diabetes detection. Appendix C describes several important ongoing governmental 

activities for diabetes detection. Other examples of specific action steps include: 

 Review and design policies that optimize strategies to address diabetes detection. 

29 
 Create an evidence base of best strategies for detecting diabetes that includes 

screening protocols for both diabetes and pre-diabetes. 

 Acknowledge community efforts that have effectively increased the percentage of 

persons diagnosed with diabetes. 

 Educate elected officials about how early detection can help improve overall quality 

of life for constituencies and the implications for reducing health care costs.

 Provide important information about population groups, such as older adults and atrisk racial and ethnic populations, and people with certain risk factors, including 

obesity, that make them more likely to have diabetes and thus have a greater need for 

screening. 

 Identify trends in new cases of type 1 diabetes, type 2 diabetes, gestational diabetes, 

and pre-diabetes to inform diabetes detection activities. 

 Create culturally sensitive diabetes awareness messages targeted to underserved 

populations that are at high risk for diabetes. 

 Examine health insurance coverage policy for public employees with respect to 

diabetes testing. 

30 
TREATMENT 

The Importance of Diabetes Treatment and Management

If left untreated or undertreated, diabetes can cause severe complications that can damage 

many vital organs in the body and lead to premature death.70 Possible complications from 

diabetes can include heart disease, blindness, lower extremity amputations, kidney failure, dental 

disease, and increased susceptibility to infections. Estimates suggest that in many states, half of 

all people with diabetes do not receive recommended preventive care services that are known to 

reduce the risk of diabetes complications.71 

The good news is that the complications from diabetes can often be prevented or delayed 

with quality medical care and by adopting healthy behaviors to manage diabetes. For example, 

the Diabetes Control and Complications Trial (DCCT) demonstrated that careful control of blood 

glucose levels resulted in delaying the onset and slowing the progression of retinopathy (eye 

disease), nephropathy (kidney disease), and neuropathy (nerve disorders) for people with type 1 

diabetes.72 Other studies such as the U.K. Prospective Diabetes Study (UKPDS)73 have shown 

similar dramatic reductions in complications with control of blood glucose for people with type 2 

diabetes. Empowering people with diabetes with knowledge and resources to proactively manage 

their disease and prevent or control diabetes complications is an important step in successful 

disease management. Friends and family members, health care professionals, schools, 

employers, health insurance providers, community organizations, the public media, and 

government agencies can all help persons with diabetes to live healthy and productive lives. This 

section suggests action steps to improve diabetes management and decrease risks for diabetes 

complications. 

Action Steps for Treatment 

Individuals 

The possible complications from diabetes can be extremely serious. There is strong 

evidence from clinical trials that many of these complications may be delayed or prevented by 

 

70 CDC, National Diabetes Fact Sheet, op.cit. 

71 Centers for Disease Control and Prevention (CDC). Levels of Diabetes-related preventive-care practices-United 

States, 1997-1999. MMWR Morbidity Mortality Weekly Report 2000; 49(42), 954-958. 

72 The Diabetes Control and Complications Trial Research Group, op.cit; and Diabetes Complications, National 

Diabetes Information Clearing House. Available at http://diabetes.niddk.nih.gov/complications/. Accessed on 

September 7, 2004. 

73 Turner, RC, op.cit. 

31 
carefully controlling blood glucose levels, blood pressure, and LDL cholesterol levels.74 To help 

manage diabetes, individuals should discuss, create, and follow a diabetes management plan with 

a health care provider and set goals for a treatment plan. The following are some specific 

suggestions to consider: 

 Ask health care providers about the ABCs of diabetes. “A” is HbA1c, a measure of 

average blood glucose; “B” is blood pressure; and “C” is LDL-cholesterol. Patients 

should determine what their levels are, what they should be, and what steps they can 

take to reach those goals.75

 Work with health care providers to establish and maintain individualized target blood 

glucose levels. Ask how often and when to measure blood glucose levels. Individuals 

should keep a record of blood glucose readings to show their health care provider so 

they can better regulate their blood glucose. 

 Be aware of the symptoms for hypoglycemia (low blood sugar) and hyperglycemia 

(high blood sugar). Individuals who experience these symptoms, should adjust their 

treatment plan and seek medical advice on how to maintain healthy blood glucose 

levels. Table 3 presents symptoms of hypoglycemia and hyperglycemia. 

Table 3. Symptoms of Hypoglycemia and Hyperglycemia

Symptoms of hypoglycemia 

 Feel weak, confused, irritable, hungry, or tired 

 Sweat a lot or get a headache 

 Feel shaky 

Symptoms of hyperglycemia 

 Feel very thirsty and tired 

 Have blurry vision 

 Have to go to the bathroom often 

 Nausea 

SOURCE: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Your guide to diabetes—type 1 and 

type 2. Available at: http://diabetes.niddk.nih.gov/dm/pubs/type1and2/lowglucose.htm. 

Hypoglycemia is a low blood sugar. Hyperglycemia is a high blood sugar.

 

74 The Diabetes Control and Complications Trial Research Group, op.cit; and Turner, RC, opt.cit 

75 The ABCs of Diabetes refers to knowing the patient’s blood glucose level through the HbA1c test and making 

sure blood pressure and cholesterol are at recommended levels. Information on “Knowing your ABCs” can be

found at: http://www.ndep.nih.gov/diabetes/control/4Steps.htm#Step2.

32 
 Follow a meal plan developed with a health care provider. This can be an important 

step for maintaining desirable blood glucose levels and avoiding complications. 

 Work with a health care provider to develop an appropriate exercise program and 

follow this plan. Appropriate exercise can be important for people with diabetes 

because it can help insulin work better to lower blood glucose levels and improve 

cardiovascular health. 

 Follow a health care provider’s recommendations for how and when to take diabetes 

medications. Discuss with a health care provider if medications do not seem to be 

working properly. 

 Individuals should ask their primary care provider about a dilated eye exam at least 

once a year as people with diabetes are at higher risk for vision problems and 

blindness. Early detection and treatment of diabetic eye disease can prevent or delay 

vision loss. 

 Request regular blood pressure checks at every medical visit and cholesterol checks at 

least once per year because people with diabetes are at higher risk for heart disease 

and stroke. Lowering blood pressure and cholesterol can reduce the risk of heart 

attack and stroke, the major cause of death in people with diabetes. 

 Individuals, who smoke cigarettes, should seek help from a health care provider to 

quit smoking to further reduce their risk for heart disease. 

 Brush teeth regularly and visit a dentist at least once every six months because people 

with diabetes are at higher risk for gum disease. 

 Check feet for sores and calluses every day, wear shoes that fit properly, and get a 

comprehensive foot exam at least once per year with a health care professional since 

people with diabetes are at a higher risk for foot problems that can be caused by 

neuropathy (nerve damage) or poor blood flow to the feet. 

 Ask for a urine test by a health professional at least once a year to monitor the level of 

protein in urine, a measure of kidney function. 

 If planning a pregnancy, consult a health care provider to make a care plan that 

focuses on good blood glucose control before and during the pregnancy. 

 Maintain records of daily self-management activities and medical visits. The checklist 

in Table 4 can help individuals and healthcare providers keep track of diabetes care. 

Other materials for managing diabetes can be found at 

http://www.ndep.nih.gov/diabetes/control/control.htm or by calling 1-800-860-8747. 

 Ask a health care provider about new medicines and medical devices, such as blood 

glucose meters and insulin pens and pumps that could help manage diabetes. 

 Seek the help of qualified health care professionals—such as a primary care provider, 

an endocrinologist, a certified diabetes educator or a registered dietician—to help 

with diabetes management. 

 Seek help and encouragement through a diabetes support group. 

33 
 Continue to obtain information on diabetes. The National Diabetes Education 

Program (http://www.ndep.nih.gov/ or 1-800-438-5383) and organizations such as the 

American Diabetes Association (http://www.diabetes.org/home.jsp or 1-800-

DIABETES), the American Association of Diabetes Educators and the Juvenile 

Diabetes Research Foundation International (http://www.jdrf.org/ or 1-800-533-

CURE) can be excellent resources to help in learning more about caring for diabetes. 

 Get information about clinical trials in progress that may identify new and more 

effective medicines and treatment regimens to treat diabetes (Available at: 

http://www.clinicaltrials.gov). 

 Talk about diabetes with family and friends to make them aware of ways they can 

help with diabetes management. 

Table 4. Diabetes Care Checklist 

Daily diabetes care activities 

G Exercise

G Follow meal plan 

G Take diabetes medicine 

G Check blood glucose as recommended by a health care provider 

G Check feet for sores that are not healing properly

G Brush teeth and floss 

At doctor visits 

G Get feet checked 

G Check blood pressure 

At least twice per year 

G Get an HbA1c test 

G Get a dental check-up and have teeth cleaned by a dental professional 

At least once per year 

G Get a dilated eye exam 

G Get a complete foot exam—checking circulation and for changes in foot shape 

G Get a urine test for kidney function 

G Get a flu shot 

G Get blood lipid levels (cholesterol) checked 

SOURCE: National Diabetes Education Program. (2001). 7 principles for controlling your diabetes for life. NIH Publication No. 

