office of research on women’s health 

Women of Color Health Information Collection 

Diabetes Mellitus 
Office of Research on Women’s 

Health Women of Color Health 

Information Collection: 

Diabetes Mellitus

The Office of Research on Women’s Health (ORWH), established in September 1990 within 

the Office of the Director, National Institutes of Health (NIH), works in partnership with the 

NIH Institutes and Centers (ICs) to ensure that women’s health research is part of the scientific framework at NIH and throughout the scientific community. ORWH collaborates with 

the Advisory Committee on Research on Women’s Health (ACRWH), comprising physicians, 

scientists, and other health professionals; and the Coordinating Committee on Research on 

Women’s Health (CCRWH), composed of the NIH IC Directors or their designees.

The ORWH mission is to: 

•	 advise the NIH Director and staff on matters relating to research on women’s health;

•	 strengthen and enhance research related to diseases, disorders, and conditions that 

affect women;

•	 ensure that research conducted and supported by NIH adequately addresses issues 

regarding women’s health;

•	 ensure that women are appropriately represented in biomedical and biobehavioral 

research studies supported by NIH;

•	 develop opportunities for and support recruitment, retention, re-entry, and advancement 

of women in biomedical careers; and

•	 support research on women’s health issues.

Additional information on the mission and programs supported by ORWH can be found 

at http://orwh.od.nih.gov/.
2 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

Introduction

The Women of Color Health Information Collection serves to highlight the importance of 

women’s health recognizing the role of culture, race/ethnicity, socioeconomic background, 

geographic location, and other factors as important contributors to the health status of women 

of diverse backgrounds. Data on the health status of women of color is not readily available 

from a single source. Although clinical trials and population-based surveys may include diverse 

populations, many do not report results disaggregated by sex and race/ethnicity or for minority 

subpopulations. A variety of sources have been included in this series to provide a description 

of various diseases and conditions in women of color. This information will be of value to 

scientists, advocates, clinicians, and policymakers in understanding the health status of women 

of color in this country in order to formulate policies and research priorities, and to develop 

and implement clinical practices which promote the health of all women.

The ultimate goal of biomedical research is to increase knowledge through sound science 

to inform the development of policies and clinical practice standards from which all women 

and men can benefit. The expanded concepts of women’s health, and therefore research, focus 

on the study and understanding of women’s health as a reflection of the myriad elements 

that contribute to the overall quality of women’s lives in the United States today. A challenge inherent to women’s health research is to establish a scientific knowledge base that will 

permit reliable diagnoses and effective prevention and treatment strategies appropriate for 

all women, including those of diverse racial/ethnic backgrounds. There is a need for a better 

understanding of how sex, gender, and cultural and racial/ethnic differences influence the 

pathobiology, etiology, diagnosis, progression, treatment, and outcomes of diseases among 

different populations.

The twenty years since the establishment of the NIH Office of Research on Women’s Health in 

1990 have seen increased attention to women’s health issues and the establishment of other federal offices, programs, legislation, and policies to foster the study of women’s health issues and 

to promote the inclusion of women and minorities in clinical research. These changes reflect 

the recognition that in order for the results of biomedical and behavioral research to be widely 

applicable, researchers and clinicians must consider how cultural, racial, and ethnic differences 

may influence the causes, diagnoses, prognosis, treatment, and outcomes of diseases among 

different populations in the design and conduct of research and the delivery of health care.
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 3

NIH funded clinical research must include women and minorities as scientifically appropriate as mandated by public law (NIH Revitalization Act of 1993, Public Law 103-43). NIH 

recognizes that there are barriers to recruiting and retaining women of diverse backgrounds 

as research subjects. Such barriers include the need for cultural diversity among researchers, 

promotion of collaborative relationships between researchers and communities, overcoming 

logistical problems related to women’s roles as caregivers and in the workplace, and an appreciation of cultural beliefs of potential research participants. As part of the NIH Inclusion 

policy, and as stated in the 1993 Revitalization Act, cost is not justification for exclusion of 

women and/or minorities as participants in clinical research. 

Just as sex/gender must be incorporated in the design of clinical research studies if the results 

of such research are to be widely applied through health care policies and interventions, so too 

must racial, ethnic, and cultural factors be taken into account in the design and conduct of 

research protocols.

