Diabetes

Mellitus

Interagency

Coordinating

Committee

Fiscal Year 2000

ANNUAL REPORT

CONTENTS

Introduction

Activities of Member Organizations 1

Meeting Summaries 33

National Diabetes Education Program 63

Appendix A

DMICC Authorizing Language 99

Appendix B

DMICC Roster 101

Appendix C

FY2000 Budget Actuals 107

Diabetes 

Mellitus 

Interagency

Coordinating

Committee

INTRODUCTION

In accordance with Section 429 of the Public Health Act, the Diabetes Mellitus Interagency Coordinating

Committee (DMICC) prepares an annual summary report of its activities as well as other Federal research 

activities in the field of diabetes. It is submitted to the Secretary, Department of Health and Human Services

(DHHS), and the Director of the National Institutes of Health (NIH). This is the annual report of the DMICC 

for Fiscal Year (FY) 2000.

LEGISLATIVE MANDATE

The DMICC was authorized by Public Law 93-354 and established in fall 1974; subsequent legislation modified

some of the charges to the Committee. The legislative authority of the Committee is presented in Appendix A.

The charge to the DMICC is to coordinate the research activities of the NIH and other Federal agencies relating 

to diabetes mellitus and its complications and to contribute to the adequacy and technical soundness of these

activities by providing a forum for communication and exchange of information.

The Committee includes representatives from Federal agencies whose programs are relevant to diabetes 

mellitus and its complications. The chairman, designated by the Director, NIH, is the Director, Division of

Diabetes, Endocrinology, and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney

Diseases (NIDDK). In FY 2000, the DMICC membership included representatives of 21 Federal organizations.

A roster of Committee members as of the close of the fiscal year is included as Appendix B.

ACTIVITIES OF THE DMICC

The DMICC facilitates cooperation, communication, and collaboration among agencies that conduct or support

diabetes-related activities. These activities may range from support for biomedical research to direct provision 

of health care services. The DMICC provides both a forum for initiating interactions and a mechanism for 

tracking progress.

During FY 2000, Dr. Allen Spiegel, the newly appointed Director of NIDDK, has elevated the chairmanship of 

the DMICC from the Director of the Division of Diabetes, Endocrinology and Metabolic Diseases to the 

Director of the NIDDK. Under the new leadership of Dr. Spiegel, the DMICC is positioned to respond to the 

recent congressional mandate addressing the issue of minority health disparities. In this regard, the DMICC

significantly focused its efforts during FY 2000 on type 2 diabetes in American Indian and Alaskan Native 

children. Also during FY 2000, the DMICC focused on diabetes quality improvement by working closely with 

the Health Care Financing Administration and its Diabetes Quality Improvement Project.

1

Agency for Healthcare Research and Quality

(AHRQ)

The Agency for Healthcare Research and Quality 

has had a broad range of activities and initiatives 

in diabetes designed to improve the quality of 

health care, reduce its costs, and broaden access 

to essential services which are impacting policies

and practices across the country.

Current Activities:

The Diabetes Quality Improvement Project (DQIP)—

based in large part on the work of the Diabetes

Patient Outcomes Research Team (PORT) and led 

by Principal Investigator, Sheldon Greenfield, this

project is a collaboration of the National Committee

for Quality Assurance, the Health Care Financing

Administration, the American Academy of Family

Physicians, the Department of Veterans Affairs, the

American Diabetes Foundation and the Foundation

for Accountability. It has developed a common core

set of diabetes performance measures that allow 

fair comparisons and stimulate quality improvement among health plans and providers. Reporting

on the DQIP measures is now required by HCFA of 

managed care plans and will be publicly available.

Initial analysis of the reports suggests that many of

the process and outcome measures have improved

but that some target levels have not been met. The

measures have also been included by NCQA in its

HEDIS reporting set. Work has begun on developing

DQIP 2.0

The Agency has funded a large number of studies

including an assessment of diabetes care in community health centers, an assessment of compliance

with ADA guidelines, and a study of dyslipidemia 

in African Americans with Type 2 DM. In addition,

diabetes was included as one of the target conditions

for an RFA focused on improving our understanding

of racial and ethnic health disparities and identifying strategies to eliminate them. This initiative,

called EXCEED (Excellence Centers to Eliminate

Ethnic/Racial Disparities), will fund over $45 million

of research and demonstration projects. Four of the

centers will be focused, at least in part, on diabetes.

Diabetes was also a target of the Translating

Research into Practice (TRIP) II RFA and a number 

of studies will focus on identifying strategies to

effectively and efficiently reduce the gap between

what is know and what is done in diabetes care.

One project is focusing on the use of multimedia 

presentations to improve patient knowledge and 

self-management of their condition.

Future Activities:

No additional diabetes-related activities were reported.

Funding for Diabetes Research:

FY 2000 funding information was not provided.

ACTIVITIES OF MEMBER ORGANIZATIONS
DMICC ANNUAL REPORT 2 FY 2000

Centers for Disease Control and Prevention (CDC)

The mission of the Centers for Disease Control and

Prevention’s Division of Diabetes Translation is to

reduce the burden of diabetes in the United States 

by combining support for public health-oriented 

diabetes control programs nationwide and translation of diabetes research findings into widespread

clinical and public health practice.

Current Activities:

CDC’s diabetes prevention and control program

includes:

• Diabetes control programs (DCP) in all 50 States 

to develop or expand diabetes control efforts.

• Applied translational research focusing on the

application of findings from recent randomized

control trials in real world settings.

• Public and private partnership of the National

Diabetes Education Program (NDEP) to educate

patients, providers, and the public.

• Developing surveillance systems for use at State

and local levels, especially for monitoring the 

diabetes burden among certain racial and ethnic

populations.

• Developing and implementing innovative 

interventions and prevention strategies for 

eliminating racial and ethnic health disparities.

Major accomplishments in FY 2000 include:

• Involving Business in Diabetes Control through 

the National Diabetes Education Program.

Published the NDEP’s Business and Managed Care

Workgroup’s Making a Difference: The Business

Community Takes on Diabetes, in December 1999.

This document, which focuses on business and 

diabetes, outlines the economic costs and health

consequences of diabetes. It also shows the 

importance of employers investing in the prevention and early detection of diabetes complications

at the worksite.

• Improving Methods To Understand the Public

Health Burden. Constructed a new model to 

forecast the future burden of diabetes in the 

United States population. The forecasting model

will strengthen CDC’s ability to address the 

future diabetes public health challenge.

• Collaborating To Improve Diabetes Care in

Community Health Centers (CHCs). Partnered 

with the Bureau of Primary Health Care and the

Institute for Health Care Improvement in the

National Diabetes Collaborative. In 1 year, the

Collaborative resulted in a three-fold increase 

in the number of persons receiving two HbA1c 

tests annually. Thirty-five of CDC’s DCPs have 

been trained on the Improvement Models and 

are working with CHCs. The collaborative’s 

mission is zero disparities, 100 percent access,

and two HbA1c tests annually.

• Building a National System To Monitor Childhood

Diabetes. Established a multicenter childhood 

diabetes registry system to conduct childhood diabetes surveillance. The centers will characterize the

types of diabetes, develop case definitions, study 

the prevalence and incidence, describe the natural

history of diabetes in children, and describe the

quality of care received during follow-up. These

activities of the childhood diabetes registry centers

will inform CDC’s efforts to develop and implement

a national public health strategy to address type 2

diabetes in children and adolescents.
DMICC ANNUAL REPORT 3 FY 2000

Future Activities:

As funds become available, CDC will continue 

to build a multifaceted National Diabetes 

Program by:

• Funding every State program at the 

Comprehensive level.

• Expanding surveillance activities to better 

understand the diabetes burden in at-risk 

populations, including racial and ethnic 

minorities, women, and children.

• Enhancing prevention research to improve 

understanding of the risk factors and health 

outcomes of diabetes.

• Undertaking prevention research activities to 

identify effective methods for preventing devastating diabetes complications and for translating

scientific findings on primary prevention of 

diabetes into public health practice.

• Expanding the National Diabetes Education

Program’s education activities and partnership 

network that is comprised of national public,

private, and voluntary organizations concerned

with the health of persons with diabetes. CDC

would also strengthen efforts to raise awareness

about the increased health risks people with 

diabetes face.

• Undertaking specific activities to address the

unique diabetes control and prevention needs of

racial and ethnic minorities.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

Health Care Financing Administration (HCFA)

Current Activities:

• On December 28th Medicare announced expanded

coverage of training for beneficiaries in selfmanaging diabetes. The Health Care Financing

Administration announced the final rule for

expanded coverage enabling beneficiaries with 

diabetes to get training from qualified providers 

in self-managing their disease. Under the regulation, any provider who is already eligible to bill

Medicare, and who meets quality standards for 

this benefit, can provide the training for Medicare

beneficiaries eligible for the service. The regulation

will take effect 60 days after publication in the

Federal Register. To qualify for this training, a 

beneficiary must be either newly diagnosed with

diabetes, or did not receive training at the time 

of diagnosis, or is at significant risk for 

complications from the disease.

• HCFA is also working with four communities to 

target Hispanic, Asian Americans, and American

Indians for self blood glucose monitoring.

• HCFA is working with the American Podiatric

Medical Association developing a foot health program with the Centers for Disease Control and

Prevention, the National Institute of Diabetes and

Digestive and Kidney Diseases, and AOA.

• In addition, HCFA is running a campaign 

“Power to Control Diabetes is in your Hand.”

The campaign is a multi-media promotion plan.

Future Activities:

No additional diabetes-related activities were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.
DMICC ANNUAL REPORT 4 FY 2000

Health Resources and Services Administration

(HRSA)

The Bureau of Primary Health Care (BPHC) of the

Health Resources and Services Administration established two strategic goals: the elimination of health

disparities and 100 percent access for minority and

underserved populations. The strategy, which supports the President’s Initiative on Race, focuses on

diabetes mellitus for the initial stage of the initiative. The other health disparity issues (infant mortality, immunization, cancer, cardiovascular disease,

and HIV) will be addressed in subsequent years.

Current Activities:

• The first goal of the initiative is to delay or

decrease the complications of diabetes by implementing a care model developed at the Sandy

MacColl Institute for Healthcare Innovation.

This evidence-based model, pioneered by Edward

Wagner, MD, at the University of Washington,

is part of a 5-year grant from the Robert Wood

Johnson Foundation that focuses on chronic 

disease care. The model of care is a populationbased model that relies on knowing which 

patients have the illness, ensuring that they 

receive evidence-based care, and actively aiding

them to participate in their own care. It has 

five basic elements: patient self-management,

clinical decision support, delivery system 

redesign, a clinical information system, and 

strong partnerships with local government and

community organizations.