99-4343L. Available at: http://www.ndep.nih.gov/diabetes/pubs/7Principles_Eng.pdf. 

34 
Families and Friends 

People with diabetes need their family members and friends to help them manage their 

disease and keep track of their diabetes care. Here are some things families and friends can do to 

support people with diabetes: 

 Plan walks or other activities with friends and family with diabetes to help them get 

regular exercise. Help them follow the advice of their health care provider about ways 

to exercise safely. 

 Prepare healthy meals that fit into meal plans for people with diabetes and prediabetes. 

 Offer to help friends or family members check their feet for sores or calluses. 

 Provide transportation to the heath care provider’s office so that friends or family 

members do not miss important medical visits. 

 Become aware of the signs and symptoms of hypoglycemia and hyperglycemia and 

how to appropriately treat them. 

 If friends or family members do not understand English, help translate patient 

education materials into a language he/she knows or help identify resources that are 

language appropriate. 

 Provide assistance to a friend or family member with diabetes that is sick with a cold,

the flu, or another type of infection or illness. Being sick can raise blood glucose and 

may make it difficult to eat properly or monitor blood glucose as needed. 

 If a child in your family has been diagnosed with diabetes, work closely with health 

care providers to develop a care plan that addresses diabetes and fits in with the 

child’s schedule. Revisit the plan on an ongoing basis to make sure that changes in 

the child’s condition or lifestyle are considered. Seek advice from health care 

providers about ways to teach children to be proactive in taking care of their diabetes. 

Schools 

Because diabetes must be managed on a daily basis, school staff (teachers, nurses, 

principals, and office staff) can play an important role in helping students manage their diabetes. 

Specific action steps for schools to take to help students manage diabetes include: 

 Provide training for school staff that work with students with diabetes. This training 

should include basic information about diabetes and the student’s needs, how to 

recognize medical emergencies, and steps to take in the event of an emergency. 

 Work with children with diabetes and their parents or caregivers to follow the 

personalized diabetes care plan devised by the family and the health care team. The 

National Diabetes Education Program has compiled a comprehensive booklet called 

35 
“Helping the Student with Diabetes Succeed: A Guide for School Personnel,” which 

can be can be found at 

http://www.ndep.nih.gov/diabetes/pubs/Youth_NDEPSchoolGuide.pdf or by calling 

1-800-860-8747. 

Table 5. Examples of Items to Include in Flow Chart for Patients with Diabetes 

Each visit 

 Weight check 

 Blood pressure check 

 Foot exam

 Diabetes education and self-management 

Twice per year 

 HbA1c test (quarterly if not within recommended range)

 Dental exam

Annual 

 Lipid profile 

 Dilated eye exam

 Physical exam for detecting nerve damage

 Serum creatinine and urinalysis for protein, microalbumin to creatinine ratio to detect kidney

disease 

Vaccines 

 Influenza (annual) 

 Pneumoccal (usually only once, repeat if over age 64 or immunocompromised and the last vaccice

was longer than 5 years ago)

SOURCE: National Diabetes Education Program (NDEP). Guiding principles for diabetes care: for health care providers. HHS

Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf. Accessed August 24, 

2004. 

Health Care Providers 

Primary care providers, such as family physicians, internists, physicians’ assistants, and nurse 

practitioners, play an important role in providing routine high-quality diabetes care as well as 

referrals to other practitioners for specialty care. As new research and drugs become available 

and practice guidelines for diabetes evolve, it is critical for health care providers to stay abreast 

of standards of care and new evidence-based treatments and devices to support diabetes 

management. Important information for providers about diabetes care can be found at 

http://www.ndep.nih.gov/resources/health.htm, http://www.betterdiabetescare.org, 

http://care.diabetesjournals.org/content/vol28/suppl_1/. Possible action steps for the primary 

care provider include: 

36 
 Help patients control blood glucose levels. The DCCT and the UKPDS demonstrated 

that intensive therapy in blood glucose management is effective in delaying the onset 

of complications and slowing the progression of diabetes.76

 Educate patients on the “ABCs of Diabetes”77 (HbA1c, blood pressure, and 

cholesterol) to lower overall risks for heart disease. Goal ranges are HbA1c of less 

than 7 percent, blood pressure of less than 130/80, and cholesterol (LDL) of less than 

100 mg/dl.78 

 Develop flowcharts that ensure patients with diabetes receive preventive and 

diagnostic services. Table 5 contains examples of care practices to include in flow 

charts for patients with diabetes.79 

 Advise women with diabetes considering pregnancy about the risks that diabetes 

poses for pregnancy and the importance of good blood glucose control before and 

during pregnancy. 

 Incorporate information management systems, such as patient registries, to track 

patient health status and receipt of preventive care services and provide information 

about the patient’s status to the entire care team. 

 Use office prompts (e.g., posters asking patients to remove their shoes and socks prior 

to the exam) to facilitate care. 

 Work with patients and their families to develop comprehensive care plans that 

include lifestyle changes and medical services needed to control blood glucose, blood 

pressure, and LDL cholesterol and prevent and manage complications from diabetes. 

Care plans should include the following: a meal plan, an exercise program to help 

patients maintain a healthy weight and good cardiovascular health, diabetes education 

to guide self-management, and a schedule to ensure that patients receive preventive 

and diagnostic care services, such as HbA1C tests, dilated eye exams, and foot exams 

in a timely manner. 

 Prescribe medications (angiotensin converting enzyme inhibitors or angiotensin 

receptor blockers) that can slow progression of diabetic kidney disease in patients 

found to have hypertension and/or elevated urinary microalbumin. 

 Ask if patients with diabetes smoke, and help those who smoke to stop smoking. 

 Help educate patients’ family members and friends about ways they can help loved 

ones with diabetes to manage the condition. 

 Refer patients with diabetes to various health care specialists and educators as 

appropriate. 

 

76 The Diabetes Control and Complications Trial Research Group, op.cit; and Turner, RC, op.cit. 

77 The ABCs of Diabetes, op.cit. 

78 National Diabetes Education Program (NDEP). Guiding principles for diabetes care: For health care providers. 

HHS Publication No. 99-4343. Available at: http://www.ndep.nih.gov/diabetes/pubs/GuidPrin_HC_Eng.pdf. 

79 ibid. 

37 
 Refer people with diabetes to community resources that can help them manage their 

diabetes. 

 Facilitate community support groups for people with diabetes and their friends and 

family to help educate them about the health problems that can be caused by diabetes 

and the ways they can manage the disease and live healthy and productive lives.

 Talk with community leaders about diabetes and the importance of supporting people 

with diabetes.

 Translate patient materials into other languages for people in the community when 

feasible. 

 Participate in clinical trials to evaluate new technologies for treating diabetes. 

 Become involved in research studies to determine effective approaches for educating 

and treating patients with diabetes in various populations, such as children, elderly 

persons, and members of specific racial/ethnic groups. 

Employers 

Potentially, any one of your employees could have diabetes now or develop the disease in 

the future. Diabetes does not discriminate; it can affect anyone, regardless of age, race/ethnicity, 

or gender. Since the prevalence of diabetes is increasing, no matter how large or small your 

workforce, your company may be increasingly affected by diabetes. Employees need your 

support and assistance to continue to be productive and effective workers. Specific actions aimed 

to control diabetes and prevent its complications may help increase overall employee 

productivity and company profitability.80 Specific action steps employers can take to support 

employees with diabetes include: 

 Review the health plans offered to employees to determine benefits for health care 

services and supplies associated with diabetes management (e.g., physician visits, 

diabetes education, dietitian visits, blood glucose testing supplies).

 Encourage public reporting of health plan and provider performance in meeting 

diabetes care objectives.

 Seek out information about diabetes to better understand the needs of employees with 

diabetes. Information is available at http://www.diabetesatwork.org/. 

Health Insurance Providers 

Health insurance providers can also support management of diabetes through education 

and outreach efforts to their members. Bringing individuals into high-quality diabetes care early 

 

80 National Diabetes Education Program (NDEP). Making a difference, the business community takes on diabetes. 

Available at: http://www.ndep.nih.gov/resources/business/index.htm.

38 
can help improve quality of life and may avoid complications. Some action steps for health 

insurance include:

 Distribute educational materials to health plan members with diabetes via direct mail 

or to health care providers for distribution.

 Inform women with diabetes about the importance of blood glucose control before 

and during pregnancy.

 Acknowledge providers that effectively use care guidelines to provide high-quality 

diabetes care.

 Consider offering health care providers incentives to follow evidence-based practice 

guidelines for care to optimize treatment outcomes.

 Educate patients about the importance of healthy lifestyle behaviors and self-blood 

glucose monitoring and management. Create patient education materials targeting 

groups that are particularly vulnerable to diabetes, such as children, people of various 

racial and ethnic groups, and elderly persons. 

 Consider designing insurance benefits that cover evidence based services needed to 

treat diabetes, including diabetes self-management education.

Communities

Community organizations can play a vital role in educating people with diabetes and their 

family members about the importance of managing diabetes to prevent complications. Various 

national organizations (e.g., the American Diabetes Association, American Association of 

Diabetes Educators) may have a local chapter in your area that is working to help your friends 

and neighbors with diabetes. Some action steps for community organizations to consider include: 

 Develop a directory of community resources for diabetes care and supplies that can 

be distributed to people with diabetes and their caregivers. 