WOMEN OF COLOR IN THE U.S. POPULATION

Of the approximately 307 million estimated U.S. residents in 2009, about 51 % were 

women, according to the U.S. Census Bureau, as shown in Table 1. There is increasing racial 

and ethnic diversity in the U.S. with a growing population of non-White women. The Census 

Bureau estimated that in 2009, almost 11 % of women in the U.S. were non-White, and 

Hispanic women constituted 7.61 % of the total U.S. population. (1)
4 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

Table 1: Total and Female Population of the United States by Race and Hispanic 

Origin (Estimated for 2009 based on 2000 Census Data)

Race and Hispanic Origin Both Sexes

Female % of 

Total Population Female

Total U.S. Population (Hispanic and Non-Hispanic) 307,006,550 50.67% 155,557,060

 White 244,298,393 40.08% 123,062,670

 Black 39,641,060 8.48% 20,704,909

 AI/AN 3,151,284 0.51% 1,569,803

 Asian 14,013,954 2.36% 7,244,461

 NH/PI 578,353 0.09% 284,281

Two or more races 5,323,506 0.88% 2,690,936

Hispanic (Total) 48,419,324 48.25% 23,362,405

 White 44,447,153 44.18% 21,392,163

 Black 1,959,516 2.04% 990,111

 AI/AN 790,477 0.77% 373,571

 Asian 327,871 0.34% 163,503

 NH/PI 129,843 0.13% 61,229

Two or more races 764,464 0.79% 381,828

Non-Hispanic (Total) 258,587,226 51.12% 132,194,655

 White 199,851,240 39.32% 101,670,507

 Black 37,681,544 7.62% 19,714,798

 AI/AN 2,360,807 0.46% 1,196,232

 Asian 13,686,083 2.74% 7,080,958

 NH/PI 448,510 0.09% 223,052

Two or more races 4,559,042 0.89% 2,309,108

Adapted from Annual Estimates of the Resident Population by Sex, Race, and Hispanic Origin for the United States: April 

1, 2000 to July 1, 2009 (NC-EST2009-03). http://www.census.gov/popest/national/asrh/NC-EST2009-srh.html. Date 

Accessed: September 10, 2010.

Hispanic origin is considered an ethnicity, not a race. Hispanics may be of any race.
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 5

LEADING CAUSES OF DEATH IN FEMALES

The seven leading causes of death of women in the U.S. are heart disease, cancer, stroke, 

chronic lower respiratory disease, Alzheimer’s disease, unintentional injuries, and diabetes. 

Based on 2006 data from the U.S. Centers for Disease Control and Prevention (CDC), 

shown in Table 2, heart disease is the leading cause of death for African American, White, 

and Hispanic women in the U.S.; cancer is the leading cause of death for American Indian/

Alaska Native and Asian/Pacific Islander women. (2)

Table 2: Leading Causes of Death in Females for the United States in 2006 by 

Percentage*

Condition All

American Indian/ Alaska 

Native

Asian/Pacific 

Islander Black White Hispanic

Heart disease 25.8 18.8 22.7 25.5 26.0 22.8

Cancer 22.0 19.2 27.2 21.6 22.0 21.7

Stroke 6.7 4.9 9.3 6.8 6.7 6.4

Chronic lower respiratory 

diseases

5.3 4.3 2.4 2.5 5.8 2.7

Alzheimer’s disease 4.2 2.2 2.3 4.5 2.7

Unintentional injuries 3.5 8.1 3.8 3.1 3.5 5.0

Diabetes 3.0 7.0 3.8 5.0 2.7 5.4

Adapted from CDC, Office of Women’s Health. Leading Causes of Death in Females United States, 2006. http://www.cdc.

gov/women/lcod/06_females_by_race.pdf . Date Accessed: September 10, 2010.

*The data represent the percent of total deaths in the race category due to the disease indicated. The racial groups (White, 

Black, American Indian/Alaska Native, and Asian/Pacific Islander) include persons of Hispanic and non-Hispanic origin. 

Persons of Hispanic origin may be of any race. 

Leading causes of death for each race/ethnicity are in bold font.
6 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

Background

Diabetes mellitus (DM) is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production or insulin action. DM can cause serious complications 

and premature death, and is one of the leading causes of death and disability in the United 

States, especially among women of color. It has a major effect on the circulatory system and 

promotes the development of conditions such as arteriosclerosis and renal failure. The CDC 

reports that in 2007, 23.6 million people, or 7.8 % of the U.S. population, had diagnosed or 

undiagnosed diabetes. (3)

Dm can cause serious complications 

and premature death and is one of the 

leading causes of death and disability 

in the united states, especially among 

women of color.