• The second national project goal is that 90 percent

of patients with diabetes will receive two HbA1c

tests annually, at least 3 months apart. Additional

project measures used by health centers focus on

patient self-management, control of glucose levels,

prevention of cardiac complications, and prevention of microvascular complications such as eye,

kidney, and foot diseases. To implement this care

model, an improvement model created by the

Associates in Process Improvement (API) and a

learning model developed by the Institute for

Healthcare Improvement (IHI) is applied. These

models stress rapid testing and change and 

learning through action and measurement over 

a 1-year period in a community of other 

organizations. This learning strategy is based 

on the IHI Breakthrough Series and is termed

“learning collaborative.”

• An infrastructure was also created in each of

HRSA’s five clusters. This support system includes 

a full-time trained coordinator and information

system specialist based in a lead primary care

association/clinical network, a lead HRSA field

office clinician, and partnerships with the Centers

for Disease Control and Prevention (CDC) and 

State diabetes control programs. The support 

system also includes faculty and technical assistance from IHI and the Sandy MacColl Institute,

Internet communications among health centers 

and faculty, and regular conference calls, site 

visits, and monthly reports.

• Eighty-eight health centers successfully 

completed the year-long diabetes collaborative.

• Thirteen learning sessions were completed.

• The outcomes from 2 national sessions and 11 

cluster-based sessions was extremely impressive.

Diabetes registries were created at each health 

center. Approximately 15,000 persons with diabetes were enrolled in these registries, which

enabled centers to track and manage the health 

of these patients. Health center team performance

was excellent. At the end of the collaborative, the

average team score was approximately 3.5, which

signified modest to significant improvement.

HbA1c performance was increased by almost 

300 percent, from about 20 percent to 60 percent.

The national average for this measure is about 

20 percent. In addition, a significant number of

health centers achieved decreases of 1 percent 

or more in HbA1c levels, a measure of glucose 

control that translates as a 17 percent reduction 

in mortality for persons with diabetes.
DMICC ANNUAL REPORT 5 FY 2000

• State diabetes control programs (DCPs) from 15

States participated in the collaborative. A survey

conducted by CDC in the last quarter of 1999

assessed technical assistance and/or resources 

provided during the past year that were generated

by this project. These outcomes included assistance

for registry development and implementation,

on-site training, flowcharts, patient guidelines,

and inclusion of health centers in DCP State 

advisory councils.

• Through a partnership with IHI, CDC, the

Washington State Diabetes Program, and the 

BPHC, a software program for managing patients

with diabetes was developed for health centers 

in the collaborative.

• Five cluster coordinators were hired and trained;

an additional five information system experts were

also hired and are now being trained to provide

support for information systems to help manage

diabetic patients.

• Partnerships were established with the Bayer

Corporation, which resulted in increased access 

to HbA1c analyzers.

• In addition to diabetes, approximately 40 health

centers began an IHI Breakthrough Series 

collaborative in February 2000 on depression 

and asthma.

Future Activities:

• In January 2000, the first group of health centers

completed the diabetes collaborative and are 

now continuing to improve, document, and report

performance in diabetes care and outcomes. A 

second group of 125 health center teams began a

second diabetes collaborative on January 22, 2000.

Joining the second collaborative are 22 State 

diabetes control programs. Like the first group,

these health centers will work for 12 months on

implementing the care model and improving and

measuring diabetes care in the following areas:

patient self-management, glycemic control,

prevention of cardiac complications, and 

prevention of microvascular complications.

An additional parameter has been added to 

the second collaborative: influenza and 

pneumococcal vaccines.

• The support system, with added information 

system capacity, will design and implement two 

to three cluster-based learning sessions, followed

by a national congress. There are a number of 

exciting cluster- and State-based initiatives as 

well. For example, through a partnership with 

the State diabetes program in South Carolina,

additional coordinators will be hired and trained 

to spread this initiative to all practices that 

provide care to the underserved in South Carolina.

There are also additional partnerships being 

developed with Bristol, Myers, Squibb and the

Microsoft Corporation.

• During the next 12 to18 months, the IHI 

Breakthrough Series approach utilized for diabetes

will be applied to cardiovascular disease. The 

first collaborative for cardiovascular disease and 

a third diabetes collaborative are scheduled to 

begin in April 2001.

Funding for Diabetes Research:

Funding remains level at about $5 million for the

Diabetes Collaborative. Due to the success of the

collaborative, during FY 2000 CDC, in partnership

with HRSA, contributed an additional $2 million 

to the State Diabetes Control programs to assist 

diabetes control officers in collaboratives with the 

community health centers.
DMICC ANNUAL REPORT 6 FY 2000

Indian Health Service (IHS)

Current Activities:

• Special Diabetes Program for Indians, 1997

Balanced Budget Act. The Indian Health Service

Diabetes Program administered Year 3 of the

Special Diabetes Program for Indians of the 1997

Balanced Budget Act. Thirty million dollars is 

distributed annually through 286 non-competitive

grants administered at 318 sites throughout 

Indian country. Eighty-four percent of the grants

are held by tribal entities. In January 2000 the 

IHS National Diabetes Program submitted its

Interim Report to Congress on the status of this

grants program, including summaries from the

quantitative and qualitative evaluations conducted

on these grant programs. Eight regional meetings

with grantees were held around the country in 

2000 to showcase successful grant programs,

share concerns, offer help, and promote regional

networks. It allowed the IHS Diabetes Program 

to provide updates on the grants process, provide

recent surveillance information, and promote 

advocacy for continuing grant funds. We worked

closely with the Tribal Leaders Diabetes 

Committee to administer this program.

• Podiatric Funding. In order to address the extensive unmet podiatry needs in IHS, the American

Podiatric Medical Association (APMA) lobbied

Congress in Year 2000 for increased funding. For 

FY 2001, an additional $1 million was appropriated

to IHS to begin hiring podiatrists and building

infrastructure to support these positions. It was

determined by the National Council of Indian

Health Podiatrists (NCIHP) that this amount of

funding would support 5 to 6 surgical podiatrists.

The IHS National Diabetes Program provided the

opportunity in January 2001 for a representative

member of the Executive Council of the NCIHP to

meet with the Tribal Leaders Diabetes Committee 

to ensure that tribal input is provided to the

process of determining location of positions and 

to begin to plan strategies for advocacy that will

increase funding in the future. The IHS National

Diabetes Program has become actively involved 

in APMA’s collaborative workgroup. This group is 

currently designing and planning the implementation of a national campaign to “reduce foot and

leg amputations in persons with diabetes.”

• Joslin Vision Eye Network. In FY 2000 and FY 2001,

an additional $1 million was appropriated to 

the IHS budget in order to address screening for 

diabetic retinopathy through a collaborative 

project with the Joslin Diabetes Center using the

Joslin Vision Network (JVN). The JVN is a remote

site diabetes retinopathy screening system that

uses low-level illumination and does not require

pupil dilation. The acquired retinal image is sent

electronically to a reading center and the analysis

sent back to the remote site. IHS has established 

a demonstration site at the IHS Phoenix Indian

Medical Center. The examining station has been set

up in the Primary Care Building with the reading

station in the Eye Department. Staff have been

hired to implement the process and screening is

currently underway. The feasibility of setting up a

remote screening station site at the Sells PHS

Indian Hospital located south of Tucson, Arizona,

on the Tohono O’odham (formerly Papago)

Reservation is being evaluated. The acquired 

retinal images will be electronically sent to the

reading station at PIMC. A third site outside of

Arizona is being considered for the future. A 

primary challenge to the implementation of JVN 

at remote sites beyond PIMC includes availability

of communication lines and staffing.

• Members of the National Institute of Diabetes and

Digestive and Kidney Diseases met with the Tribal

Leaders Diabetes Committee (TLDC) in February

2000 to propose a collaborative relationship to

address issues of concern related to diabetes and

American Indian and Alaska Native communities.

• In May 2000, the National Institutes of Health 

hosted the TLDC regularly scheduled meeting 

one day prior to the DMICC meeting on “Type 2

Diabetes in American Indian and Alaska Natives:

Focus on Children.”
DMICC ANNUAL REPORT 7 FY 2000

• NIH, IHS National Diabetes Program, TLDC, and

representatives of the American Indian Higher

Education Consortium have met to establish a

working relationship that will address the lack 

of American Indian and Alaska Native students 

in biomedical sciences, particularly research.

• There is close collaboration on the National

Diabetes Prevention Center project in Gallup,

New Mexico.

• The Director of the IHS Diabetes Program serves 

on the Centers for Disease Control and Prevention

(CDC) Division of Diabetes Translation Advisory

Committee.

• CDC provides educational and epidemiologic 

support to the IHS National Diabetes Program 

with two full-time positions.

• IHS provides expert guidance related to program

development and modification based on participant

evaluation for the American Diabetes Association’s

outreach initiative program for American Indian

and Alaska Natives: Strong in Body and Spirit.

• IHS participates on the committee and helps 

with distribution of program materials for the

Association of American Indian Physicians 

subcommittee initiative of the National Diabetes

Education Program.

• Four diabetes sessions were held as part of the

National Indian Health Board’s annual Consumer

Conference.

• IHS co sponsored a lipid consensus conference at

the Center for Native American Health.

• IHS developed an automated audit for the National

Indian Council on Aging monograph series.

• IHS established a partnership with the Board of 

the American Indian Higher Education Consortium

(AIHEC) to help build tribal college and university

capacity and infrastructure for diabetes programming activities in American Indian and Alaska

Native communities.

• Education Standards. The IHS National Diabetes

Program, with agency and Tribal leader support,

is taking the lead in establishing an Indian Health

Diabetes Education Accreditation Program. This

will allow the development of a flexible process 

to certify Indian health diabetes education 

programs and allow American Indian and Alaska

Native education programs to seek medicare 

reimbursement.

• Clinical Standards (Diabetes Care and Outcomes

Audit). The IHS National Diabetes Program 

updated the IHS Standards of Care for Diabetes 

in 2000 to reflect new science and best practices.

These standards are distributed to providers IHSwide through a network of regional Area Diabetes

Consultants and local Diabetes Coordinators.

Future Activities:

The National Diabetes Program is coordinating an

obesity prevention initiative targeting Head Start

children (0-5), families, staff and communities. Five

tribal Head Start programs were recently selected 

to pilot the initiative. Each site will develop a comprehensive multi-faceted approach in addressing

obesity based on current best practices and each

site’s respective community need.

Funding for Diabetes Research:

FY 2000 funding information was not provided.
DMICC ANNUAL REPORT 8 FY 2000

National Cancer Institute (NCI)

The National Cancer Institute supports several 

areas of research that are relevant to diabetes and

that could potentially lead to new knowledge not

only about cancer, but also about diabetes and 

other diseases. There is a similarity in certain of the 

disease-causing and disease-modifying pathways

that may be important to understanding both cancer 

and diabetes. For example, studies of the epidemiology of renal cell cancer may help to determine

whether subgroups of the disease, characterized by

different genetic alterations, are associated with 

different modifying factors — including obesity,

hypertension, and diabetes. Researchers are also

striving to determine the existence of a major 

susceptibility gene for pancreatic cancer by examining possible risk modifiers, including diabetes 

and pancreatitis. Other research is testing whether

an association between pancreatic cancer and 

factors such as energy intake, obesity, or diabetes

mellitus is mediated through insulin-like growth 

factors and binding proteins.