 Support efforts to raise awareness for diabetes by participating in local and national 

walk, run, or bike rides for diabetes. 

 Coordinate efforts with groups that address chronic conditions related to diabetes, 

such as obesity and heart disease. 

 Partner with local media outlets to develop and distribute messages about the 

importance of managing diabetes. 

 Distribute information about diabetes treatment and management within the 

community (e.g., at stores, shopping malls, senior citizen centers, etc.). 

 Organize support groups where people with diabetes and their caregivers can meet 

with health professionals and their peers to discuss ways to manage diabetes. 

 Coordinate with local members of various racial/ethnic groups to develop patient 

education materials in different languages and formats. 

39 
 Encourage local restaurants and food chains to flag menu items that are appropriate 

for people with diabetes and/or provide nutritional information content of menu 

items. 

 Join with local Chambers of Commerce to recognize employers for providing 

working conditions that support people with diabetes (e.g., Health Friendly 

Workplace awards). 

 Partner with State Diabetes Prevention and Control Programs run by the State Health

Department. 

Media 

Different kinds of popular media (e.g., television, radio, newspapers) can be used to 

inform people with diabetes and their caregivers about the importance of quality diabetes 

treatment and self-management. Specific action steps for working with the media include: 

 Promote messages about managing diabetes by distributing information provided in 

health communication campaigns developed by the National Diabetes Education 

Program (available at http://www.ndep.nih.gov/campaigns/campaigns_index.htm;

http://www.ndep.nih.gov/campaigns/tools.htm#psa). 

 Promote National Diabetes Awareness Month (November of each year) on national, 

state, and local levels. 

 Distribute messages in multiple languages so the information reaches people who do 

not speak English. Tools in various languages are available at: 

http://www.ndep.nih.gov/diabetes/pubs/catalog.htm#PubsHispLatino and 

http://www.ndep.nih.gov/diabetes/pubs/catalog.htm#PubsAsianAm. 

 Partner with community clinics to provide information about where to go for diabetes 

care.

 Partner with medical professionals, federal, state, and local governments, and privatesector community entities to help the public understand the importance of managing 

and treating diabetes. 

 Collaborate with public health researchers to test media messages and identify the 

most appropriate and effective messages to reach people with diabetes.

 Work with officials to provide public access networks to broadcast local conferences 

or training videos on diabetes management.

 Partner with local schools of nursing, medicine, and other health professionals to 

encourage young people to pursue careers in health care.

 Invite local celebrities, community leaders, health professionals, and citizens with 

diabetes to participate on radio or television talk shows and discuss their experiences 

40 
with diabetes and the importance of self-management and medical care. Similarly, 

newspapers can include feature stories about community members and their 

experiences with diabetes.

 Work with local professional organizations to identify and acknowledge health care 

providers who have excelled in diabetes treatment and education efforts.

 Recognize local, state, and national programs that have been successful in helping 

people with diabetes get the care and education they need.

Researchers and Professional Educators 

Researchers and professional educators can play an important role to advance knowledge 

of diabetes treatment, develop new strategies to prevent its complications, and translate the 

research into messages that can reach those affected by diabetes and those working in this arena. 

Further, researchers and professional educators can help ensure that appropriate information is 

gathered to help inform policy makers. The following are some action items for these groups to 

consider: 

 Continue research on finding a cure and enhanced treatments for diabetes. 

 Explore partnerships with communities and other groups to help translate evidencebased practices and evaluation strategies to activities of these groups. 

 Investigate the costs of diabetes and provide this information to officials and policy 

makers at federal, state, tribal, and local levels. 

 Identify and address barriers to services that limit access to care for persons with 

diabetes. 

 Continue applied qualitative research into successful treatment protocols and diabetes 

management strategies; studies into quality of life issues; and exploration of future 

systems capacity issues.

 Employ community-based research methods to engage the community in research 

(i.e., needs assessments, clinic site visits, focus groups). 

State and local, Tribal, and Federal Governments 

State and local, tribal, and federal governments can serve as important role models for 

other organizations by actively engaging in efforts to advance knowledge and take steps to 

minimize complications from diabetes, improve patient care, and enhance access to care. The 

following are suggestions for accomplishing this: 

 Review and support policies and programs that help people with diabetes live healthy 

and productive lives. 

41 
 Examine health plan benefits for government employees to ensure coverage of 

evidence-based services to prevent or delay complications from diabetes. 

 Support research to develop new effective strategies, devices, and medications for 

diabetes. 

 Support efforts that help to decrease racial and ethnic disparities in diabetes care. 

 Conduct surveillance activities to monitor trends in the prevalence of diabetes (i.e., 

the number of people who have diabetes) to inform diabetes treatment efforts. 

 Continue to create and update educational materials for people with diabetes, their 

caregivers, employers, and schools that are available in various languages and 

formats to increase knowledge and understanding of this disease and how to help 

people with diabetes prevent or delay complications. 

 Support efforts to recruit and train members of the healthcare workforce that can help 

people with diabetes in their communities live healthy lives. 

 Continue to develop an evidence base of best practices for treating and managing 

diabetes. For example, the National Diabetes Education Programs Better Diabetes 

Care Web site (http://betterdiabetescare.nih.gov/index.htm)—provides best practice 

models, links, and resources to professionals for diabetes management—and the 

Indian Health Services’ Indian Health Diabetes Best Practice Model Approaches 

(http://www.ihs.gov/MedicalPrograms/Diabetes/index.asp)—provides 14 best 

practice model approaches for successful diabetes prevention, treatment, and 

education practices in American Indian and Alaskan Native communities.

42 
LIST OF 

ACRONYMS AND ABBREVIATIONS 

AADE American Association of Diabetes Educators 

ACOG American College of Gynecologists and Obstetricians 

ADA American Diabetes Association 

AHRQ Agency for Healthcare Research and Quality 

AoA Administration on Aging 

ASPE Assistant Secretary for Planning and Evaluation 

BPHC Bureau of Primary Health Care, HRSA 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare and Medicaid Services 

DCCT Diabetes Control and Complications Trial 

DDT Division of Diabetes Translation, CDC 

DNPA Division of Nutrition and Physical Activity, CDC 

DPP Diabetes Prevention Program

DRWG Diabetes Research Working Group, NIH 

FDA Food and Drug Administration 

HbA1c glycosylated hemoglobin or hemoglobin A1c

HDL High Density Lipoprotein 

HHS U.S. Department of Health and Human Services 

HP 2010 Healthy People 2010 

HRSA Health Resources and Services Administration 

IHS Indian Health Service 

LDL Low Density Lipoprotein 

LEA Lower Extremity Amputation 

NCCDPHP National Center for Chronic Disease Prevention and Health Promotion, CDC 

NDAP National Diabetes Action Plan 

NDEP National Diabetes Education Program, NIH/CDC 

NDL National Diabetes Laboratory 

NIDDK National Institute of Diabetes and Digestive and Kidney Diseases, NIH 

NIH National Institutes of Health 

OMH Office of Minority Health, OPHS 

TRIAD Translating Research Into Action for Diabetes 

UKPDS UK Prospective Diabetes Study 

USPSTF U.S. Preventive Services Task Force 

WISE WOMAN Well Integrated Screening and Evaluation for Women Across the Nation 

43 
44 
Appendix A: 

Steps to a HealthierUS

45 
46 
STEPS TO A HEALTHIERUS 

 Steps to a HealthierUS (Steps) is a major initiative of the U.S. Department of Health and 

Human Services (HHS) that advances President George W. Bush’s HealthierUS goal of helping 

Americans live longer, better and healthier lives. Recognizing that the United States is facing 

several serious public health challenges, Secretary Tommy G. Thompson launched Steps to a 

HealthierUS in 2003. At the heart of this program lie both personal responsibility for the choices 

Americans make and social responsibility to ensure that policy makers support programs that 

foster healthy behaviors and prevent disease. The Steps initiative envisions a healthy, strong U.S. 

population supported by a health care system in which diseases are prevented when possible, 

controlled when necessary, and treated when appropriate. This initiative is a shift in the 

traditional approach to the health of our citizens, moving us from a disease care system to a 

health care system. 

Realizing that small changes over time can yield dramatic results, the Steps initiative is 

committed to identifying and promoting programs that encourage small behavior changes. With 

a strong emphasis on proven interventions and existing science, Steps will promote the 

following: 

 Health promotion programs to motivate and support responsible health choices. 

 Community initiatives to promote and enable healthy choices.

 Health care and insurance systems that put prevention first by reducing risk factors 

and complications of chronic disease. 

 State and Federal policies that invest in the promise of prevention for all Americans. 

 Cooperation among policy makers, local health agencies, and the public to invest in 

disease prevention instead of spending our resources to treat diseases after they occur. 