The two main types of DM are 

type 1 and type 2. In type 1 

diabetes, which affects 5 to 10 % 

of people with DM, the autoimmune destruction of pancreatic 

islet cells results in failure of 

insulin production leading to 

hyperglycemia. Type 2 diabetes 

affects 90 to 95 % of people with DM and has risk factors including older age, obesity, family 

history of DM, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. People with type 2 diabetes are able to produce insulin, but do not 

metabolize glucose effectively, because they have insulin resistance or insufficient production 

of insulin. (3) Symptoms of DM include fatigue, polydipsia, frequent urination (especially at 

night), weight loss, blurred vision, frequent infections, and impaired wound healing. (4) 

Although type 2 diabetes was once most prevalent among older adults, its prevalence among 

children and adolescents is increasing. (5)

Any degree of glucose intolerance with onset or first recognition during pregnancy is called 

gestational diabetes mellitus (GDM) and is associated with an increased risk of fetal complications and development of type 2 diabetes by both mother and child. Approximately 5 to 10 % 

of women with GDM develop diabetes immediately following pregnancy, typically type 2. In 

addition, women with a history of GDM have a 40 to 60 % chance of developing DM in the 

subsequent 5 to 10 years. (3) Currently, GDM is diagnosed in about 7 % of pregnancies, (6) 

however, in March 2010, an international study group proposed updated criteria and universal 

screening, which could increase the incidence rate to 18 % of pregnancies. (7) (8)
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 7

Susceptibility and Impact

NEW DIAGNOSED CASES OF DIABETES

Over of 1.6 million new cases of DM were diagnosed in people ages 20 years or older in the 

U.S. in 2008. (9) The differential impact of this disease on morbidity and mortality across 

racial/ethnic groups, as exhibited in the table and figures which follow, is significant. Based on 

2002–2003 data, new cases among youth were 19 per 100,000 per year for type 1 diabetes 

and 5.3 per 100,000 for type 2 diabetes. Non-Hispanic White youth had the highest rate of 

new cases of type 1 diabetes. While the rate of new cases of type 1 diabetes was higher than 

for type 2 diabetes among non-Hispanic White youth (10-19 years), the opposite was found 

among Asian/Pacific Islander and American Indian youth. African American and Hispanic 

youth had comparable rates of new cases of type 1 and type 2 diabetes. (3)

TOTAL DIAGNOSED CASES OF DIABETES

Data collected by the CDC National Health Interview Survey, presented in Table 3, 

delineate the age-adjusted percentages of persons 18 years of age and over with diabetes 

from 2004-2008. (10)

Table 3: Age-adjusted Percentages of Adults 18 years of age and over with DM 

by Race, United States, 2004-2008

Sex

American Indian 

or Alaska Native White

Black or African 

American Asian Hispanic

Both Sexes 17.5 6.6 11.8 8.0 10.6

Females 16.2 6.2 12.1 7.1 10.7

Males 18.2 7.2 11.3 8.9 10.6

Adapted from CDC National Health Statistics Reports: Health Characteristics of the American Indian and Alaska Native Adult 

Population: United States, 2004-2008. Table 4. http://www.cdc.gov/nchs/data/nhsr/nhsr020.pdf. Date Accessed: July 28, 2010.

The category race refers to persons who indicated only a single race group. Persons who indicated a single race other than the 

groups shown are not shown separately due to small sample sizes. Persons who indicated not Hispanic or Latino and multiple 

races are excluded from the table. Persons of Hispanic or Latino origin may be of any race or combination of races. The 

category not Hispanic or Latino refers to all persons who are not of Hispanic or Latino origin, regardless of race. Respondents were asked if they had ever been told by a doctor or other health professional that they had these conditions. Female 

respondents were instructed to exclude pregnancy-related diabetes. Responses from persons who said they had borderline 

diabetes were treated as unknown with respect to diabetes. 

NOTES: Estimates are age adjusted using the projected 2000 U.S. population as the standard population and using four 

age groups: 18–24 years, 25–44 years, 45–64 years, and 65 years and over. See Technical Notes for information regarding 

time frame for questions asking about conditions. Estimates are based on household interviews of a sample of the civilian, 

noninstitutionalized population. 
8 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

National survey data from 2004 to 2008 for people 18 years or older indicate that 17.5 % of 

American Indian or Alaska Natives, 6.6 % of non-Hispanic Whites, 8.0 % of Asians, 10.6 % of 