Current Activities: 

• Because obesity is a risk factor for cancer,

diabetes, and several other diseases, one research

team is focusing on two interrelated pathways for

the association of obesity with estrogen and

insulin. First, obesity and associated hyperinsulinemia may influence cancer risk directly through

its effects on insulin-like growth factor and its 

binding proteins, and second, obesity may also

influence cancer risk indirectly through its effects

on estrogen levels. A multicenter study is therefore

being conducted to examine the role of genes that

influence obesity, insulin, and insulin receptors 

in the etiology of breast and endometrial cancer.

The role of selectin ligand-carbohydrate interactions in tumor cell metastasis is the subject of

another NCI-supported study that may aid in the

development of therapeutic interventions for 

cancers, diabetes, and possibly other diseases.

• The National Cancer Institute also supports

research on immunologic mechanisms of disease

that are relevant not only to cancer, but also to 

type 1 diabetes, a disease in which the body’s

immune defense system attacks and destroys the

insulin-producing cells of the pancreas. NCIfunded investigators are studying transgenic mice

carrying insulin-promoted SV40 T antigen genes

that target the development of islet cell carcinomas. They hope to determine: (1) the cellular and

molecular changes necessary to induce malignant

transformation in this system; (2) the mechanisms

and interrelationship of self-tolerance, autoimmunity, and the failure of tumor immunity; and 

(3) the nature of alternative immune tolerance or

autoimmunity toward pancreatic beta cells,

which are the target of autoimmunity in human

type 1 diabetes.

• Another research project on dendritic cell biology

and therapy is examining the mechanism of 

dendritic cell-based tumor immunization as well 

as dendritic cell-mediated therapy of autoimmune

diabetes. The observation that the anti-tumor 

effect of alpha-galactosylceramides is mediated 

by NKT cells, a specialized set of T cells, has led 

to an investigation of the consequences of NKT 

cell activation during the course of neoplastic,

infectious, and autoimmune conditions, including

autoimmune diabetes in the non-obese diabetic

(NOD) mouse strain.

• An important biologic mechanism involved in 

both cancer and diabetes is angiogenesis, the

spread of new blood vessels. Angiogenesis not 

only promotes the growth and spread of tumors,

but it is also involved in wound healing and in 

the development of many disease conditions,

including diabetic retinopathy — in which the 

proliferation, breakage, and leakage of blood 

vessels in the eye can lead to blindness. A metabolite of linoleic acid, 13-hydroxy-10,12-octadecadienoic acid, promotes angiogenesis in the chick

chorioallantoic membrane. Because linoleic acid 

is the major polyunsaturated fatty acid in the

American diet, as well as one of the most abundant
DMICC ANNUAL REPORT 9 FY 2000

fatty acids of phospholipids in the arterial wall,

studies are underway to confirm its angiogenic

properties in a mammalian system. Potential 

targets of anti-angiogenesis therapy include the

integrin alpha5beta1 and its ligand, fibronectin.

The expression of these molecules is being 

characterized in the blood vessels of normal and

diseased tissues in preparation for the development of new approaches to the therapeutic 

modulation of angiogenic disease.

• In both cancer and diabetes, several underlying 

cellular mechanisms, such as those involved in 

cell signaling and cell regulation, are thought to

play a major role in disease processes. These 

mechanisms include membrane transport of hormonal substances, maintenance of intracellular

communication pathways, functioning of cellular

growth factors, and expression of genes that 

influence insulin and obesity. Importantly, the 

findings of basic research in either cancer or 

diabetes may have considerable application to 

the other disease, as well as broad relevance 

across a wide spectrum of diseases.

Future Activities: 

No additional diabetes-related activities

were reported.

Funding for Diabetes Research:

FY 2000 funding for diabetes-related research 

was approximately $5.5 million, an increase of 

$1.1 million over FY 1999.

National Center for Health Statistics (NCHS)

The Centers for Disease Control and Prevention

(CDC), National Center for Health Statistics is the

Nation’s principal health statistics agency. NCHS’s

mission is to provide statistical information that 

will guide actions and policies to improve the 

health of the American people. Inherent to this is 

the emphasis to respond to major public health

issues, especially diabetes.

Current Activities: 

• The National Health and Nutrition Examination

Survey (NHANES), currently in the field, is collecting the following diabetes-related measures: 

fasting plasma glucose, glycosylated hemoglobin,

blood pressure, lipids, micro-albuminuria,

anthropometry, nutritional status, diabetes family

history, peripheral vascular disease and peripheral

neuropathy, visual acuity, oral health, physical

functioning, and access to care. Information is 

collected on people with diagnosed and 

undiagnosed diabetes.

• NHANES continues to collect DNA and sera and

NCHS is a national repository of surplus sera and

over 8,000 DNA cell lines. Specimens are available

for serologic or DNA studies, such as the study 

of GAD antibodies in collaboration with the

University of Pittsburgh that began in FY 2000.

• The National Health Interview Survey (NHIS),

which has been in continuous operation since 

1957, obtains national prevalence data of type 1

and diagnosed type 2 diabetes.

• NCHS, working with the Health Care Financing

Administration (HCFA), has produced a linked 

data set that looks at the longitudinal progression

to end-stage renal disease (ESRD) for people with

and without diabetes. NCHS contracted with Johns

Hopkins University to analyze data and to produce

national fact sheets on diabetes-related ESRD.
DMICC ANNUAL REPORT 10 FY 2000

• NCHS staff collaborated with other organizations

and researchers in academia and in the private 

and public sector to release new diabetes health

statistics and study findings, including baseline

measures of Healthy People 2010 national health

objectives, which include 17 objectives on diabetes,

new growth charts for infants and youth (which 

are relevant to those interested in the emerging

concern of type 2 diabetes in children), and 

uniform State-specific estimates of diabetes risk

factors, prevalence, ESRD attributed to diabetes,

and mortality (in collaboration with the Council 

of State and Territorial Epidemiologists, the

Association of State and Territorial Chronic 

Disease Program Directors, and Centers for 

Disease Control and Prevention colleagues).

Future Activities:

The Center plans to continue collecting and 

analyzing diabetes information from NHANES,

NHIS, and other health information systems. This

information will be used to monitor progress 

toward achieving the Healthy People 2010 national

health objectives for diabetes, assist the National

Diabetes Education Program by providing health 

statistics about diabetes and its complications,

and provide national health data for diabetes

researchers.

• NCHS also will continue to collect, store, and 

share DNA and serum specimens from NHANES.

• NCHS will make available the new NHANES/

Medicare national follow-up data on chronic 

kidney disease primarily due to diabetes.

• Finally, the Center is planning to improve the

reporting of diabetes mortality data by working

with the States to introduce electronic death 

certificate systems that interact with physicians

through a series of prompts to assure high 

quality reporting.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

National Center for Research Resources (NCRR)

The National Center for Research Resources 

develops and supports research technologies and 

shared resources that are critically important to 

the research efforts directed at maintaining and

improving the health of our Nation’s citizens. To

facilitate health-related research, NCRR also supports the development and use of sophisticated

instrumentation and technologies, animal models 

of human disease, and clinical research environments. NCRR programs provide support for the

career development of biomedical investigators 

who address new and emerging biomedical technologies for both patient and veterinary research 

on diabetes. The current NCRR diabetes research

portfolio includes approximately 600 basic and 

clinical research subprojects. Selected highlights 

of NCRR-supported research activities and future

plans that relate to diabetes are presented below.

Current Activities:

• Adherence to high-fiber diets by patients having 

type 2 diabetes results in improved glucose control

and lowered cholesterol and triglyceride levels.

• The body fat of AIDS patients is redistributed in 

a manner that results in insulin resistance and

increased risk for cardiovascular disease. This 

is thought to be a result of changes in the 

immune system.

• Polycystic ovarian disease is a common cause of

infertility. Treating these women with metformin

improved their rate of ovulation and consequent

rate of conception.
DMICC ANNUAL REPORT 11 FY 2000

• A new assay revealed that infants having insulin

auto-antibodies were much more likely to develop

type 1 diabetes before the age of 4. A mouse model

that mimics this observation was also developed.

• NMR spectroscopy revealed in rats a basis for 

connecting glycogen levels in the brain with 

diabetes-related hypoglycemia. Hypoglycemia

unawareness develops in insulin-treated patients

with recurrent hypoglycemia who are no longer

able to detect symptoms of hypoglycemia until 

they develop confusion or lose consciousness.

• A new sensor system to monitor oxygen movement

into single clonal pancreatic beta cells demonstrated a clear oxygen flux oscillation that 

exhibits a periodicity equivalent to the known

fusion and release of insulin containing vesicles,

implying a pivotal role for the organelles in the

release process.

• Early gestational androgen excess in the rhesus

monkey may impair insulin secretion by pancreatic

beta cells, and late gestational androgen excess

alters insulin sensitivity.

• Stem cell regulatory pathways have been defined

through genome-wide gene expression analyses.

This database will be an invaluable resource for

understanding pancreatic islet and other stem cell

and tissue replacement.

• The association between obesity and the percentage of Hawaiian ancestry, unexplained by differences in diet and physical activity, suggests genetic

factors play an important role in the high prevalence of obesity observed among Native Hawaiians.

• The General Clinical Research Centers (GCRCs) are

home to many national cooperative diabetes programs (e.g., Diabetes Prevention Program (DPP),

Diabetes Prevention Trial for Type 1 Diabetes, EDIP,

EDIC) as well as corporate-sponsored drug trials.

• The impact of diabetes on minority communities 

is studied within the GCRCs.

• Pancreas and kidney transplant protocols are 

active at GCRCs.

• MRI cores are used to evaluate not only the

anatomic consequences of diabetes but real-time

metabolic changes within major organ systems.

• Microarray technology cores have been established

to study genomic mutations that could identify

individuals at risk for developing diabetes and

related disorders.

• Nursing-intense insulin clamp studies continue 

at most GCRCs.

• K23, K24, and K30 training programs support

career development of biomedical investigators 

to develop new and emerging biomedical technologies for diabetes research.

• Strategies for islet cell xenotransplantation in

macaques are being optimized to treat diabetes.

• Gene probes were used in mouse models to map

traits, including obesity, which is significant in 

diabetes pathogenesis.

• Porcine models were used to investigate the 

significance of coronary artery disease in type 2

diabetes.

Future Activities:

• NCRR has been joined by the National Institute 

of Diabetes and Digestive and Kidney Diseases 

and the Juvenile Diabetes Research Foundation

International to develop up to six Resource 

Centers to harvest, isolate, study, and distribute

clinical grade, human islet cells suitable for 

transplantation into qualified type 1 diabetics.

Applicants that receive a favorable peer review

should be able to begin operation in fall 2001.