The goal of the Steps initiative is to reverse the growth in the number of people suffering 

from chronic diseases like asthma, diabetes, cancer, heart disease and stroke, as well as factors 

that contribute to them such as obesity, poor nutrition, physical inactivity, and tobacco use. The 

intent of Steps is to reach the broadest number of Americans by using multiple approaches and 

involving groups and organizations to foster health, physical activity and good nutrition. To date, 

these approaches have focused on communities, businesses and organizations, and the actions

that they can take to influence individuals’ choices and actions to improve health. The Steps

initiative has multiple components including: 

 Grants to Communities: As the cornerstone of the Steps initiative, in 2004, HHS 

funded 22 cooperative agreements to 40 communities for a total of $35.7 million to 

establish community-wide partnerships to improve the health and well being of 

individuals by encouraging people to maintain physically active lifestyles and make 

healthy lifestyle choices.

47 
 Grant to a National Organization: In FY 2004, HHS awarded a $2 million grant to 

the national office of the YMCA. With more than 2,500 YMCA’s in the country, this 

funding will help strengthen the network of local YMCA chapters by developing and 

implementing strategies to work together with the 40 Steps grant communities also 

funded in 2004.

 Roundtable Discussions: The Secretary hosted a series of Roundtable discussions, 

which brought together interested stakeholders including academia, insurers, business 

executives, health care providers, and researchers. The purpose of these roundtables 

was to highlight the importance of prevention and specifically discuss best 

approaches to stem the tide of chronic diseases and encourage healthy lifestyles - 

regular physical activity and balanced diets. The roundtables also identified obstacles 

to adopting healthy habits. 

 Secretary’s Challenge--Steps to a HealthierHHS: This is an HHS worksite health 

promotion program encouraging Department employees to become more physically 

active. This voluntary initiative promotes the benefits of a healthy lifestyle by 

challenging employees to be on the move—at least 30 minutes a day, five days a 

week for six weeks. Nearly 800 employees participated, and 25 percent completed the 

pilot program in the Washington, DC, area. 

 Annual Prevention Summit: Held on April 15-16, 2003 in Baltimore, Maryland, 

the inaugural Steps to a HealthierUS: Putting Prevention First Summit focused 

attention on the urgency of prevention and on promising approaches for tackling key 

challenges. At this conference, the Secretary laid out his priorities and programs for 

Steps to a HealthierUS. The second annual summit was held on April 29-30, 2004, in 

Baltimore, Maryland. Future summits are planned. 

 Annual Awards for Innovation: Another component of the Steps initiative is the 

Steps Innovation in Prevention Awards Program. In December 2003, HHS awarded 

the first set of eight Steps Innovation Awards in seven categories, to groups and 

organizations recognizing their accomplishments and highlighting the concrete health 

improvements that each has achieved. The second round of awards will be 

announced in December 2004. 

 Partnerships: Another aspect of the Steps initiative is the partnerships program

where HHS seeks to work with other public and private sector organizations to 

support and promote healthier living. It is designed to encourage innovative 

opportunities to promote healthier living and prevent chronic diseases and conditions.

 Secretarial Workgroups and the Blueprint for Action: Recognizing the 

importance of many chronic diseases such as cancer, cardiovascular disease, and 

asthma, the Secretary established five senior staff workgroups on specific areas that 

were identified as presenting particular opportunities for cross-Departmental 

coordination and that are central to advancing health promotion and disease 

48 
prevention: overweight and obesity, diabetes, tobacco, media and messages, and 

health literacy. This work provided the basis for the Secretary’s Prevention: A 

Blueprint for Action released in April of 2004. This Blueprint outlines simple action 

steps to guide individuals in their quest for healthier lifestyles. It also encourages 

other interested parties and organizations, such as providers, employers, communities,

insurers, media, schools, and government to collaborate and cooperate to overcome 

obstacles, to promote healthy lifestyles and reduce the burden of chronic diseases. 

More information about Steps to a HealthierUS is available at: http://www.healthierus.gov/steps. 

49 
50 
Appendix B: 

Medicare and Diabetes 

51 
52 
MEDICARE AND DIABETES 

The Medicare program is a federal health insurance program for people age 65 or older, people 

under age 65 with certain disabilities, and people with end-stage renal disease (ESRD). Medicare 

covers more than 40 million beneficiaries. 

Current Medicare Coverage of Services and Supplies for Individuals with Diabetes 

Medicare covers important services and supplies for individuals with diabetes. 

• Self-Management Training Services 

Medicare currently covers diabetes self-management training under Part B for certain 

beneficiaries who are at risk for complications from diabetes. Under Medicare fee-forservice (FFS) a beneficiary pays 20% of the Medicare-approved amount after the yearly Part 

B deductible. 

• Medical Nutrition Therapy Services 

Medicare Part B also covers medical nutrition therapy services for people with diabetes or 

kidney disease. These services can be given by a registered dietician or nutrition 

professional and include diet counseling and therapy services to help a beneficiary manage 

their diabetes. Under Medicare FFS, a beneficiary pays 20% of the Medicare-approved 

amount after the yearly Part B deductible. 

 

• Diabetic Supplies and Therapeutic Shoes 

Medicare Part B covers diabetic self-testing equipment and supplies for beneficiaries who 

have diabetes. Medicare covers the same supplies for people with diabetes whether or not 

they use insulin. The self-testing equipment and supplies include glucose testing monitors, 

blood glucose test strips, lancet devices and lancets, and glucose control solutions. There 

may be some limits on the supplies or how often a beneficiary may receive the supplies. 

Medicare also covers therapeutic shoes for people with diabetes who qualify under Medicare 

Part B. The coverage includes depth-inlay shoes, custom-molded shoes and shoe inserts. 

Current Coverage of Preventive Services for Individuals with Diabetes 

Currently, Medicare Part B covers several preventive services that are important to individuals 

with diabetes. 

• Flu and Pneumococcal Pneumonia Vaccinations 

Medicare Part B covers flu and pneumococcal pneumonia vaccinations. All Medicare 

beneficiaries are covered. Under Medicare FFS, there are no out-of-pocket costs for 

beneficiaries if the health care provider accepts assignment. 

• Glaucoma Screening 

For beneficiaries who are at high risk for glaucoma, including people with diabetes or a 

family history of glaucoma Medicare covers glaucoma screening once every 12 months. The 

screening must be performed or supervised by an eye doctor who is legally allowed to do this 

53 
service in the State. Under Medicare FFS, a beneficiary pays 20% of the Medicare-approved 

amount after the yearly Part B deductible. 

• Other Preventive Services 

Medicare also provides coverage for the following preventive benefits under Part B: bone 

mass measurement, colorectal cancer screening, mammography screening, screening pap 

smear and pelvic exams and prostate cancer screening. 

Medicare Modernization Act of 2003 Improvements for Individuals with Diabetes 

The new law enhances diabetes coverage for beneficiaries by adding several improvements. 

• Welcome to Medicare Physical 

Beginning in 2005, the new law provides new coverage of a one-time preventive physical 

exam within 6 months of a beneficiary’s enrollment under Part B. The initial preventive 

physical will consist of a comprehensive examination that will allow the physician to 

diagnose problems early when treatment is more effective. In addition, the physician and 

office staff will provide education, counseling and referral to other preventive services

covered by Medicare. 

• Cardiovascular Screening Tests 

The new law provides Medicare coverage of cardiovascular screening blood tests, including 

tests for total cholesterol, high-density lipoprotein, and triglycerides. 

• Diabetes Screening Tests 

Beginning in 2005, the new law will supply new coverage of diabetes screening tests for 

persons at risk for diabetes, including a fasting plasma glucose test and such other tests as the 

Secretary may determine appropriate. Eligible risk factors include hypertension, 

dyslipidemia, obesity, prior identification of impaired fasting glucose or glucose tolerance, or 

at least two of the following: overweight, family history of diabetes, history of gestational 

diabetes or delivery of a baby over 9 pounds. 

• Medicare Part D Drug Benefit 

The new Medicare Part D drug benefit will cover insulin and associated diabetic supplies 

(including syringes) beginning in 2006. 

• Medication Therapy Management 

Beginning in 2006, the new comprehensive prescription drug benefit will include drug 

therapy management for beneficiaries with multiple chronic diseases, including diabetes, 

who take multiple drugs and spend more than a specified amount annually on drugs covered 

under the prescription drug benefit. The drug management programs will help ensure the 

best therapeutic outcomes and reduce the risk of adverse medication events. 

54 
Appendix C: 

Development of Diabetes: A National Plan for 

Action 

55 
56 
DEVELOPMENT OF DIABETES: A NATIONAL PLAN FOR ACTION 

Prompted by the Secretary’s commitment to disease prevention and health promotion, 

and efforts of interested individuals and organizations, the creation of Diabetes: A National Plan 

for Action (hereby referred to as the National Diabetes Action Plan—NDAP) offers an important 

opportunity to identify and coordinate activities among relevant stakeholders to improve diabetes 

prevention, detection and care. The development of the action plan reflects the cross cutting 

interest in this topic and the dedication of many entities to the prevention, detection and 

treatment of diabetes. 

The goals of the NDAP are: 

1. Increase national awareness of diabetes, its impact, and what various stakeholders can do 

to prevent or manage the disease; 

2. Reduce the prevalence of diabetes and factors that increase the risk of diabetes; 

3. Promote improved detection, monitoring, and treatment of the disease; and 

4. Identify existing public and private efforts to facilitate coordination and to leverage 

existing resources for detection, prevention, and treatment of diabetes. 