Hispanics, and 11.8 % of non-Hispanic African Americans had diagnosed diabetes after adjusting for population age differences. Of the total female population over age 18, the prevalence 

of diagnosed diabetes was 16.2 % in American Indian or Alaska Native women, 12.1 % in 

non-Hispanic African American women, 7.1 % in Asian women, 10.7 % in Hispanic women, 

and 6.2 % in non-Hispanic White women, after adjusting for population age differences. (10) 

Diabetes affects American Indian/Alaska Native populations disproportionally as compared 

to other racial/ethnic groups in the U.S., with an increasing prevalence and a predilection 

for youth. Data from the 2005 Indian Health Service user population database indicate that 

14.2 % of the American Indians and Alaska Natives ages 20 years or older who received care 

from the Indian Health Service had diagnosed diabetes. Of the total adult population served 

by the Indian Health Service, 16.5 % had diagnosed diabetes after adjusting for population 

age differences, with rates varying by region from 6 % among Alaska Native adults to 29.3 % 

among American Indian adults in southern Arizona. (3)

The prevalence of DM has increased for all racial/ethnic populations in the United States 

since 1980, as shown in Figure 1. (11) In 2007, the age-adjusted prevalence of diagnosed diabetes was 8.0 % and 9.3 % among Hispanic and African American women, respectively, with 

older women much more likely to be diabetic. The age-adjusted prevalence rate among White 

women was 5.0 % with much less pronounced differences in prevalence rates by age group. 

In 2007, 12.7 % of African American women had diabetes, the highest diabetes prevalence 

rate among women, which surpassed Hispanic or Latina and White women, with respective 

rates of 10.9 and 6.1 %. Among Hispanics, rates were 9.5 %, 9.4%, and 4.6 % for Mexican/

Mexican American, Puerto Rican, and Cuban women, respectively. (11)
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 9

Figure 1: Age-Adjusted Percentage of Civilian, Non-institutional Population 

with Diagnosed Diabetes by Race, Sex, and Hispanic Origin, United States, 

1980-2007 (CDC)

Adapted from CDC, Diagnosed Diabetes by Race/Ethnicity, Sex and Age. Available at: http://www.cdc.gov/diabetes/statistics/prev/national/menuage.htm. Date Accessed: September 10, 2010.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

Age-Adjusted percentage

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

1980

2007

In 2002, diabetes prevalence among American Indian or Alaska Native women at least twenty 

years old was 15.9 %. The age-adjusted prevalence of diagnosed diabetes among American Indian/Alaska Native women increased by approximately 28 % between 1994 and 2002, compared 

to an approximately 58 % increase among all women in the United States over age twenty. 

(12) A 2003 study found that diabetes was more common among Zuni women than among 

other American Indian women and Zuni men. Twenty-four percent of Zuni females ages 20 

and older had previously been told by a health professional that they were diabetic, while the 

rate of diabetes among Zuni men was much lower. (13) A 2004 survey of Asian Indian women 

ages 20 and older, living in Georgia, found that 13.6 % had diabetes and compared this finding 

to the rates of diabetes in other populations of women in the United States and Asian Indian 

immigrants in other countries. (14) 
10 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

In a 2000 survey of Puerto Rican adults in New York City, 11.8 % of women reported 

having been diagnosed with diabetes, compared to 10.6 % of men. (15) A 1996–2000 survey 

of adults living in Puerto Rico found comparable rates. (16) A 2004 study of elderly Mexican 

American adults in southwestern states found that 22.6 % of the women had diabetes. (17) 

Comparable numbers of elderly Mexican American women living throughout the United 

States reported having diabetes. (11)

GDm occurs more frequently among 

african american, Hispanic/latina 

american, and american Indian women.

GDM occurs more frequently 

among African American, 

Hispanic/Latino American, and 

American Indian women. (3) A 

2002 survey of women in Colorado found the lowest prevalence GDM among non-Hispanic White women (3.1 %) and the 

highest among Asian women (6.8 %), with 5.4 and 5.5 % of Hispanic and African American 

women, respectively, reporting GDM. (18) In 2005-2007, more Native Hawaiian women 

reported having been told by a doctor that they had diabetes while they were pregnant (2.2 

%) than any other racial/ethnic group in Hawaii. This compares to 2.0 % of Filipino, 1.6 

% of Chinese, 1.3 % of Japanese, and 1.2 % of White women who responded to the survey. 