NCRR will dedicate approximately $11 million 

over the next 5 years to establish and support 

the infrastructure of this effort.
DMICC ANNUAL REPORT 12 FY 2000

• NCRR is developing Centers of Clinical Research

Excellence (CCRE) at Research Centers in Minority

Institutions (RCMI). One of these CCREs will focus

on diabetes in minority populations, particularly 

on the epidemiology, genetics, and treatment of 

diabetes. This Center could synergistically collaborate with RCMI grantees and existing diabetes

centers. NCRR anticipates that further development

of the Regional Mutant Mouse Centers program

will increase the demand for use of genetically

altered animals in research including diabetes.

Funding for Diabetes Research: 

Additional FY 2000 funding information was 

not provided.

National Eye Institute (NEI)

The National Eye Institute’s (NEI) mission is to 

conduct and support research, training, health 

information dissemination, and other programs 

concerned with blinding eye diseases, visual 

disorders, mechanisms of visual function, preservation of sight, and the special health problems 

and requirements of the blind. Diabetes is responsible for diabetic retinopathy, an eye disease that 

is the leading cause of blindness in people between

the ages of 24 and 70 years. This disease is characterized by a progressive breakdown of the normal

retinal vascular system.

Current Activities:

• NEI sponsored a workshop entitled “Genetics of

Diabetic Retinopathy” on September 21–22, 2000,

in Bethesda, Maryland. The workshop brought

together clinicians, epidemiologists, statistical

geneticists, and molecular geneticists in order to

further research on diabetic retinopathy. The 

workshop explored the epidemiological evidence 

for genetic factors in diabetic retinopathy.

Recommendations from the workshop will have 

a direct impact on determining the direction of

future research aimed at improving the treatment

and management of diabetic eye disease.

• NEI joined the National Institute of Diabetes 

and Digestive and Kidney Diseases (NIDDK), the

National Institute of Dental and Craniofacial

Research (NIDCR), the National Institute of

Neurological Disorders and Stroke (NINDS), and 

the National Heart, Lung and Blood Institute

(NHLBI) in a program announcement (PA) on 

“The Role of Growth Factors in the Development 

of Diabetic Complications” (PA-99-159). This PA

encourages grant applications on the role of 

growth factors in the etiology and pathogenesis 

of the micro- and macrovascular complications 

of diabetes.

• NEI is helping to support both the ACCORD 

(Action to Control Cardiovascular Disease Risk in

Diabetes) and Look AHEAD (Action for Health in

Diabetes) studies, large multicenter trials supported by NHLBI and NIDDK to assess treatments to

reduce risk of cardiovascular disease in type 2 

diabetes. For this trans-NIH effort, NEI is sponsoring an eye examination component in order to

collect epidemiological data.

• Through its National Eye Health Education

Program (NEHEP), the Institute coordinated 

the National Diabetes Month Eye Initiative in

November 1999. This initiative increases awareness of diabetic eye disease and the importance 

of dilated eye exams for everyone with diabetes 

and is sponsored by the NEHEP Partnership,

which represents over 60 leading public and 

private organizations. In addition, diabetic eye 

disease awareness information was disseminated 

to both English and Spanish print, radio, and 

television media.

• Consistent with the recommendations of the 

congressionally established Diabetes Research

Working Group (DRWG), the NEI will support 
DMICC ANNUAL REPORT 13 FY 2000

two new initiatives. The first involves evaluation 

of new treatments for diabetic macular edema.

These include both medical and surgical 

approaches. A pilot study is being developed at 

the NEI clinical center to pilot methods to evaluate less intense photocoagulation, vitamin E 

supplementation, and lipid lowering. The pilot

study is intended to set the stage for a major 

multicenter randomized clinical trial for the 

treatment of diabetic macular edema. The second

initiative seeks to identify genetic associations 

in patients with microvascular complications of

diabetes. NEI will supplement the FIND (Family

Investigation of Nephropathy and Diabetes) 

study funded by NIDDK to investigate the genetics

of individuals and special populations of patients

with renal disease. NEI will support detailed 

eye examinations for these patients and will 

search for genetic associations with microvascular

disease.

Future Activities: 

• NEI will continue to incorporate the scientific 

priorities outlined in the Report of the

Congressionally Established Diabetes Research

Working Group in making funding decisions.

• NEHEP will continue to develop and implement

out-reach activities for people with diabetes.

• NEI will co-fund with the Juvenile Diabetes

Foundation International and the American

Diabetes Association, as well as others organizations, a workshop entitled “Implementation of

Screening and Eye Exams for Diabetic Retinopathy”

on February 27–28, 2001. This workshop will

address the challenge of providing screening 

and eye exams for diabetic retinopathy from a

health services research perspective. The meeting

will provide an overview of retinopathy examination and screening strategies and the need 

for these examinations. The goal of the workshop 

is to develop strategies for the health services 

community.

Funding for Diabetes Research: 

NEI’s FY 2000 expenditure for diabetes-related 

projects was approximately $27 million.

National Heart, Lung and Blood Institute

(NHLBI)

The National Heart, Lung and Blood Institute has

developed a comprehensive research program to

understand the pathogenesis, improve treatment,

and develop effective prevention strategies to

address the cardiovascular complications of 

diabetes, the major cause of death in patients with

diabetes. Despite reductions in cardiovascular 

disease (CVD) mortality in the general population,

patients with diabetes continue to have 2 to 4 

times the CVD rates of non-diabetics of the same 

age and gender, and studies indicate that current

treatments to prevent these complications may be

somewhat less effective among those with diabetes

than in the non-diabetic population.

Current Activities:

• NHLBI funded two major clinical trials to evaluate

therapy to reduce cardiovascular complications 

of diabetes. The Action to Control Cardiovascular

Disease Risk in Diabetes (ACCORD) trial will 

study 10,000 patients and evaluate the benefits 

of intensified control of hyperglycemis over more 

conventional glucose control and also test the 

benefits of aggressive blood pressure control 

and intensified control of the dyslipidemia associated with diabetes on CVD rates. The Bypass

Angioplasty Revascularization Investigations II

Diabetes (BARI 2D) trial will study 2,800 patients

and evaluate whether elective coronary artery

revascularization plus optimal medical management of cardiovascular risk factors and symptoms

is superior to optimal medical management 

alone. It will also evaluate the important issue 
DMICC ANNUAL REPORT 14 FY 2000

of whether reducing insulin resistance provides 

protection against cardiovascular complications 

by testing whether insulin-sensitizing drugs are

superior to insulin or oral insulin secretogogues 

at levels of glycemic control that are attainable

with current conventional treatment regimens.

• NHLBI is also helping to fund the National

Institute of Diabetes and Digestive and Kidney

Diseases’ (NIDDK’s) SHOW trial, which will evaluate the effect of obesity treatment on cardiovascular complications in type 2 diabetic patients.

• While the above trials will provide important 

information for clinicians on ways to reduce the

burden of cardiovascular complications in patients

with diabetes, it remains difficult to achieve and

maintain normoglycemia over the long periods 

necessary to minimize complications. Studies of

how diabetes causes excess CVD should lead to

development of new therapies that can reduce the

adverse effects of diabetes on the heart and large

vessels without requiring intensive efforts at 

glucose control. NHLBI has expanded basic

research related to macrovascular complications 

of diabetes, including five large program project

grants co-sponsored with the Juvenile Diabetes

Foundation. Topics include the role played by

hyperglycemia and insulin resistance in the genesis of cardiovascular disease in diabetes; the

effects of chronic hyperglycemia and dyslipidemia

on atherogenesis; the effect of diabetes on endothelial function and oxidative stress; the possibility

that the cardiac and vascular sequella of diabetes

are due to chronically accelerated generation of

lipid second messengers; and studies in a type 1

diabetic cohort assessing factors that have been

found to relate to carotid artery wall thickness 

or involved in atherosclerosis and clinical CVD,

including the lipoprotein subclass profile, LDLantibody complexes, and markers of inflammation.

Other studies are evaluating the atherogenic effect

of the accumulation of advanced glycation end

products (AGE) in patients with diabetes.

• NHLBI has also participated in the program of

small, innovative grants aimed at improved 

understanding of diabetic macrovascular complications. These have involved studies of the effects

of diabetes on vascular smooth muscle cells, its

effect on circulating growth factors, and the effect

of salt restriction on insulin sensitivity. A new 

initiative was funded to understand the etiology 

of diabetes-associated cardiomyopathy. This may 

be more important than previously recognized

since population studies have shown that diabetic

patients have an excess of unexplained congestive

heart failure.

Taken together, these clinical and basic studies

should provide better guidance for physicians to

reduce cardiovascular complications of diabetes 

in the near future and provide easier to use, more

effective therapies to achieve in later years.

Future Activities:

• In response to the strong recommendation of the

Diabetes Research Working Group, NHLBI is 

cooperating with NIDDK in developing improved

animal models of diabetic complications, a crucial

limiting factor in expanding studies of how 

diabetes produces chronic micro- and macrovascular changes.

• While collaborating on the NIDDK mouse model 

initiative, NHLBI will also prepare an initiative 

to develop larger animal models for studies of 

vascular complications of diabetes.

Funding for Diabetes Research: 

NHLBI support for studies of diabetes-related

macrovascular disease has continued to increase,

rising to $58,956,099 in FY 2000, an increase of

approximately $16,500,000 over the funds provided

in FY 1999. Funding for this work will expand 

further as the major clinical trials begin actively

recruiting participants in FY 2001.
DMICC ANNUAL REPORT 15 FY 2000

National Human Genome Research Institute

(NHGRI)

The National Human Genome Research Institute 

supports two ongoing diabetes projects being conducted by investigators in the Division of Intramural

Research and their collaborators. Both studies aim 

to identify genetic variations that lead to increased

susceptibility to type 2 diabetes mellitus.

Current Activities:

• Africa America Diabetes Mellitus Study (AADM).

During the past several years, the National

Institutes of Health’s (NIH’s) Office of Research 

on Minority Health (ORMH) has supported an 

innovative research collaboration between investigators from Howard University in Washington, D.C.

and scientists in the intramural research program

of NHGRI. The goal of these studies is to establish

a Center at Howard University for collaborative

research on genomic analyses of diseases that 

disproportionately affect African Americans.

The collaboration involves support for a project

involving African Americans affected with 

diabetes. Initial efforts to define the scientific 

focus and objectives of the Center have been

addressed through peer-reviewed contracts with

Howard University as the Coordinating Center 

for the Africa America Diabetes Mellitus Study.

Because of the high frequency of environmental 

risk factors for diabetes in the African-American

population, it is potentially more powerful to 

study genetic risk factors in West Africans, since

they are thought by many anthropologists to be 

the founding population of modern African

Americans and have fewer dietary and nutritional

confounding variables. Five recruitment sites in

Nigeria and Ghana were selected through a peer

review process. Patient samples and other clinical

data are sent to the AADM Coordinating Center 

at Howard University. Based on the successful

recruitment of study participants during a 1-year

pilot project, a full-scale study was implemented 

in September 1998 with an anticipated total of 400

pairs of siblings affected with diabetes mellitus.