The process to develop the NDAP involved: 

1. An Internal Advisory Committee from the U.S. Department of Health and Human 

Services (HHS); 

2. A series of three participatory town hall meetings; and 

3. A literature review. 

Internal Advisory Committee 

The NDAP Internal Advisory Committee, comprised of senior officials from the various 

HHS agencies, provided advice on the scope and content for the plan. In addition, the Advisory 

Committee provided guidance throughout the NDAP development process and helped to 

establish the focus and parameters of the plan. The committee also reviewed a draft of the plan 

and provided input on the recommendations and action steps. 

Advisory Committee Members 

 Michael O’Grady, PhD (Committee Chair)

Assistant Secretary for Planning and Evaluation 

57 
 Kevin Keane 

Assistant Secretary for Public Affairs 

 Howard Zucker, MD, JD, LLM 

Acting Deputy Assistant Secretary for Health, Office of Public Health and Science 

 Garth Graham, MD, MPH 

Acting Deputy Assistant Secretary for Minority Health, Office of Minority Health, Office 

of Public Health and Science 

 Nathan Stinson, Jr., PhD, MD, MPH, 

Formerly the Deputy Assistant Secretary for Minority Health, Office of Minority Health 

 Carolyn Clancy, MD 

Director, Agency for Healthcare Research and Quality 

 John Wren 

Director for Planning and Policy Development, Administration on Aging 

 Frank Vinicor, MD 

Director, Division of Diabetes Translation, Centers for Disease Control and Prevention 

 Sean Tunis, MD 

Chief Medical Officer/Director, Office of Clinical Standards and Quality, Centers for 

Medicare & Medicaid Services 

 Lester Crawford, DVM, Ph.D. 

Deputy Commissioner of Food and Drugs, Food and Drug Administration 

 Sam Shekar, MD, MPH 

Associate Administrator, Bureau of Primary Health Care, Health Resources and Services 

Administration 

 Craig Vanderwagen, MD

Acting Chief Medical Officer, Indian Health Service 

 Allen Spiegel, MD 

Director, National Institute of Diabetes and Digestive and Kidney Diseases National 

Institutes of Health 

Town Hall Meetings 

Three town hall meetings provided public forums for the Secretary to listen to comments 

from the diabetes community. The information gathered in these forums helped to inform the 

development of NDAP. 

58 
The general structure of each town hall meeting consisted of a half-day session, which

opened with an introduction by the Secretary or a senior HHS official. This was followed by a 

series of statements from HHS staff and invited national, state, and local experts and 

policymakers on diabetes data concerning prevention, detection, and treatment, for each of the 

town hall meetings respectively. The presentations were followed by an open-microphone 

session where individuals and representatives of the diabetes groups asked questions or made 

comments. 

The meetings were advertised through local newspapers (including newspapers with high 

minority readership) and radio. In addition, letters of invitation were sent to local groups and 

leaders in the diabetes community, public health sector, and health services field. Both a Web 

site and a toll-free telephone line were provided for participants to register and obtain additional 

information. 

The town hall meetings were held in different locations around the country and each 

focused on a different facet of diabetes: 

Putting Prevention Into Practice: A Diabetes Town Hall Meeting 

The Cincinnati Hilton Netherland Plaza 

Cincinnati, Ohio 

March 29, 2004 

Expert Panel: 

Secretary Thompson 

Allen Spiegel, MD, Director, NIDDK 

The Honorable Jennette Bradley, Lieutenant Governor and Director of Commerce 

for Ohio

J. Nick Baird, MD, Director, Ohio Department of Health 

James Holsinger, PhD, Secretary of the Cabinet for Health Services, Kentucky 

Steve Collier, Superintendent, Norwood City Schools 

Jerry Mallicoat, Vice President of Midwest Marketing, Anthem Blue Cross/Blue 

Shield 

Francine Kaufman, MD, Past President, The American Diabetes Association 

Nicole Johnson, Miss America 1999 

59 
Diabetes Detection and Education: Steps to a HealthierUS 

Doubletree Hotel 

Little Rock, Arkansas 

June 18, 2004 

Expert Panel:

Secretary Thompson 

The Honorable Mike Huckabee, Governor of Arkansas 

Allen Spiegel, MD, Director, NIDDK 

Donald A. Young, MD, Deputy Assistant Secretary for Health Policy/ASPE 

Jane Kelly, MD, Program Director, National Diabetes Education Program, CDC 

Fay Boozman, MD, MPH, Director, Arkansas Department of Health 

Virginia Zamudio, RN, MSN, CDE, President, American Association of Diabetes 

Educators 

Victor H. Gonzalez, MD, National Board Member, American Diabetes 

Association

Simmie Armstrong, Jr., MD, Pine Bluff Family Medical Center, Arkansas 

Treatment of Diabetes:Steps to a HealthierUS 

Westin Seattle 

Seattle, Washington 

July 26, 2004 

Expert Panel:

Secretary Thompson 

George R. Nethercutt, Jr, JD, U.S. House of Representatives, Chairman of the 

Congressional Diabetes Caucus 

Michael O’Grady, PhD, Assistant Secretary for Planning and Evaluation, HHS 

Allen Spiegel, MD, Director, NIDDK 

Mary Selecky, Secretary, Washington Department of Health 

Francine Kaufman, MD, Past President, The American Diabetes Association 

Steven Kahn, MB, ChB, Director of Research and Development, VA Puget Sound Health 

Care System

Gerald Nepom, MD, PhD, Director, Benaroya Research Institute at Virginia Mason, 

Juvenile Diabetes Research Foundation International 

Joe Finkbonner, R.Ph, MHA, Director of the Epidemiology Center, Northwest Portland 

Area Indian Health Board

Bradley J. Enegren, Vice President and General Manager, Research and Development, 

Medtronic, Inc. 

Nicole Johnson, Miss America 1999 

Angela Bartels, RN, BSN, Diabetes Coordinator, 45th Street Medical Clinic 

60 
In total, approximately 1,200 people attended the three town hall meetings. The 

participants represented a broad cross-section from the diabetes community, including people 

living with diabetes and their friends and family members; people at risk for diabetes who have 

been successful making behavioral changes; health care providers; physicians; people who have 

worked with persons with diabetes; experts, public health practitioners, and researchers; 

legislators; diabetes advocacy groups; and private-sector entities. 

Literature Review 

In addition to information gathered through the town hall meetings, additional resources 

collected from a variety of sources informed the NDAP, including input from the internal HHS 

advisory group and information shared by HHS agencies. A thorough literature review was 

conducted. In addition, information submitted by interested organizations (e.g., American 

Diabetes Association, Juvenile Diabetes Research Foundation, American Association of 

Diabetes Educators) was also examined. 

61 
62 
Appendix D: 

Current Federal Diabetes Activities/Highlights 

63 
64 
CURRENT FEDERAL DIABETES ACTIVITIES/HIGHLIGHTS 

Multiple agencies within the federal government have initiated a broad range of diabetes 

prevention, detection, and treatment activities. Many state and local agencies have adopted and 

implemented these activities and programs. Selected examples of these federal efforts are listed 

below. Web site addresses are provided (where applicable) for more detailed information. 

Prevention

Various agencies within the U.S. Department of Health and Human Services (HHS) have 

developed health communication campaigns to raise awareness of diabetes and educate patients, 

providers, employers, and school personnel about how to prevent or delay complications from

diabetes. 

 Steps to a HealthierUS: Putting Prevention First—This program is part of President 

Bush’s HealthierUS initiative which focuses on preventing chronic diseases and 

conditions, including obesity, asthma, diabetes, heart disease, stroke, and cancer. It 

includes funds for innovative community-based programs to address asthma, diabetes, 

and obesity. The Steps campaign is a bold shift from a disease care system that relies

almost exclusively on physician interventions to a health care system where a 

community-based public health infrastructure supports individuals in making healthy 

lifestyle choices. More information is available at http://www.healthierus.gov/steps. (See 

Appendix A) 

 Initial Preventive Physical Examination and Other New Medicare BenefitsThe 

Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 

establishes coverage of a one-time “Welcome to Medicare Physical Examination” within 

6 months of a beneficiary’s first coverage under Part B, with the goal of health promotion 

and disease detection. The benefit covers a physical exam (including measurement of 

height, weight and blood pressure, and an electrocardiogram) and includes education, 

counseling and referral with respect to screening and other preventive services. The 

effective date is January 1, 2005, for new beneficiaries whose coverage period under 

Medicare Part B begins on or after that date. The MMA also adds coverage for 

cardiovascular and diabetes screening for Medicare beneficiaries, which also begins on 

January 1, 2005. 