(19) GDM is also more common among obese women and women with a family history 

of diabetes (3)

DEATH RATES FROM DIABETES

In the United States, DM is among the leading causes of death for females and accounted 

for 3.0 % of deaths in women in 2006 (see Table 2). As can be seen in Table 2, DM was the 

fourth leading cause of death in 2006 among African American (5.0 %), American Indian/

Alaska Native (7.0 %), and Hispanic (5.4 %) women, the fifth leading cause of death among 

Asian/ Pacific Islander (3.8%) women, and the seventh among White women (2.7 %). (2) In 

addition, diabetes complications have a deleterious effect on the prognosis of cardiovascular 

disease. (3) In 2007, the mortality rates from diabetes among American Indian/Alaska Native 

and non-Hispanic African American women were higher than that of Asian/Pacific Islander 

and non-Hispanic White women—25.3 and 34.6 per 100,000 American Indian/Alaska Native 

women and non-Hispanic African American women, respectively, versus per 11.6 and 23.9 per 

100,000 Asian/Pacific Islander and non-Hispanic White women, respectively. (20)
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 11

Figure 2: Age-Adjusted Diabetes Death Rates per 100,000 by Race, Sex, and 

Hispanic Origin, United States, 1980–2006 CDC

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

20042006

1980 0.0

10.0

20.0

30.0

40.0

50.0

60.0

All

White

Asian or Pacific Islander

Males

Black or African American

Hispanic or Latino

Females

American Indian or Alaska Native

White, not Hispanic or Latino

Age-Adjusted death rate per 100,000 population

Adapted from CDC, 2009. Health United States, 2009. Table 26. http://www.cdc.gov/nchs/data/hus/hus09.pdf. Date 

Accessed: July 28, 2010.

Figure 2 shows the age-adjusted death rates per 100,000 people from DM by race, sex, and 

Hispanic origin between 1980 and 2006. According to CDC data, females, overall, are less 

likely than males to die from diabetes. White women have significantly lower diabetes mortality rates in comparison to African American and Hispanic or Latina women. Only Asian/

Pacific Islanders have a lower death rate from DM than Whites. (21) As a result, diabetes 

must be understood as a chronic health disease that differentially affects women of color, 

specifically African American and Hispanic or Latina women and profoundly impacts the 

lives of individuals, families, and communities.

ASSOCIATED CONDITIONS AND OUTCOMES

obesity and overweight: Obesity and overweight are risk factors for DM. Analysis of 

data from the 2007-2008 National Health and Nutrition Examination Survey by the CDC 

indicates that in U.S. adults 20 years and older, an estimated 34.2% were overweight, 33.8% 

were obese, and 5.7% were extremely obese. (22) Overweight specifically refers to an excessive amount of body weight that may come from muscle, bone, adipose tissue, and water.
12 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

Obesity specifically refers to an excessive amount of adipose tissue. Body Mass Index (BMI) 

is a measure of body weight relative to height that is often used to identify if an individual is at 

a healthy weight, overweight, or obese and to characterize associated risks (23). In 2007-2008, 

among women age 20 and older, the age-adjusted prevalence of obesity (BMI > 30) was higher 

among non-Hispanic Black (49.6 %) and Mexican-American women (45.1 %) women than 

among non-Hispanic White (33 %) women. (22)

In the united states, Dm is among the 

leading causes of death for females and 

accounted for 3.0 % of deaths in women 

in 2006 

Cardiovascular disease and 

hypertension: Adults with 

diabetes have heart disease death 

rates approximately two to four 

times higher than adults without 

diabetes and the risk for stroke is 

two to four times higher among people with diabetes. In 2004, heart disease and stroke were 

noted on 68 % and 16 % of diabetes-related death certificates among people aged 65 years 

or older, respectively. In 2003-2004, approximately 75 % of adults with diabetes also had high 

blood pressure or used anti-hypertensive medications. (3)

blindness: Diabetic retinopathy is one of the leading causes of blindness in the United States 

and occurs when the retina is damaged due to aneurysms, hemorrhages, and retinal vascular 

abnormalities due to diabetes. Diabetic retinopathy causes 12,000 to 24,000 new cases of 

blindness each year. (3) A 2004 study of the prevalence of diabetic retinopathy among adults 

over age 40 in the U.S. indicated that White women with diabetes had a higher prevalence 

of any level of retinopathy than African American and Hispanic women. However, African 

American women with diabetes had the highest prevalence of vision-threatening retinopathy 

(10 %), compared to White (8.1%) and Hispanic (7.7 %) women ages 40 and older. (24)

renal disease: Diabetes is the leading cause of renal failure in U.S. In 2005, it accounted for 