This goal was met in the fall of 2000. Genotyping 

of samples from West Africa is currently underway

at the Center for Inherited Disease Research in

Baltimore. The study has not only started to yield

high-quality data, but has assisted in the recruitment of several top-flight scientists to the Center 

at Howard University.

• Finnish-US Investigation of NIDDM (FUSION)

Genetics. NHGRI assisted in the development of a

consortium of groups who have agreed to pool 

their linkage data on type 2 diabetes in order to

study the genetic factors involved in this disease.

The consortium currently has support from the

National Institute of Diabetes and Digestive and

Kidney Diseases and includes all of the major

groups in the United States with large family 

collections and a few European groups as well.

The Institute’s intramural program includes a

major project, known as the Finland-United States

Investigation of Non-Insulin Dependent Diabetes

Mellitus (abbreviated FUSION), which is studying 

a large cohort in Finland of sibling pairs affected

with type 2 diabetes and their relatives. The 

data from the FUSION project represents a major

component of the type 2 consortium’s effort.

Data collection includes blood samples and 

clinical data.

This project involves a whole genome search for

genes conferring susceptibility to diabetes, or 

intermediate traits such as insulin resistance, in

2,500 DNA samples. More than 1 million genotypes

were performed in phase I of the study, the results

of which were published recently (Ghosh et al.,

2000; Watanabe et al., 2000). In the past year, a

whole genome search was performed on a replication sample; analysis of these data is ongoing. The

project already has identified at least two regions

on chromosome 20 that seem to harbor susceptibility genes. These and several other potential 

gene locations are being followed up by candidate

gene evaluation and linkage disequilibrium 

analysis in this unique population.
DMICC ANNUAL REPORT 16 FY 2000

Future Activities: 

No additional diabetes-related activities 

were reported.

Funding for Diabetes Activities: 

FY 2000 funding information was not provided.

References:

Ghosh et al. (2000) The Finland-United States 

investigation of non-insulin-dependent diabetes 

mellitus genetics (FUSION) study. I. An autosomal

genome scan for genes that predispose to type 2 

diabetes. Am J. Hum. Genet. 67(5): 1174-1185.

Watanabe et al. (2000) The Finland-United States

investigation of non-insulin-dependent diabetes 

mellitus genetics (FUSION) study. II. An autosomal

genome scan for diabetes-related quantitativetrait loci. Am J. Hum. Genet. 67(5): 1186-2

National Institute of Allergy and Infectious

Diseases (NIAID)

The National Institute of Allergy and Infectious

Diseases supports research into the immunopathogenesis of autoimmune diseases, including type 1

diabetes. NIAID also promotes the application of

basic immunology research to the clinical investigation of autoimmune diseases, including type 1 

diabetes mellitus, and to studies that could improve

kidney and islet transplantation outcomes. The 

objectives of this research are to increase understanding of pathologic immune responses in order 

to prevent, diagnose, or treat individuals with

autoimmune diseases or those needing organ transplants. NIAID’s support for research on autoimmune

diseases, including research related to diabetes,

has increased significantly in the past year.

Current Activities:

• NIAID’s Autoimmunity Centers of Excellence, a

cooperative network of centers, performs clinical

trials of novel immunotherapies in multiple

autoimmune diseases, including type 1 diabetes,

and conducts basic research into the pathogenesis

of autoimmunity, immune modulation, and selftolerance. The network is developing a trial of 

anti-CD3 antibody for prevention of diabetes in

individuals at risk for development of type 1 

diabetes. The National Institute of Diabetes and

Digestive and Kidney Diseases (NIDDK), The

National Institute of Arthritis and Musculoskeletal

and Skin Diseases (NIAMS), and the National

Institutes of Health’s (NIH’s) Office of Research on

Women’s Health (ORWH) co-sponsor this program.

• Through the Immune Tolerance Network, NIAID,

NIDDK, and the Juvenile Diabetes Research

Foundation International are co-sponsoring a

multinational study designed to replicate the 

very promising results with islet transplantation

achieved in 12 brittle diabetics at the University 

of Alberta, all of whom no longer require insulin

injections, with some islet transplant recipients 

as long as 14 months post-transplantation. The

“Edmonton” protocol for islet preparation and 

clinical transplantation will be expanded to 40

patients at 10 sites in the United States, Canada,

and Western Europe. This new approach is based

on a steroid-free immunosuppressive regimen 

and rapid transplantation of an increased number

of islet cells prepared to maximize viability.

• Also through the Immune Tolerance Network,

NIAID is supporting a phase II clinical trial of 

anti-CD3 antibody in patients with new onset 

type 1 diabetes to prevent the loss of C peptide

function. This approach has shown promise in a

phase 1 study.
DMICC ANNUAL REPORT 17 FY 2000

• Through the Request for Applications (RFA),

“Cooperative Study Group for Autoimmune Disease

Prevention,” NIAID is supporting a cooperative program focused on the development of toleragenic

vaccines for the prevention of autoimmune diseases

with an emphasis on type 1 diabetes. The focus 

of this program is the development through animal

and human studies of the basic knowledge of the

immune response necessary to rationally design

preventive interventions. The Study Group funded

under this RFA will develop a plan articulating the

goals of the Group and will have significant means

through support of innovative pilot projects, clinical studies, and cooperative resources to implement

the plan to discover potential targets for interventions to prevent human disease. NIDDK, NIAMS,

the National Institute of Child Health and Human

Development (NICHD), the National Institute of

Dental and Craniofacial Research (NIDCR), NIH’s

ORWH, and the Juvenile Diabetes Research

Foundation International are co-sponsors.

• In FY 2000, NIAID joined several Institutes and

Centers and the Juvenile Diabetes Research

Foundation International in supporting the 13th

International Histocompatibility Working Group

(IHWG), an international network of laboratories

that will collect and share data on genes of the

human leukocyte antigen (HLA) complex and their

association with diseases like type 1 diabetes in

which susceptibility is linked to the HLA. In 

addition, IHWG will launch a project to discover

single nucleotide polymorphisms (SNPs) in potential type 1 diabetes-related genes. Once SNPs are

identified, researchers in type 1 diabetes will be

able to analyze their patient populations for the

presence of these variations. The results of these

projects will provide a much greater insight into

the mechanisms of autoimmune diseases and

increase our ability to predict an individual’s 

disease predisposition.

• The NIAID, together with Merck Genome Research

Institute, the Juvenile Diabetes Research

Foundation International, and the Welcome Trust,

is supporting the transfer of the non-obese 

diabetic (NOD) congenic strains developed at the

Merck Laboratories by Linda Wicker and John 

Todd to Taconic Farms. Merck Laboratories is 

closing down its NOD mouse program and this 

will allow these unique strains to be available for

use by investigators seeking to understand the

pathogenesis and genetics of type 1 diabetes and

other autoimmune diseases.

• The NIAID Multiple Autoimmune Disease Genetics

Consortium (MADGC) is a repository of genetic 

and clinical data and materials from families 

in which three or more individuals are affected 

by two or more distinct autoimmune diseases

(http://www.madgc.ord). This resource will 

provide materials to promote research aimed at

discover-ing the human immune response genes

involved in autoimmunity, including type 1 

diabetes. MADGC began enrolling families in 

May 2000. To date, 15 families have been enrolled

with 20 more in process.

• The Non-Human Primate Transplantation Tolerance

Cooperative Study Group, supported by NIAID 

and NIDDK, evaluates the safety and efficacy of

promising tolerance induction treatment strategies

in non-human primate models of kidney and islet

transplantation. Dr. Norma Kenyon’s (University 

of Miami) data on costimulation blockade for islet

transplantation shows that anti-CD154 induction

and maintenance therapy results in long-term 

graft survival to over 800 days in some animals.

The results of these large animal studies are 

providing information critical to the design of 

scientifically sound and ethically acceptable 

human clinical trials.
DMICC ANNUAL REPORT 18 FY 2000

• NIAID funded an RFA (FY 2000) on “Innovative

Research in Mucosal Immunity” to support novel

projects to advance our understanding of mucosal

immune response, which is likely to be important

in the development of antigen-specific approaches

to modulate the immune response in type 1 

diabetes and understanding the oral complications

of diabetes. NIDCR and the Crohn’s and Colitis

Foundation co-sponsored this initiative.

• NIAID issued an RFA, “Hyperaccelerated Award/

Mechanisms in Immune Disease Trials,” to support

studies of mechanisms underlying clinical trials 

for immune-mediated diseases. In order to 

meet the timeline of industry-supported clinical 

trials, NIAID in collaboration with the Center for

Scientific Review has established a process whereby review and award of applications is greatly

accelerated (13 weeks). The National Institute on

Aging, NIAMS, NIDDK, and the National Institute 

of Neurological Disorders and Stroke also support

the RFA.

• NIAID co-sponsors, along with NIDDK, NICHD, and

other Federal and private partners, the Diabetes

Prevention Trial for Type 1 Diabetes, a multicenter

clinical trial to determine whether early intervention with parenteral or oral insulin in at-risk

relatives of individuals with type 1 diabetes can

delay the development of the disease. In addition,

in FY 2001, NIAID and NICHD will co-sponsor the

NIDDK Type 1 Diabetes TrialNet to support new

approaches to treat or prevent type 1 diabetes.

• NIAID, in collaboration with NIDDK and NICHD,

issued an RFA for “New Strategies for Treatment 

of Type 1 Diabetes” to support the development 

of novel strategies, including immunomodulatory

therapies, for the treatment of type 1 diabetes.

This RFA was supported by funds allocated for

type 1 diabetes (FY 2000).

• NIDDK, NIAID, and the National Heart, Lung and

Blood Institute issued an RFA, “Gene Therapy

Approaches for Diabetes and Its Complications,”

to support the development of novel gene therapy

approaches for the treatment of diabetes and its

complications. Awards for successful applicants 

are planned for FY 2001.

Future Activities:

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

National Institute of Arthritis and

Musculoskeletal and Skin Diseases (NIAMS)

Currently, the National Institute of Arthritis and

Musculoskeletal and Skin Diseases has no grants 

or initiatives or immediate future plans for 

diabetes-related activities.
DMICC ANNUAL REPORT 19 FY 2000

National Institute of Child Health and 

Human Development (NICHD)

Consistent with the National Institute of Child Health

and Human Development’s mission to promote 

the development of healthy children, understanding 

the factors that contribute to the development of 

diabetes is a particularly important issue, given the

prevalence of both type 1 and type 2 diabetes in children and the serious complications of diabetes later

in life. To this end, NICHD has focused its efforts on

the earliest pathogenesis of type 1 diabetes and on

optimizing insulin therapy in children with type 1

diabetes. In addition, NICHD has targeted research

on the origins of type 2 diabetes in adolescents and

on gestational diabetes mellitus in pregnant women.