 Small Steps, Big Rewards: Prevent Type 2 Diabetes—A feature of the National Diabetes 

Education Program, this educational campaign was introduced in November 2002. The 

campaign and its multicultural components introduced in 2004, are built on the findings 

of the Diabetes Prevention Program clinical trial conducted by the National Institute of 

Diabetes and Digestive and Kidney Diseases. The program Web site provides tool kits 

and other products intended to motivate people to reduce their risk for type 2 diabetes by 

losing a modest amount of weight and being more physically active. More information is 

available at http://www.smallstep.gov/ or 

http://www.ndep.nih.gov/campaigns/SmallSteps /SmallSteps_index.htm

65 
 Weight Control Information Network (WIN)— This network is a national information 

service of the National Institute of Diabetes and Digestive and Kidney Diseases. WIN 

develops and distributes science-based materials on obesity, weight control, physical 

activity, and nutrition for patients, health care professionals, and others in English and 

Spanish. WIN also created the Sisters Together: Move More, Eat Better media program

that encourages Black women 18 and over to maintain a health weight by becoming more 

physically active and eating healthier foods. More information on WIN is available at 

http://win.niddk.nih.gov/index.htm.

 National Diabetes Information Clearinghouse (NDIC)—The NDIC is an information 

dissemination service of the National Institute of Diabetes and Digestive Kidney 

Diseases. The NDIC was established to increase knowledge and understanding about 

diabetes among patients, health care professionals, and the general public through the 

effective dissemination of information. Patients and health care providers can contact the 

NDIC with inquiries about diabetes and order educational material. More information is 

available at http://diabetes.niddk.nih.gov. 

 National Agenda for Public Health Action: A National Public Health Initiative on 

Diabetes and Women’s Health—This initiative offers recommendations to help health 

professionals, women and their families, health care systems, worksites, communities,

and schools address the burden of diabetes among women. The Centers for Disease 

Control and Prevention is working with public- and private-sector partners to implement 

the plan. More information is available at 

http://www.cdc.gov/diabetes/pubs/action/index.htm.

 Take Time to Care About Diabetes—This campaign developed by the Food and Drug 

Administration Office of Women’s Health is intended to raise women’s awareness of the 

seriousness of diabetes and the importance of taking steps to treat the disease to avoid 

heart and kidney problems, blindness, stroke, or amputation of a lower limb. More 

information is available at 

http://www.fda.gov/womens/taketimetocare/diabetes/default.htm.

 Diabetes Today Developed by the Centers for Disease Control and Prevention’s 

(CDC) Division of Diabetes Translation, Diabetes Today is a course that provides 

training for public health professionals and community leaders to learn how to mobilize 

communities to address diabetes. This curriculum is based on the philosophy that people 

can take charge of diabetes at the community level. Rather than relying on expensive 

medical treatment after the complications of diabetes have developed, community 

members—such as people with diabetes and their families, health professionals, and 

other concerned individuals—can work together to prevent and control diabetes. For 

more information, call toll-free 1-877-CDC-DIAB, e-mail diabetes@cdc.gov, or visit the

Diabetes Today National Training Center and the Pacific Diabetes Today Resource

Center. More information is available at http://www.diabetestodayntc.org/. 

 Making Systems Change for Better Diabetes Care As part of National Diabetes 

Education Program, this comprehensive Web site provides information and tools to make 

effective systems changes and provide better quality care for the diagnosis, treatment, and 

prevention of diabetes. More information is available at http://betterdiabetescare.nih.gov/. 

66 
 Diabetes Prevention Program (DPP) The Diabetes Prevention Program (DPP) was a 

multi-center clinical trial led by the National Institute of Diabetes and Digestive and 

Kidney Diseases at 27 sites around the country. The study demonstrated that sustained 

lifestyle changes, including modest weight loss and regular physical activity, 

substantially reduced progression to type 2 diabetes, especially among older adults who 

were at very high risk. DPP showed that people with pre-diabetes (i.e., elevated blood 

glucose levels that are not yet high enough to be classified as diabetes) can prevent or 

delay the onset of type 2 diabetes by losing 5 percent to 7 percent of their body weight 

and participating in moderate physical activity (e.g., walking 30 minutes per day 5 days 

per week). Results from DPP were so compelling that the trial was ended a year early. 

The lifestyle intervention worked equally well for men and women and all racial/ethnic 

groups, and it was most effective among people aged 60 and older.81 

 Nutrition and Physical Activity to Prevent Obesity and Other Chronic Diseases 

program The Centers for Disease Control and Prevention’s Division of Nutrition and 

Physical Activity developed this program in response to the growing epidemic of 

overweight and obesity in the United States. This is a comprehensive program designed 

to help states maximize the effectiveness of their efforts to prevent obesity by addressing 

two related risk factors: nutrition and physical activity. The goal of the program is to 

make the United States a nation where all people can achieve and maintain a healthy 

body weight. Through a cooperative agreement process, this initiative provides funds to 

states for up to five years for programs aimed at reducing the rate of obesity among their 

citizens. More information is available at 

http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs/index.htm.

 Diabetesatwork.org—The National Diabetes Education Program’s business and managed 

care Web site www.diabetesatwork.org is an online diabetes and health resource kit that 

can help businesses and managed care companies assess the impact of diabetes in the 

work place. It presents employers with an interactive assessment tool to demonstrate the 

economics of better diabetes prevention and control guidance for choosing health care 

plans, and tools for developing worksite interventions and wellness programs. It also 

provided easy-to-understand information for employers to help employees manage their 

diabetes and take steps toward reducing the risk for diabetes-related complications such 

as heart disease. More information can be found at http://wwww.diabetesatwork.org 

 National Diabetes Prevention Center (NDPC)This Centers for Disease Control and 

Prevention funded national center, is working to identify, design, adapt, and share 

effective programs for diabetes prevention and control in American Indian and Alaskan 

Native communities. The NDPC supports initiatives in tribal education systems, 

information technology, diabetes self-management education, sharing diabetes prevention 

efforts across American Indian and Alaska Native communities, and translating 

promising practices that are both culturally relevant and science-based. More information 

is available at http://www.cdc.gov/diabetes/projects/ndpc.htm. 

 

81The Finnish Diabetes Prevention Study conducted by the National Public Health Institute–Helsinki yielded 

similar findings supporting the importance of maintaining a healthy weight to prevent type 2 diabetes.; and 

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with

lifestyle intervention or Metformin. New Eng J Med 346(6):393-403.

67 
 You Can! CampaignDeveloped by the Administration on Aging, the You Can!—Steps 

to a Healthier Aging campaign is a part of the Steps to a HealthierUS initiative. The You 

Can! campaign is designed to increase the number of older adults who are active and 

healthy through a partnership approach to mobilizing communities. These community 

partnerships will increase public awareness and provide appropriate programs to help 

older Americans improve their nutrition and physical activity. 

 Health Disparities Collaborative –Diabetes PreventionThe Health Resources and 

Services Administration, Bureau of Primary Health Care in collaboration with the 

Centers for Disease Control and Prevention, National Institutes of Health, and other 

partners, including the Institute for Healthcare Improvement are working to prevent 

diabetes among high risk individuals served by Federally Funded Health Centers. A 

Health Disparities Collaborative Diabetes Prevention pilot has been completed with 

excellent results in patient outcomes. The learning from the Diabetes Prevention 

collaborative will be integrated with the Cardiovascular Collaborative for improved 

primary health care in Federally Funded Health Centers. (See Current Activities—

Treatment section for additional information on the Health Disparities Collaboratives).

Detection 

Agencies within the U.S. Department of Health and Human Services (HHS) have 

developed a number of initiatives to promote detection of diabetes in the U.S. Agencies are also 

conducting research into the most effective strategies for screening pre-diabetes as well as type 2 

diabetes. 

 Diabetes Detection InitiativeThis HHS initiative is a community-based effort to 

identify persons with undiagnosed type 2 diabetes and refer them for follow-up blood 

testing and treatment, if appropriate. It uses community involvement strategies within 

health systems in communities throughout HHS regions. It is being pilot tested in 10 

locations through 2004. Early diagnosis and proper treatment of diabetes can prevent or 

delay serious diabetes-related health problems. More information is available at 

http://www.ndep.nih.gov/ddi. 

 SEARCH for Diabetes in YouthRising rates of diabetes among youths are a growing 

public health concern. The Centers for Disease Control and Prevention and the National 

Institutes of Health are funding this 5-year, multicenter study to examine the status of 

diabetes among U.S. children and adolescents. More information is available at 

http://www.searchfordiabetes.org/index.cfm. 

 The U.S. Preventive Services Task Force (USPSTF) This Task Force was convened 

by the U.S. Public Health Service to conduct comprehensive reviews of clinical research 

to assess the merits of preventive measures, including screening tests, counseling, 

immunizations, and chemoprevention. The Task Force comprises an independent panel of 

primary care and prevention experts from the private sector. To date, USPSTF has 

conducted reviews of evidence related to screening for type 2 diabetes and gestational 

diabetes, obesity in adults, and counseling for physical activity and healthy diet. 

http://www.ahrq.gov/clinic/uspstfix.htm 

68 
 Healthy Aging InitiativeA joint project by the Administration on Aging and the 

Centers for Disease Control and Prevention in which grants are awarded to states to 

implement evidence-based disease prevention programs at the community level. There 

are fourteen collaborative projects with State Units on Aging and State Health 

Departments, including one project focused on diabetes screening, 7 projects focused on 

physical activity, and three projects focusing on assisting older Americans with disease 

self-management. 