44 % of new cases. In that year, 46,739 people with diabetes began treatment for end-stage 

renal disease and a total of 178,689 people with end-stage renal disease due to diabetes were 

living on chronic dialysis or with a renal transplant in the United States and Puerto Rico. (3)
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 13

neuropathy/Vasculopathy and amputation: The majority of people with DM have 

mild to severe forms of nervous system damage, (25) and more than 60 % of nontraumatic 

lower-limb amputations occur in people with DM – approximately 71,000 in 2004. (3) A 

national study looking at the incidence of lower extremity amputation in Americans with 

DM, reported that more amputations occurred among African Americans than Whites, but 

the difference was statistically significant only for those who developed DM over the course 

of the study (3.4 % vs. 1.4 %). Further, the effect of race diminished after adjusting for 

education, hypertension, and smoking. (26) Data from The Strong Heart Study, a study of 

cardiovascular disease and its risk factors in 13 American Indian communities, found that risk 

for lower extremity amputation for Native American men with DM was over twice that of 

Native American women with DM. (27)

Overall, the health outcomes of African Americans (both women and men) with DM are far 

worse than those of Whites; blindness, (24) amputation, (26) end-stage renal disease, (28) 

and death related to DM complications (21) disproportionately affect African Americans. In 

a 2002 study of insured people with DM in northern California, African American women 

were found to have higher incidence of stroke, congestive heart failure, and end-stage 

kidney disease than White, Asian, and Latino women with DM. However, White women 

had the highest incidence of myocardial infarction and lower extremity amputation among 

the women studied. (28)

COST OF DIABETES

The total estimated cost of diagnosed diabetes in the United States in 2007 was over $174 

billion, approximately $116 billion for direct medical costs and $58 billion for indirect costs 

for example, disability, work loss, premature mortality. After adjusting for age and sex differences, the average annual medical expenditures were 2.3 times higher for people with diagnosed 

diabetes. Factoring in the additional costs of undiagnosed diabetes, pre-diabetes, and gestational 

diabetes accounts for an estimated total cost of diabetes in the United States in 2007 of $218 

billion: $18 billion for the 6.3 million people with undiagnosed diabetes, $25 billion for the 

57 million American adults with pre-diabetes and $623 million for the 180,000 pregnancies 

during which gestational diabetes is diagnosed. (29)
14 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

Conclusion

The research findings highlighted in this publication draw attention to the influence of sex, 

gender, cultural, and racial and ethnic differences in the epidemiology, diagnosis, prognosis, and 

outcomes of diabetes mellitus. These data provide the research basis for developing therapeutic 

strategies and approaches to improve care for all racial and ethnic groups including women of 

color, an extremely heterogeneous group in and of itself. It is important to keep these health 

differences between and among populations of women and men in mind when treating 

women of color who have been diagnosed with or are at risk for DM.

The challenge becomes to refine the knowledge base and understanding such that individualized care can be provided to each and every woman of color, regardless of race or ethnicity and 

health status. It is essential that the training of health care professionals and the development of 

clinical practice standards take into consideration the role of race and ethnicity, socioeconomic 

background, geographic location, and other factors which affect health.

Scientific knowledge about human health and disease is enriched with the inclusion of a 

diverse population of participants in clinical studies. Collaboration between clinicians, public 

health practitioners, the community, and clinical research teams is vital to the success of 

research that addresses DM in women of color. It is through research that incorporates factors 

such as sex/gender and race/ethnicity in the study design, conduct, and analysis, that the body 

of knowledge can be expanded and evidence-based health care for DM can be delivered to all 

women of color. Resources for information on clinical research include:

•	 ClinicalTrials.gov (http://clinicaltrials.gov/)

•	 ORWH Outreach Publications for the Inclusion, Recruitment and Retention of 

Women and Minority Subjects in Clinical Research (http://orwh.od.nih.gov/inclusion/

incloutreach.html)
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 15

Research Highlights

This section summarizes a few examples of NIH-supported research on DM and highlights 

the importance of research in advancing scientific knowledge and expanding understanding 

of the etiology and prognosis of diseases such as DM.

the Diabetes Prevention Program

Both lifestyle and oral hypoglycemic agents can reduce the development of type 2 diabetes in 

high risk groups. The Diabetes Prevention Program (DPP) was a major multicenter controlled 

clinical trial that examined the efficacy of an intensive life-style intervention or treatment with 

the oral diabetes drug metformin in the prevention or delay of onset of type 2 diabetes in a 

high risk population. At the beginning of this clinical trial, all participants were overweight and 

had blood glucose levels higher than normal but not high enough for a diagnosis of DM—a 

condition called pre-diabetes. Sixty eight percent of the 3234 participants were women and 