Current Activities: 

In efforts to prevent this disease, NICHD has pioneered methods in ascertaining risk factors and

stratifying levels of risk for type 1 (juvenile) diabetes

mellitus according to genetic and immunologic 

markers. This work forms the basis of the Diabetes

Prevention Trial for Type 1 Diabetes, a major collaborative, trans-NIH study aimed at preventing or

delaying the onset of type 1 diabetes. Among its 

more recent efforts, NICHD:

• Is working with the Juvenile Diabetes Foundation

International to co-fund a large prospective 

study of infants who have relatives with type 1 

diabetes, to ascertain the earliest changes in gene

expression in those infants who become diabetic.

• Initiated a clinical research study entitled 

“Tolerability and Pharmacokinetics of Inhaled

Insulin in Children 6-11 Years of Age with Type 1

Diabetes.” Up to 36 units of insulin per day can be

delivered through the airway system of the lungs.

If researchers can show that inhaled insulin is as

efficacious as insulin injected subcutaneously, this

will be a great milestone in treatment of diabetes,

overcoming the children’s fear of injections and 

difficulty complying with intensive insulin therapy.

• Initiated a 16-site, 5-year, prospective, international

study of hyperglycemia and adverse pregnancy 

outcomes. This study of gestational diabetes 

mellitus will enroll 25,000 women early in their

pregnancy and will follow them through their 

gestation, delivery, and postpartum period. Their

infants will be studied as well.

• Is co-sponsoring several initiatives that address 

the prevention and treatment of diabetes, including

those to study the following: (1) Development of 

the Endocrine Pancreas; (2) Type 2 Diabetes in 

the Pediatric Population; and (3) Fetal Origins of

Adult Disease.

Future Activities: 

Upcoming diabetes activities for NICHD include:

• Collaborating with the National Institute of

Diabetes and Digestive and Kidney Diseases

(NIDDK) and the National Institute of Allergy 

and Infectious Diseases (NIAID) in seeking to 

develop a Network of 20 centers to perform 

clinical trials of new immunomodulatory agents 

to treat or prevent type 1 diabetes.

• Joining NIDDK and NIAID in funding four Centers

of Excellence in immunology research to develop

vaccines and other new immunomodulatory agents

designed to treat, delay, or prevent type 1 diabetes.

• Funding a clinical trial designed to ascertain 

how to implement effectively the principles of the

Diabetes Control and Complications Trial (DCCT) 

in children with type 1 diabetes in an effort to

reduce the incidence of hypoglycemia.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.
DMICC ANNUAL REPORT 20 FY 2000

National Institute of Dental and Craniofacial

Research (NIDCR)

The mission of the National Institute of Dental and

Craniofacial Research is to support research on 

the causes, prevention, diagnosis, and treatment 

of oral and craniofacial diseases and conditions,

including oral complications associated with 

diabetes. These complications include greater prevalence and severity of periodontal diseases and

increased susceptibility to oral mucosal infections,

salivary gland dysfunction, and neuropathies 

resulting in loss or alteration of taste, smell, and

mucosal sensory perception. NIDCR also supports

research on the effects of oral diseases and conditions on metabolic control of blood glucose.

Current Activities:

• As part of its strategic planning process, NIDCR

held a workshop on the oral complications of 

diabetes (December 6-7, 1999).

• The Institute’s basic science research efforts

included studies in the following areas:

– The role of non-enzymatic glycation of extracellular

proteins in periodontal diseases (FY 1997 Balanced

Budget Act).

– Impaired macrophage/monocyte function in

patients with diabetes.

– Gingival connective tissue destruction in patients

with diabetes.

– Regulation of B-cell autoimmunity by 

Interleukin-10.

– Characterization of diagnostic pancreatic autoantigens in serum and saliva of type 1 diabetes

patients (FY 1997 Balanced Budget Act).

• Clinical research areas included:

– Diabetes as a risk factor for periodontitis.

– Investigations into the associations between 

periodontitis, diabetes, and heart disease.

– Treatment of periodontitis in Southwest Native

Americans with type 2 diabetes.

– Randomized clinical trial to evaluate the effect 

of treating periodontal infection on improving

glycemic control in type 2 diabetes patients.

• Translational research focused on salivary gland

dysfunction in animals and humans with diabetes.

• NIDCR conducted several diabetes-related 

behavioral and health promotion programs on 

(1) oral health and diabetes; (2) glycemic control 

in older diabetics; and (3) population-based

approaches for oral health care in diabetes

patients.

• NIDCR’s training and career development program

provided clinical research opportunities in oral 

and systemic diseases including diabetes.

Future Activities:

• NIDCR and the American Academy of

Periodontology will co-sponsor a conference in

April 2001 to look at the relationship between oral

health and diabetes. In planning this conference,

the Institute will work closely with other Institutes

and Centers of the National Institutes of Health

such as the National Institute of Diabetes and

Digestive and Kidney Diseases as well as the

American Association for Dental Research and the

American Diabetes Association.

• In addition, NIDCR will support supplements to

examine the oral microbiology and immunology of

patients with type 1 diabetes (FY 1997 Balanced

Budget Act).
DMICC ANNUAL REPORT 21 FY 2000

Funding for Diabetes Research: 

The NIDCR support for diabetes research in FY 2000

was approximately $4.1 million. Of this total, $2.0

million was for intramural research and $2.1 million

was for extramural research.

National Institute of Diabetes and Digestive 

and Kidney Diseases (NIDDK)

The National Institute of Diabetes and Digestive and

Kidney Diseases is the lead agency of the Federal

Government for research efforts to combat diabetes

and its complications. The Division of Diabetes,

Endocrinology and Metabolic Diseases has responsibility for extramural programs related to diabetes

research and research training. Additional diabetesrelated activities are supported by the Division of

Intramural Research, the Division of Digestive

Diseases and Nutrition, and the Division of Kidney,

Urologic, and Hematologic Diseases. In addition,

NIDDK is responsible for overseeing the deployment

of special funds to support research on the prevention and cure of type 1 diabetes provided through 

the Balanced Budget Act of 1997 and its subsequent

extension.

Current Activities: 

NIDDK supports a vigorous program of both basic

and clinical research to further understanding of the

development, treatment, and prevention of diabetes

and its complications. To maximize research on 

diabetes, the Institute has fostered collaborations

among the many Institutes and Centers of the

National Institutes of Health (NIH), as well as with

the Centers for Disease Control and Prevention 

(CDC), the Juvenile Diabetes Research Foundation

International, and the American Diabetes

Association. Some examples of ongoing activities 

and new initiatives for FY 2000 follow:

• Prevention of Type 1 Diabetes. Type 1 diabetes 

is an autoimmune disease in which there is 

destruction of the insulin-secreting beta cells 

of the pancreatic islets.

– NIDDK is spearheading a major clinical trial,

the Diabetes Prevention Trial for Type 1 Diabetes

(DPT-1), to determine whether early intervention,

using the antigen-based therapies of insulin 

injections or oral insulin, can delay the onset of 

the disease in at-risk, non-diabetic relatives of 

individuals with type 1 diabetes. The DPT-1 is 

also supported by the National Institute of Allergy

and Infectious Diseases, the National Institute 

of Child Health and Human Development, the 

National Center for Research Resources, the

American Diabetes Association, the Juvenile

Diabetes Research Foundation International,

and industry.

– A new NIDDK initiative that will greatly facilitate

additional clinical research to prevent or reverse

type 1 diabetes is the type 1 Diabetes TrialNet —

an approach recommended by the congressionally

established Diabetes Research Working Group.

Spearheaded by NIDDK, this effort is co-sponsored

by the National Institute of Allergy and Infectious

Diseases and the National Institute of Child Health

and Human Development. The TrialNet will include

clinical centers, recruitment networks, and a coordinating center. It will provide the research infrastructure needed for future design and execution 

of pilot studies and expanded clinical research.

With the TrialNet, more rapid clinical testing 

of novel approaches to treatment and prevention 

will be possible as soon as they emerge from 

fundamental investigations. The TrialNet will 

thus enable efficient performance of intervention

studies to preserve pancreatic beta cell function 

in new-onset cases of type 1 diabetes and,

ultimately, to prevent onset of the disease.
DMICC ANNUAL REPORT 22 FY 2000

• The Beta Cell. Gaining knowledge about the beta

cells of the pancreatic islets is important to both

type 1 and type 2 diabetes because they are the 

key to insulin production and resulting glucose

control. A conference entitled, “Stem Cells and

Pancreatic Development” was sponsored by NIDDK,

with support from the Juvenile Diabetes Research

Foundation International and the American

Diabetes Association. This conference brought

together an international group of physicians and

scientists to discuss the knowledge base and

opportunities for further research.

• Islet Transplantation for Type 1 Diabetes. The 

congressionally directed Diabetes Research

Working Group set forth islet transplantation as 

an extraordinary research opportunity.

– In pursuing this area of research, NIDDK, in a 

collaborative effort with the National Institute of

Allergy and Infectious Diseases and the Juvenile

Diabetes Research Foundation International, has

funded numerous centers to develop improved 

protocols for islet transplantation in humans.

In addition, the NIDDK Division of Intramural

Research has initiated a clinical research program

that will explore new approaches to both kidney

and islet transplantation for diabetes — in 

collaboration with the Department of Defense,

the National Institutes of Health Clinical Center,

and the Diabetes Research Institute of the

University of Miami.

– NIDDK and the Juvenile Diabetes Research

Foundation International are also co-sponsoring

the Immune Tolerance Network (ITN) initiative,

a collaboration involving numerous research 

institutions spearheaded by the National Institute

of Allergy and Infectious Diseases. The ITN will

solicit, develop, implement, and address clinical

strategies, including biological assays, for the 

purpose of inducing and maintaining immune 

tolerance in patients receiving kidney and islet

transplants. The Transplantation and Autoimmunity

Branch of the NIDDK Division of Intramural

Research is one of 11 centers participating in the

ITN’s testing of the “Edmonton Protocol” in 

performing transplant procedures in a larger 

number of patients. This clinical research will 

further assess the effectiveness of the technique

and identify any long-term risks associated 

with steroid-free immunosuppressive therapies.

Researchers hope the study will serve as a 

platform for testing new treatments in which the

permanent reversal of diabetes can be achieved

without the lifelong need for immunosuppressive

drugs. In addition, the NIDDK will support two

additional studies to determine if one pancreas 

can provide sufficient islets for transplantation 

into one patient. In support of all of these efforts,

the National Center for Research Resources of 

NIH is establishing several centers aimed at 

maximizing islet harvesting processes.

• Genetic Underpinnings of Diabetes and Its

Complications. Diabetes and its complications 

have strong genetic determinants. Even though 

diabetes appears to develop as a result of many

factors, virtually all forms appear to have genetic

influences, with the likely involvement of multiple

genes. NIDDK is involved in major initiatives to

capitalize on new knowledge about the human

genome and the genetics of diabetes.

– The Institute is a leading partner in support of 

the International Type 2 Genetic Linkage Analysis

Consortium. The purpose of the Consortium is to

combine data from multiple genome scans and 

thus increase the probability of gene discovery.