Treatment 

The availability of high-quality diabetes care services is crucial to support persons with 

diabetes in their efforts to manage the disease and prevent complications. Agencies within HHS 

support a variety of programs intended to measure and inform the quality of diabetes care in the 

United States. 

 National Healthcare Quality and Disparities Reports—These congressionally mandated 

annual reports on health care quality and health disparities in the United States include a 

broad set of performance measures that will be used to monitor the nation’s progress 

toward improved health care quality. Each of these reports contains measures that 

specifically address diabetes care. More information is available at 

http://www.qualitymeasures.ahrq.gov. 

 The National Quality Measures ClearinghouseTM (NQMCTM), Sponsored by HHS’s 

Agency for Healthcare Research and Quality (AHRQ), The National Quality Measures 

Clearinghouse (NQMC) is a database and Web site for information on specific evidencebased health care quality measures and measure sets. NQMC is sponsored by AHRQ to 

promote widespread access to quality measures by the health care community and other 

interested individuals. As of spring 2004, the NQMC contained 23 measures that address 

diabetes care. More information is available at http://www.ahrq.gov/qual/measurix.htm. 

 Diabetes Care Quality Improvement: A Resource Guide for State Action The Agency 

for Healthcare Research and Quality (AHRQ), in partnership with The Council of State 

Governments, produced the Diabetes Care Quality Improvement: A Resource Guide for 

State Action and its companion workbook, to help states assess the quality of diabetes 

care and develop quality improvement strategies. These tools provide an overview of the 

factors that affect quality of care for diabetes; present the core elements of health care 

quality improvement; assist state policymakers in using the data from AHRQ's 2003 

National Healthcare Quality Report for planning state-level quality improvement 

activities; and, provide a variety of best practices and policy approaches that national 

organizations, the Federal Government, and states have implemented related to diabetes 

quality improvement. The Diabetes Care Quality Improvement: A Resource Guide for 

State Action is available online at http://www.ahrq.gov/qual/diabetes/. The companion 

workbook is available at http://www.ahrq.gov/qual/diabetes/workbk.htm. Printed copies 

may be ordered by calling 1-800-358-9295 or by sending an e-mail to 

ahrqpubs@ahrq.gov. 

 The Community Guide to Preventive ServicesThe Task Force on Community 

Preventive Services is a 15-member nonfederal task force supported by the Centers for 

69 
Disease Control and Prevention (CDC). CDC scientists review the effectiveness of health 

care interventions for the task force, which then makes recommendations to the public 

health community and health care delivery organizations. The recommendations 

generated by the task force are combined to form the Guide to Community Preventive

Services, which includes a section on diabetes. To improve the health of people with 

diabetes, the task force reviewed the evidence of the effectiveness of diabetes disease and 

case management and self-management education. More information is available at 

http://www.thecommunityguide.org/diabetes/default.htm.

 Health Disparities Collaborative -DiabetesThe Health Resources and Services 

Administration, Bureau of Primary Health Care in collaboration with the Centers for 

Disease Control and Prevention, National Institutes of Health, and other partners, 

including the Institute for Healthcare Improvement are working to improve diabetes care 

within Federally Funded Health Centers. The purpose of the Health Disparities 

Collaborative–Diabetes is to improve diabetes care and performance measures through 

improved health care delivery systems, and to increase access and decrease health 

disparities among medically underserved populations. The learning from the Diabetes 

collaborative will be integrated with the Cardiovascular Collaborative for improved 

primary health care in Federally Funded Health Centers. 

In addition, the Diabetes and Diabetes Prevention (see Current Activities—Prevention 

section) collaboratives are intended to generate and document improved health outcomes 

for underserved populations and transform clinical practice through models of patient 

centered care, improvement, and learning; develop infrastructure, expertise, and 

multidisciplinary leadership to support and drive improved health status; and build 

strategic partnerships, which have increased access to expertise, computer software, 

discounted pharmaceuticals and HbA1c tests, laboratory equipment, direct community 

resources for patients, health education materials, and community-level marketing and 

educational resources. More information is available at http://www.healthdisparities.net/ 

 Indian Health Service (IHS)—The Indian Health Service (IHS), National Diabetes 

Program (NDP) promotes collaborative strategies for the prevention of diabetes and its 

complications in the 12 IHS Service Areas through coordination of a network of 19 

Model Diabetes Programs and 13 Area Diabetes Consultants. The NDP also manages the 

Special Diabetes Program for Indians grant program with 332 grantees in 35 states. In 

addition, the IHS has developed standards of care that are routinely updated to help 

provide consistent, quality care to patients with diabetes. More information is available at 

http://www.ihs.gov/MedicalPrograms/Diabetes/. 

 Healthy People 2010 (HP2010) Healthy People 2010 is a set of disease prevention and 

health promotion objectives for the nation to achieve by 2010. It includes 17 objectives 

specifically aimed at reducing the disease and economic burden of diabetes and 

improving the quality of life for all persons who have or are at risk for diabetes. In 

addition, Centers for Disease Control and Prevention, Division of Diabetes Translation’s 

National Objectives include measures for tracking the quality of diabetes care received. 

For example, these programs assess the number of foot exams, eye exams, and annual 

HbA1c tests conducted. 

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 The Centers for Medicare & Medicaid Services (CMS) The Centers for Medicare & 

Medicaid Services (CMS) provides benefits to Medicare beneficiaries for diabetes selfmanagement training, medical nutrition therapy, prescription drugs, and select testing 

equipment for persons with diabetes. In addition, CMS sponsors the National Diabetes 

Eye Exam Program that matches Medicare beneficiaries aged 65 and older who have 

diabetes and have not had a medical eye exam in the past 3 years with a volunteer 

ophthalmologist in their area to receive a free comprehensive eye exam and up to 1 year 

of follow-up care for any condition diagnosed at the initial exam. For more information 

about Medicare coverage of diabetes services, go to http://www.cms.hhs.gov. 

 The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) This 

Institute of the National Institutes of Health supports basic and clinical research at 

universities and medical centers throughout the U.S. and at research facilities in 

Bethesda, Maryland and Phoenix, Arizona. NIDDK research forms the scientific 

foundation for improvements in diabetes care and for messages delivered via the National 

Diabetes Education Program. Examples of NIDDK-supported research include the 

Diabetes Control and Complications Trial and the Diabetes Prevention Program

(previously discussed). There are many other ongoing diabetes research efforts. One 

important effort is Trial Net, an international network of investigators, clinical centers, 

and core support facilities whose aim is to recruit patients and support studies that will 

result in an improved understanding of type 1 diabetes disease development and conduct 

prevention trials (http://www.diabetestrialnet.org). Another is TEDDY (The 

Environmental Determinants of Diabetes in the Young), which is developing and 

carrying out research to identify environmental causes of type 1 diabetes in genetically 

susceptible individuals (http://www.teddystudy.org/). A third is STOPP-T2D (Studies to 

Treat or Prevent Pediatric Type 2 Diabetes), which is conducting pilot studies for a 

school-based trial directed at preventing the risk factors for type 2 diabetes in middle 

school children, and a multicenter clinical trial of optimal treatment for adolescents with 

type 2 diabetes (http://www.todaystudy.org/). For more information on type 1 and type 2 

diabetes research, please visit http://diabetes.niddk.nih.gov/. 

 The Diabetes Control and Complications Trial (DCCT)  provided evidence that 

improving control of blood glucose levels delays the onset and progression of eye, 

kidney, and nerve diseases caused by diabetes. An ongoing epidemiologic follow-up 

study of this population, Epidemiology of Diabetes Interventions and Complications 

(EDIC) study, has shown that the effectiveness of a limited period of intensive glycemic 

control on reducing complications persist 20 years after the study began and become even 

stronger over time. More information is available at 

http://diabetes.niddk.nih.gov/dm/pubs/control/index.htm.

 National Diabetes Education Program (NDEP)—Helping the Student with Diabetes 

Succeed: A Guide for School Personnel—This comprehensive guide is designed to 

empower school personnel, parents, and students to create a safe learning environment 

and provide equal access to educational opportunities for all children with diabetes. More 

information is available at http://www.ndep.nih.gov/resources/school.htm. 

 The Diabetes Research Working Group (DRWG) was established in 1997 to develop a 

comprehensive plan of recommended future diabetes research initiatives. The group met 

over the period of one year and generated Conquering Diabetes: A Strategic Plan for the 

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21st Century (available at http://www.niddk.nih.gov/federal/dwg/dwgmain.htm), which 

addressed three main topics: 

• Extraordinary Opportunities in Diabetes Research—rapidly expanding, 

crosscutting areas in which increased investment or development of new 

mechanisms will significantly speed research in areas such as genetics of

diabetes, autoimmunity and the beta cell, and obesity. 

• Special Needs for Special Problems—research targeted to specific 

populations, complications, and methodological approaches. 

• Resource and Infrastructure Needs—expanding research infrastructure 

(e.g., trained professionals and technology). 