45 % were from minority groups: African American, Alaska Native, American Indian, Asian 

American, Hispanic/Latino, or Pacific Islander. This is the largest high risk population 

including minorities ever studied. (30)

There was a statistically and clinically significant reduction in the development of DM in both 

the life-style intervention group (participants who lost a modest amount of weight through 

dietary changes and increased physical activity) and the metformin–treated group, with reductions in risk of developing type 2 diabetes of 58 % and 31 %, respectively. The DPP resolved 

its research questions earlier than projected, and following the recommendation of an external 

monitoring board, the study was halted a year early. (31)

The DPP cohort has been followed in the DPP Outcomes Study (DPPOS). Maintaining its 

68 % participation of women, the DPPOS is the largest study population with pre-diabetes 

and the only population with type 2 diabetes studied from time of onset. The study cohort 

will provide insights regarding the clinical course of these metabolic disorders and will provide 

information on the persistence of the prevention or delay of type 2 diabetes and event rates 

for microvascular and macrovascular disease. In addition, the DPP followed by the DPPOS is 

the longest follow-up study of sustained weight loss ever conducted. Of major interest is the 

outcome of continued lifestyle change and long term weight loss, and metformin intervention 

in the female and minority subgroups during the DPPOS. (32)
16 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

During the DPP-DPPOS 10 year outcomes study, the treatment groups had similar diabetes 

incidence rates, but the reduction in cumulative incidence from DPP interventions persisted. 

Other risk factor changes suggested intervention benefits beyond simply reducing glycemia. 

(32)

united states-mexico border Diabetes Prevention and Control Project

The major goal of the United States-Mexico Border Diabetes Prevention and Control Project 

is to prevent diabetes complications by controlling diabetes among people who have type 2 

diabetes in the United States-Mexico border region. The project developed and implemented 

strategies in collaboration with the 10 U.S.-Mexico Border States, the Pan American Health 

Organization (PAHO), and various federal, state, academic, and nonprofit organizations 

with an interest in diabetes prevention and control. (33)

This is a border wide collaborative research effort between two neighboring nations extending 

60 miles on each side of the 2,040 mile international boundary between the United States and 

Mexico. It includes the southern portions of four U.S. states (Arizona, California, New Mexico, 

and Texas) and the northern portions of six Mexican states. This project is comprised of a crosssectional study of the prevalence of diabetes, prediabetes, overweight in adults, and preventive 

health practices. This two-phase collaborative project includes a survey of diabetes prevalence 

and risk factors, as well as training for community health workers (CHWs) and health care 

providers. Training is being implemented in seven strategically selected sites along the border, in 

English or Spanish as preferred by the health care providers and CHWs, to enhance DM awareness and treatment throughout the community. (34)

Through this project over 1.11 million inhabitants of the bi-national border region have been 

diagnosed with diabetes. Over 40 % of the adults in the Mexico Border States and 11.6 % 

of Hispanic/Latino adults in the U.S. Border States were not aware that they had diabetes. 

The prevalence of overweight and obesity was lower among adults with diabetes in Mexico at 

27 % than in the United States at 54.5 %. (34) In the border area, 35.6 % of women were 

overweight, and 34.4 % of women were obese. (35) 
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 17

Poverty and Diabetes

A 2005 study has shown that type 2 diabetes and socioeconomic status exhibit an inverse relationship in Hispanic, non-Hispanic African American, and non-Hispanic White women, 

although the same is less true for men. For women of all three groups, as the number of years 

of education and the Poverty Income Ratio (PIR) rise, the likelihood of developing type 2 

diabetes decreases. The PIR is computed by dividing family income by the federal poverty 

level. (36) Another study, however, found that among White (but not African American) 

women, increased educational attainment was associated with lesser risk of developing 

DM. (37)

Researchers examined the associations of PIR, education, and occupational status with type 

2 diabetes prevalence among African American and non-Hispanic White women and men 

aged 40 to 74 years. They analyzed cross-sectional data from the Third National Health and 

Nutrition Examination Survey, controlling for age and examination-related variables. Among 

African American women, there was a strong, graded association between PIR and diabetes, 

which remained significant after adjusting for other risk factors. All 3 variables were significantly associated with DM among non-Hispanic White women, but only PIR was significantly 

associated with diabetes in non-Hispanic White men. There were no significant associations for 

African American men. From this analysis, it appears that socioeconomic status is associated 

with type 2 diabetes prevalence among women, but not consistently among men. Diabetes 

prevalence was more strongly associated with PIR than with education or occupational status. 