The groups involved in the Consortium are 

pursuing a fine mapping effort of potential

susceptibility genes for type 2 diabetes located 

on several chromosomes. Intensified support for 

the Consortium will also permit additional 

analyses to determine whether unique susceptibility genes exist in African Americans, who are 

disproportionately affected by type 2 diabetes.
DMICC ANNUAL REPORT 23 FY 2000

– NIDDK and the Juvenile Diabetes Research

Foundation International are working closely to

establish a Type 1 Diabetes Genetics Consortium.

The initial objective would be to pursue the results

of three genome-wide scans for type 1 diabetes,

which have recently been completed. These scans

have identified several genetic regions as likely 

containing diabetes susceptibility genes. A combined analysis of these three datasets could identify the most promising areas for further study of

genes that confer susceptibility to type 1 diabetes.

– To identify the genes responsible for the kidney

complications of diabetes, the Institute is now

launching a new genetics initiative called “FIND”—

the Family Investigation of Nephropathy and

Diabetes. This initiative will focus on family 

studies designed to uncover candidate genes 

associated with type 1 or type 2 diabetes, genes

associated with development of complications,

and genes relevant to those identified in animal

models. A specific objective will be to search 

for susceptibility genes in subpopulations of

Caucasians, African Americans, Hispanic

Americans, and Native Americans across the 

United States.

• Type 2 Diabetes In Children. Type 2 diabetes has

traditionally been considered a disease of adults

because the age of onset is frequently after age 

40 and it is often associated with obesity. Children

with diabetes usually have been presumed to 

have type 1 diabetes; however, in recent years, an

increasing number of children who appear with

elevated blood glucose levels are being diagnosed

with type 2 diabetes. The increase in reports of 

type 2 diabetes among children parallels a similar

rise in the adult population, as obesity has become

a major public health concern. In children, the

increased incidence of type 2 diabetes appears 

to be occurring largely in minority populations —

Hispanic Americans, African Americans, and 

Native Americans — again paralleling the 

disproportionate burden this disease places on 

the same minority populations in adulthood.

To combat type 2 diabetes in children, NIDDK,

along with the National Institute of Child Health

and Human Development, is supporting research 

to promote greater understanding of its causes,

to refine diagnostic criteria, to define metabolic

abnormalities, and to formulate treatment options.

In addition, NIDDK recently issued two research

solicitations for a coordinating center and clinical

centers to develop community or school-based 

primary prevention programs that can be applied

in a cost-effective manner to decrease the risk 

factors for type 2 diabetes and to reduce the incidence of this disease in children and adolescents.

Treatment options will be studied to determine the

safest, most effective, and cost-effective strategies

to achieve and maintain normal blood glucose 

levels in the pediatric population.

• Type 2 Diabetes. Two factors play an important 

role in the growing public health burden of type 2

diabetes — the changing demographics of America

in terms of age, ethnicity, and race and the increasing prevalence of obesity, a major risk factor for 

the disease. Diabetes is the sixth leading cause of

death in the United States and the third leading

cause of death in some minority groups. It places

an especially heavy burden on growing segments 

of the U.S. population — elderly and minority

groups. NIDDK is spearheading NIH-wide research

efforts to combat diabetes and obesity in order to

stem the tide of this devastating disease.

– A clinical trial of great significance to type 2 

diabetes is “Look AHEAD”— Action for Health in

Diabetes. This large, multicenter trial is designed 

to determine whether interventions to produce 

sustained weight loss in obese individuals with

type 2 diabetes will improve health. The trial is

expected to recruit a patient population whose

overall ethnic and racial composition will reflect

the prevalence rates for diabetes in the United

States. NIDDK is sponsoring this trial along with

the National Heart, Lung and Blood Institute, the

National Institute of Nursing Research, the

National Center for Minority Health and Health
DMICC ANNUAL REPORT 24 FY 2000

Disparities, the National Institute of Health’s 

Office of Research on Women’s Health, and the

Centers for Disease Control and Prevention.

– For those at risk for type 2 diabetes, an ongoing

NIDDK clinical trial may provide important 

knowledge about prevention strategies. The

Diabetes Prevention Program (DPP) is comparing

three regimens: the current conventional advice

regarding diet and exercise; a more intensive

lifestyle intervention of diet and exercise; and 

the drug metformin — a medication approved for

treatment of type 2 diabetes. The DPP has now

completed patient recruitment, with a total of 

more than 3,800 participants — 45 percent of 

whom are from minority groups. Findings from 

this study may help advance understanding of 

the factors that lead to the development of type 2

diabetes and provide strategies for its prevention.

– The National Diabetes Education Program (NDEP),

a collaborative initiative of NIDDK and the Centers

for Disease Control and Prevention, involves 200

public and private partnerships to promote early

diagnosis and improve the treatment and outcomes

for individuals with diabetes. A key feature of 

the program’s partnership is the participation of

individuals who represent communities of African

Americans, Hispanics/Latinos, Native Americans/

Alaska Natives, and Asian and Pacific Islanders.

The NDEP is currently conducting a series of 

diabetes awareness campaigns using the theme,

“Control Your Diabetes for Life.” This theme is 

built on the landmark clinical trials that showed

the importance of blood glucose control in preventing diabetic complications. By reinforcing 

this theme, the NDEP encourages patients with 

diabetes to manage the disease closely in order 

to live healthier lives. The campaigns target both

general audiences and the populations disproportionately affected by diabetes. Television, radio,

and print public service announcements, educational materials, and information kits for the 

media and for communities are helpful products 

of the NDEP. The program is currently developing

campaigns to encourage health care providers 

to work with their patients to improve glucose 

control, and to identify, diagnose, and treat 

children with type 2 diabetes.

NIDDK is expanding its commitment to the NDEP

to develop and promote diabetes messages that

reflect the most up-to-date scientific evidence 

about diabetes control, treatment, and prevention.

NIDDK has also featured type 2 diabetes in its

Health Disparities Strategic Plan.

• Complications of Diabetes. NIDDK is undertaking

several new and expanded initiatives designed 

to further understanding of the key mechanisms

involved in development of the complications of

diabetes and the means to reduce or prevent them.

For example, a solicitation entitled “New Therapies

for Diabetic Foot Disease” encourages research 

on the etiology and pathogenesis of diabetic foot

ulcers and development of effective prevention 

and treatment modalities. It is hoped that this

solicitation will lead to new diagnostic, prognostic,

and therapeutic strategies to reduce the burden 

of diabetic foot disease. The National Institute of

Nursing Research is also supporting this initiative.

– A solicitation entitled “Race/Ethnic Disparities in

the Incidence of Diabetes Complications” will 

investigate differences among contemporary populations in the United States, categorized by race,

ethnicity, and other factors, in risk factors for the

development and rates of complications in diabetes. Research supported through this initiative

may also aid in determining the extent to which

other factors, including metabolic and genetic 

variations, medical care, socioeconomic status,

and behavior account for these differences.

– At the more basic science level, another initiative

will support research to further understanding 

of the pathogenesis of endothelial dysfunction 

in diabetes at the molecular and cellular level.

Advances from this research may provide new 
DMICC ANNUAL REPORT 25 FY 2000

targets for pharmacologic or genetic manipulations

to prevent complications of the disease. In addition,

NIDDK will establish national centers for the 

purpose of detailed metabolic phenotyping of

mouse models potentially useful for understanding

diabetes and its complications and obesity.

– An initiative sponsored by the National Institute 

of Neurological Disorders and Stroke, and 

supported by NIDDK and the Juvenile Diabetes

Research Foundation International, may lead 

to increased understanding of the mechanisms 

by which diabetes results in painful, disabling 

peripheral neuropathy, autonomic neuropathy,

impaired counterregulation and hypoglycemia

unawareness, and other neurological complications. It is the intent of this initiative to attract

basic neuroscientists to the study of diabetic 

neuropathy and neurobiology relevant to diabetes

and enhance interdisciplinary approaches to

research in this area.

– In November 1999, NIDDK, the National Institute 

of Allergy and Infectious Diseases, the National

Heart, Lung and Blood Institute, the National

Center for Research Resources, the Juvenile

Diabetes Research Foundation International, and

the American Diabetes Association sponsored a

meeting entitled, “Gene Therapy Approaches for

Diabetes and Its Complications.” One of the 

recommendations from the meeting was to support

additional studies to develop novel approaches

using gene therapy for the treatment of diabetes

and its complications. There are many approaches

to interfering with the development of type 1 

diabetes and to treating the complications resulting from both type 1 and type 2 diabetes that

would appear to be amenable to gene therapy 

technology. A solicitation spearheaded by NIDDK

also encourages development of gene therapy

approaches for type 1 diabetes and its complications and to their application in appropriate 

animal models or small pilot studies.

Future Activities: 

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

National Institute of Environmental Health

Sciences (NIEHS)

Juvenile diabetes is an autoimmune disease that

strikes early and can create problems throughout

life. Recent studies have raised the possibility that

environmental factors, such as nitrates in well 

water, increase the risks of juvenile diabetes. The

possibility of finding controllable environmental 

factors in the etiology of juvenile diabetes has 

widespread support. Studies in the United Kingdom,

Finland, and Colorado indicate that the incidence 

of childhood diabetes is higher in areas with 

elevated levels of nitrate in the drinking water. This

finding is significant for agricultural communities

because well water can have elevated nitrate levels 

in areas where there is extensive use of fertilizers.

Current Activities:

• The association between nitrates and juvenile 

diabetes is preliminary but merits further 

investigation in a rigorous prospective study,

such as would be possible within the 

Agricultural Health Study.

• NIEHS is currently studying diabetes along 

with other health outcomes in the Agricultural

Health Study.
DMICC ANNUAL REPORT 26 FY 2000

• NIEHS investigators are also investigating the 

role of menstrual and reproductive risk factors 

in diabetes and are looking at mechanisms of 

how environmental agents can affect pancreatic

cancer cells.

Future Activities: 

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

National Institute of General Medical Sciences

(NIGMS)

The National Institute of General Medical Sciences

supports research and research training in the basic

biomedical sciences that provide the foundation 

for a better understanding of fundamental life

processes. Some of this work has relevance to 

understanding and treating diabetes.

Current Activities:

• NIGMS supports the Human Genetic Cell

Repository, a collection of over 6,600 cell lines 

from individuals with a wide variety of genetic 

disorders, including diabetes, and from normal

individuals. Cell lines in the collection include

those from individuals with various types of 

diabetes, including insulin-dependent diabetes 

mellitus (IDDM) and diabetes mellitus and

insipidus with optic atrophy. The repository

includes an extensive collection of cell lines from

members of an extended pedigree with maturityonset diabetes of the young. This collection is of

value in studies designed to map and characterize

the gene(s) responsible for the disorder. NIGMS 

has an interest in understanding how genetic and

environmental components interact to result in

complex diseases such as diabetes.