 Be Smart About Your Heart: Control the ABCs of Diabetes—This campaign, developed 

by the National Diabetes Education Program, encourages people with diabetes to control 

not only their blood glucose (sugar), but also their blood pressure and cholesterol. More 

information is available at 

http://www.ndep.nih.gov/campaigns/BeSmart/BeSmart_index.htm

 National Kidney Disease Education Program (NKDEP)—The National Kidney Disease 

Education Program, sponsored by the National Institute of Diabetes and Digestive and 

Kidney Diseases, aims to raise awareness of the seriousness of kidney disease, the 

importance of testing those at high risk, and the availability of treatment to prevent or 

slow kidney failure. The NKDEP is designed to close the gap between evidence and 

practice by educating people at risk and physicians, with the goal of identifying kidney 

disease in its early, treatable stages. More information on the NKDEP can be found at 

http://www.nkdep.nih.gov. 

 National High Blood Pressure Education Program (NHBPEP)—This goal of this 

program, which is coordinated by the National Heart, Lung, and Blood Institute of the 

National Institutes of Health, is to reduce death and disability related to high blood 

pressure through programs of professional, patient, and public education. The NHBPEP 

is a cooperative effort among professional and voluntary health agencies, state health 

departments, and many community groups. More information is available at 

http://www.nhlbi.nih.gov/about/nhbpep. 

 National Cholesterol Education Program (NCEP)—The goal of the National 

Cholesterol Education Program is to contribute to reducing illness and death from heart 

disease in the U.S. by reducing the percent of Americans with high blood cholesterol. 

The NCEP directs educational efforts targeted at both health professionals and the public. 

The program aims to raise awareness and understanding about high blood cholesterol as a 

risk factor for heart disease and the benefits of lowering cholesterol levels as a means of 

preventing heart disease. More information about this program, which is coordinated by 

the National Heart, Lung, and Blood Institute of the National Institutes of Health, can be 

found at http://www.nhlbi.nih.gov/about/ncep/. 

 National Eye Health Education Program (NEHEP)—The focus of the National Health 

Education Program is on public and professional education programs that encourage 

early detection and timely treatment of diabetic eye disease and glaucoma and the 

appropriate treatment for low vision. This program is coordinated by the National Eye 

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Institute of the National Institutes of Health in partnership with a variety of public and 

private organizations. More information can be found at http://www.nei.nih.gov/nehep/. 

 Family Center Support ProjectThe Centers for Disease Control and Prevention, 

Division of Diabetes Translation has undertaken a 5-year behavioral research project that 

will identify and examine nontraditional psychosocial factors regarding diabetes 

education and the family. These factors include community characteristics, health care 

reimbursement, family processes, diabetes education, provider-patient characteristics, 

acculturation or westernization, as well as psychological factors. Previously unrecognized 

factors include racism, living arrangements, perceptions of safety, and intergenerational 

coping skills, and their overall impact on psychological well being. More information is 

available at http://www.cdc.gov/diabetes/projects/family.htm. 

 Translating Research Into Action for Diabetes (TRIAD) Translating Research Into 

Action for Diabetes is a 5-year, six-center prospective study of managed care and 

diabetes quality of care, costs, and outcomes in the United States. In its third year, this

important study is the first and largest multicenter study of diabetes quality of care, 

quality of life, and factors affecting them. TRIAD is currently developing plans to carry 

out a detailed assessment of socioeconomic status and how it relates to quality of care 

and health status with diabetes. Sponsored by Centers for Disease Control and Prevention 

and National Institute of Diabetes and Digestive and Kidney Diseases, TRIAD’s overall 

goal is to examine the influence of managed care structure on processes and outcomes of 

diabetes care. More information is available at http://www.triadstudy.org/. 

 National Diabetes LaboratorySince 1997, the Centers for Disease Control and 

Prevention (CDC) has dedicated $3 million annually to a National Diabetes Laboratory 

(NDL) to support emerging scientific efforts to help prevent and treat type 1 diabetes. 

CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of 

Diabetes Translation, and the National Center for Environmental Health are collaborators 

on this project. For example, scientists are working to develop and evaluate laboratory 

technology for improving the measurement of genetic risk factors for type 1 diabetes and 

its complications, to study autoantibodies of type 1 diabetes, and to develop other 

projects that will improve the lives of people with type 1 diabetes. For more information, 

call toll-free 1-877-CDC-DIAB, e-mail diabetes@cdc.gov, or visit CDC’s National

Center for Environmental Health’s National Diabetes Laboratory at

http://www.cdc.gov/nceh/dls/diabetes.htm.

 Administration on Aging—Evidenced-Based Disease Prevention Program: In 2003, the 

Administration on Aging launched a new grants program and a public/private partnership 

to increase older people’s access to programs that have proven to be effective in reducing 

their risk of disease, disability and injury. One of the focus areas, disease selfmanagement, funds community chronic disease efforts, including those for diabetes. For 

more information, please visit http://www.aoa.gov/prof/evidence/evidence.asp 

 National Agenda for Public Health Action: A National Public Health Initiative on 

Diabetes and Women’s Health—This initiative offers recommendations to help health 

professionals, women and their families, health care systems, worksites, communities,

and schools address the burden of diabetes among women. The Centers for Disease 

Control and Prevention is working with public- and private-sector partners to implement 

73 
the plan. More information is available at 

http://www.cdc.gov/diabetes/pubs/action/index.htm.

 Take Time to Care About Diabetes—This campaign developed by the Food and Drug 

Administration, Office of Women’s Health is intended to raise women’s awareness of the 

seriousness of diabetes and the importance of taking steps to treat the disease to avoid 

heart and kidney problems, blindness, stroke, or amputation of a lower limb. More 

information is available at 

http://www.fda.gov/womens/taketimetocare/diabetes/default.htm.

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Appendix E: 

Are You at Risk for Diabetes? 

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76 
DIABETES: YOU COULD BE AT RISK — TAKE THE TEST, KNOW YOUR SCORE!

Diabetes means your blood sugar (glucose) is too high. How 

would you know? Are you often thirsty, hungry, or tired? Do

you urinate often? Do you have sores that heal slowly,

tingling in your feet, or blurry eyesight? Even without these signs,

you could still have diabetes. 

Diabetes is a serious disease. It can cause heart attack or stroke, 

blindness, kidney failure, or loss of feet or legs. But diabetes can 

be controlled. You can reduce or avoid these health problems.

Take the first step. Find out if you are at high risk.

Know your risk of having diabetes now. Answer these quick questions. For each Yes answer, add the number of points listed. All No 

answers are 0 points. 

Question Yes No

Are you a woman who has had a baby weighing more than 9 pounds at birth? 1 0 

Do you have a sister or brother with diabetes? 1 0 

Do you have a parent with diabetes? 1 0

Find your height on the chart. Do you weigh as much as or more than 

the weight listed for your height? 5 0

Are you under 65 years old and get little or no exercise in a typical day? 5 0 

Are you between 45 and 64 years old? 5 0

Are you 65 years old or older? 9 0

Add Your Score 

These questions are from the American Diabetes Association’s on-line “Diabetes Risk Test” (http://www.diabetes.org/info/risk/risktest.jsp). 

AT RISK WEIGHT CHART 

Height Weight 

 (Pounds)

4’10......................................................129 

4’11......................................................133 

5’0........................................................138 

5’1........................................................143 

5’2........................................................147 

5’3........................................................152 

5’4........................................................157 

Height Weight 

 (Pounds)

5’5........................................................162 

5’6........................................................167 

5’7........................................................172 

5’8........................................................177 

5’9........................................................182 

5’10......................................................188 

5’11......................................................193 

Height Weight 

 (Pounds)

6’0 ........................................................199 

6’1 ........................................................204 

6’2 ........................................................210 

6’3 ........................................................216 

6’4 ........................................................221 

KNOW YOUR SCORE

If you scored . . . then your risk is . . . 

10 or more points High for having diabetes now. Please bring this form to your health care provider 

soon. If you don’t have insurance and can’t afford a visit to your provider, contact your

local health department.

3 to 9 points Probably low for having diabetes now. Keep your risk low. If you’re overweight, lose 

weight. Be active most days, and don’t use tobacco. Eat low-fat meals with fruits, 

vegetables, and whole-grain foods. If you have high cholesterol or high blood pressure,

talk to your health care provider about your risk for diabetes.

I SCORED 10 OR MORE — HOW CAN I GET TESTED FOR DIABETES? 

If you have . . . then do this . . . 

Individual or group private health insurance See your health care provider. If you don’t have a provider, ask your insurance company 

about providers who take your insurance. Deductibles and co-pays will apply.

Medicaid See your health care provider. If you don’t have a provider, contact a state Medicaid 

office or contact your local health department.

Medicare See your health care provider. Medicare will pay the cost if the provider has a reason for

testing. If you don’t have a provider, contact your local health department.

No insurance Contact your local health department for more information about where you could be 

tested or call your local health clinic.

For more information, contact the Department of Health and Human Services, National Diabetes Education Program at 1-800-438-5383 or online at 

http://www.ndep.nih.gov. 

SOURCE: U.S. Department of Health and Human Services, Diabetes Detection Initiative. Diabetes. You could be at risk—take the test—know your score! 

Available at: http://www.ndep.nih.gov/ddi/resouces/risktest.pdf Adapted from the American Diabetes Association’s risk assessment

77