These associations were largely independent of other risk factors, especially among African 

American women. These data suggests that economic resources should be addressed in efforts 

to explain and reverse the increasing prevalence of DM in the United States. (37)

Diabetes in Pima Indians

Half of adult Pima Indians living in Arizona have diabetes and 95 % of those with DM are 

overweight. For the past 30 years, the Pima Indians have worked with investigators at the 

NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to understand the genetic, environmental, and lifestyle factors at the root of the DM epidemic in their 

community. These longitudinal studies, which have allowed researchers to look at individuals 

over a long period of time and also multiple generations of families, have helped to prove that 

obesity is a major risk factor for the development of diabetes. For instance, these studies have 
18 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

shown that before gaining weight, overweight people have a slower metabolic rate compared 

to people of the same weight. Further, since some of the children born within this community after the study began are now 28 to 30 years old, researchers are able to understand how a 

mother’s DM can influence a child’s health in adulthood. (38)

One theory for the prevalence of DM observed in the Pima community is based on the 

concept of a “thrifty gene,” proposed in 1962 by geneticist James Neel. This theory posits that 

populations, such as the Pimas, who traditionally experienced periods of feast and famine due 

to a reliance on hunting for food, may have developed a genetic mutation which allowed them 

to store fat during times of plenty so that they would not starve during times of famine. Since 

these populations have adopted the typical Western lifestyle, with less physical activity, a high 

fat diet, and access to a constant supply of calories, this gene may now work against them, 

continuing to store calories in the form of unhealthy amounts of fat. (39) In fact, NIDDK 

researchers recently visited a Pima community living as their ancestors did in a remote area of 

the Sierra Madre mountains of Mexico. While the thirty-five Mexican Pimas that were studied were genetically similar to the Arizona Pimas, only three had diabetes, and the population 

as a whole was not overweight, emphasizing the importance of lifestyle and diet in preventing 

the onset of DM. (38)

the Weight-Control Information network

The Weight-control Information Network (WIN) is a national information service of the 

NIDDK. WIN provides the general public, health professionals, the media, and Congress 

with up-to-date, science-based information on weight control, obesity, physical activity, and 

related nutritional issues.

Sisters Together: Move More, Eat Better is a national initiative of the WIN, designed by 

NIDDK to encourage African American women ages 18 and over to maintain a healthy 

weight by becoming more physically active and eating healthier foods. Sisters Together 

works with national and local newspapers, magazines, radio stations, schools, and consumer 

and professional organizations to raise awareness among African American women about 

the health benefits of regular physical activity and healthy eating. This effort is timely since 

recent statistics indicate that nearly 80 % of African American women are overweight or obese.
Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus • 19

Sisters Together offers three age-appropriate and culturally relevant brochures that give 

African American women, and their families and friends, practical, science-based tips to help 

them move more, eat better, and ultimately, improve their quality of life. (40)

For more information or to obtain materials, contact the NIDDK at: 

Toll free: 1-877-946-4627 Fax: (202) 828-1028 E-mail: win@info.niddk.nih.gov

Weight-control Information Network, 1 WIN Way, Bethesda, MD 20892-3665

ADDITIONAL INFORMATION

Additional information on DM and the health of women and minorities can be found at:

•	 The National Institute of Diabetes and Digestive and Kidney Diseases (http://www2.niddk.

nih.gov/)

•	 The National Diabetes Information Clearinghouse (http://diabetes.niddk.nih.gov/)

•	 The National Institute on Minority Health and Health Disparities (http://ncmhd.nih.gov/)

•	 The Office of Research on Women’s Health (http://orwh.od.nih.gov/)

•	 Women’s Health Resources (http://womenshealthresources.nlm.nih.gov)

•	 The CDC Diabetes Public Health Resource (http://www.cdc.gov/diabetes/)

•	 The HHS Office of Women’s Health - Diabetes (http://www.womenshealth.gov/illnessdisability/types-illness-disability/diabetes.cfm)

•	 The HHS Office of Minority Health – Diabetes Section (http://minorityhealth.hhs.gov/

templates/browse.aspx?lvl=2&lvlID=21)
20 • Women of Color HealtH InformatIon ColleCtIon • DIabetes mellItus

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u.s. department of health and human services 

national institutes of health 

office of research on women’s health 

http://orwh.od.nih.gov

april 2011 

nih publication no. 10-7680