• The Institute supports a portfolio of grants to

develop better statistical methods for mapping 

and identifying genes underlying complex traits,

develop mathematical models for studying 

gene-gene and gene-environment interactions,

investigate DNA sequence variation and its 

evolution, examine gene activities and the consequences of abnormalities in these activities,

and optimize sampling strategies.

• NIGMS also supports pre- and postdoctoral 

training that emphasizes statistical and computational skills and workshops to provide additional

training in statistical methods to biologists.

• NIGMS support for research on the mechanisms

underlying individual variations in drug response,

while not specifically targeting diabetes, has the

potential to have an impact on the treatment of 

diabetes and its complications. Researchers are

studying the structural features of a powerful

peripheral vasodilator related to insulin and 

identified as an important prospective drug for

peripheral angiopathies associated with diabetes.

• NIGMS, in conjunction with several other

Institutes, is supporting a mouse mutagenesis 

and phenotyping center whose emphasis is the

high-throughput generation and identification of

mice with mutations in developmental defects,

including those that affect organogenesis.

• NIGMS is also participating in the Trans-NIH

Zebrafish Initiative, whose goal is to improve the

genomic resources for the zebrafish, a potentially

valuable model for diabetes.
DMICC ANNUAL REPORT 27 FY 2000

• For many of the cell lines in the Human Genetic

Cell Repository, DNA is also available. In a major

new initiative, the Repository has cooperated with

the National Human Genome Research Institute to

acquire a collection of cell lines, and DNA, from 

500 unrelated individuals representative of the

diversity of the U.S. population. This resource has

already been of great value to researchers for the

discovery of DNA polymorphisms, an important

step in identifying genes involved in complex

genetic disorders such as diabetes.

Future Activities:

NIGMS will continue to support basic research that

focuses on underlying mechanisms and principles

that are expected to shed light on both normal and

disease processes and to lead to the development of

new modes of treatment and prevention.

Funding for Diabetes Research: 

FY 2000 funding is estimated to be $4,964,000,

which represents an increase over the $3,704,000

spent in FY 1999.

National Institute of Mental Health (NIMH)

The National Institute of Mental Health supports

research on co-morbid mental and medical disorders

(e.g., depression or anxiety disorders and diabetes)

when there is a central and explicit focus on a 

mental disorder(s)/symptoms/or related disability.

Studies of risk and protective processes linking the

co-morbid mental and medical disorders are encouraged, as are the development and initial testing of

interventions aimed at preventing or treating adverse

outcomes in both domains. NIMH supports intervention research when the prevention or treatment of

mental disorders/symptoms/related disability are

among the primary outcomes of the study. When the

prevention or treatment of diabetes and its complications, or improved adherence to regimens for 

diabetes and its complications, are the primary 

focus of study, studies should be assigned to the

National Institute of Diabetes and Digestive and

Kidney Diseases (NIDDK).

Current Activities: 

• With NIDDK and the National Institutes of Health’s

(NIH’s) Office of Behavioral and Social Sciences

Research, NIMH developed plans for an FY 2001

Request for Applications (RFA) and related conference on co-morbid depression and mental 

disorders in patients with diabetes, renal disease,

and obesity/eating disorders. The conference was

scheduled for January 29–30, 2001, at the Natcher

Center on the NIH campus. The RFA is planned 

for release in spring 2001.

• In addition to the FY 2001 RFA and conference,

NIMH solicits research on co-morbid mental 

disorders and diabetes under its ongoing program

announcement, “Research on Co-Morbidity:

Etiology and Prevention,” PA-99-071, which may 

be found at http://www.nimh.nih.gov/grants/

99-071.html.

Future Activities:

Going forward, this central and explicit focus on

mental disorders will be a critical criterion for the

funding of new grants related to diabetes and its

complications. NIMH activities include a range 

of grants, some with a primary focus on mental 

disorders and diabetes, as well as some where the 

focus on these co-morbid disorders is not as central

and explicit.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.
DMICC ANNUAL REPORT 28 FY 2000

National Institute of Neurological Disorders 

and Stroke (NINDS)

Fiscal Year 2000 (FY 2000) information was 

not available.

National Institute of Nursing Research (NINR)

The National Institute of Nursing Research supports

and conducts research and research training on 

the biological and behavioral processes that underlie

promotion of health, amelioration of illness and its

sequelae, and effective delivery of care. One purpose

of this research, specific to diabetes, is to understand

how to promote health-sustaining behavior and to

improve quality of life by relieving the effects of 

disease processes and their progression. Nursing

research focuses on how physical and psychological

responses to diabetes symptoms and treatment of

the disease affect health throughout the lifespan.

NINR research programs pay particular attention to

special populations affected by diabetes.

Current Activities: 

NINR activities are designed to support research

related to diabetes interventions, self-management,

quality of life, special and diverse population needs,

problems of defined age groups and across the lifespan, basic research, genetics, and other initiatives

relevant to clinical practice and client outcomes.

• Two program announcements (PAs) were published

in January and June of 2000 specific to diabetes

research, “Enhancing Adherence to Diabetes 

Self-Management Behaviors” and “Diabetes SelfManagement in Minority Populations.” These 

PAs are consistent with the Diabetes Research

Working Group (DRWG) recommendations. NINR

was a participant in this working group.

• Funded grants relating to diabetes research included career development, postdoctoral training, and

research. Diabetes-specific topics included ethnic

variation in type 2 diabetes prevention knowledge,

cardiac risk factors in type 1 and 2 adolescents,

autonomy and self-care in type 1 diabetes adolescents, Spanish language self-management programs, an intervention study of American Indian

groups on behavior change in type 2 diabetics, a

description of the process of integrating diabetes

self-care in Mexican-Americans with type 2 diabetes in the southwest, interventions for AfricanAmerican women with diabetes, an intervention 

for parents of young children with newly diagnosed diabetes, and biophysical determinants of

diabetes foot ulcer healing.

Future Activities:

In 2001, NINR plans to continue to support research

that focuses on problems experienced in diabetes

populations. Research efforts will be guided by the

following goals:

• NINR plans to focus support on promising ongoing

and new diabetes research areas while building 

on recent nursing science advances.

• NINR will work collaboratively with other

Institutes and organizations to increase and 

facilitate diabetes research activities.

Funding for Diabetes Research: 

In response to an FY 2000 Area of Opportunity on

“Enhancing Adherence to Diabetes Self-Management

Behaviors,” NINR had a significant increase in 

diabetes funding from $1.3 million in FY 1999 to 

$3.9 million in FY 2000.
DMICC ANNUAL REPORT 29 FY 2000

National Institute on Aging (NIA)

The mission of the NIA as it relates to diabetes

research and related issues, is to support biomedical

and behavioral research leading to improved 

therapies to prevent diabetes and its complications,

as well as improved quality of life of older 

diabetic patients.

Current Activities:

• The NIA continues to support studies on how

known risk factors associated with vasculopathy

influence the synthesis and function of advanced

glycosylated endproducts (AGE) receptors, and to

provide a molecular basis for future epidemiology

studies and treatment of diabetes- and age-related 

vascular disease.

• Studies are also focusing on the development of

interventions to reduce abdominal fat and on the

factors mediating regional differences in body 

fat noted in older non-insulin dependent diabetes

mellitus (NIDDM) patients. Previous studies supported by NIA have demonstrated that age-related

changes in the quality of skeletal muscle may play

a role in insulin resistance. For example, it has

been shown that there is an age-related decrease 

in GLUT4 levels in skeletal muscle, in conjunction

with the development of insulin resistance. To date,

much of the intervention development efforts have

focused on different types of exercise to either

reduce central adiposity or to improve GLUT4 

levels. NIA-supported investigators are also examining the time line of the metabolic benefits of 

exercise. For example, these studies will help to

identify how often older NIDDM patients need to

exercise to maintain exercise-induced improvements in glucose metabolism.

• Insulin resistance is a metabolic disorder that may

precede the development of type 2 diabetes in older

adults. Since physical inactivity and obesity are 

the two main factors contributing to insulin resistance, previous studies had compared the effects 

of short-term endurance exercise versus reduced

caloric intake on insulin sensitivity in older obese

men and women. These findings indicated that

short-term exercise is more effective than diet in

enhancing insulin action in older individuals with

abnormal glucose tolerance. However, data from

animal models suggest that caloric restriction 

can prevent and/or delay the onset of age-related

pathologies, including insulin insensitivity. NIA 

is currently exploring the clinical implications of

caloric restriction in the development of future

interventions for the prevention of diabetes in 

old age.

• NIA was a co-sponsor of the National Institute of

Diabetes and Digestive Diseases’ (NIDDK’s) Request

for Applications (RFA) “Innovative Approaches to

Prevention of Obesity.” The NIA is supporting two

studies resulting from this RFA. These studies will

specifically explore strategies to prevent weight

gain in menopausal women and in older women 

following smoking cessation.

• The NIA continues to be a co-sponsor of the 

NIDDK study, Diabetes Prevention Program (DPP).

Future Activities:

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.
DMICC ANNUAL REPORT 30 FY 2000

National Institute on Alcohol Abuse and

Alcoholism (NIAAA)

The National Institute on Alcohol Abuse and

Alcoholism (NIAAA) encourages research to understand the role of alcohol consumption as a risk 

factor in the development of diabetes mellitus.

NIAAA also supports research to determine the

effects of moderate alcohol consumption on diabetes.

Several studies suggest that alcohol consumption

may directly or indirectly contribute to the development of type 1 diabetes. This contention is based 

on the following observations: (1) alcohol may impair

the release of insulin from the pancreas; (2) chronic

alcohol intake can increase plasma levels of TNF,

which has been shown to cause apoptosis of pancreatic beta cells that in turn may decrease beta cell

number and insulin secretion; and (3) chronic alcohol

consumption may impair beta cell function by 

eliciting immunotoxicity.

Chronic alcohol consumption also has been implicated in the development of type 2 diabetes based on

the following findings: (1) chronic alcohol feeding in

rats reduces the number of insulin binding sites on

isolated hepatocytes; (2) alcohol impairs insulinmediated tyrosine phosphorylation of insulin receptors in a tumor cell line; (3) chronic alcohol exposure

blunts tyrosine phosphorylation of insulin receptor

substrate-1 in rat hepatocytes and a tumor cell line;

and (4) chronic alcohol exposure inhibits the activity

of rat hepatocyte phosphotidylinositol-3kinase,

which stimulates glucose transport. These effects of

alcohol may lead to insulin resistance and impaired

glucose transport.

Current Activities: 

NIAAA supports six projects that investigate the 

relationship between alcohol intake and diabetes.

The following research areas are under 

investigation:

• Impact of moderate alcohol consumption on 

the risk of diabetes mellitus.

• Effects of fetal alcohol exposure on the 

biochemical and physiological changes in the

insulin response and glucose homeostasis.

• Mechanism of induction of P450-2E1 (an alcoholinducible enzyme) in diabetes.

• Molecular mechanisms of disruption of insulinmediated glucose transport by ethanol.

• Alcohol consumption effects on glycemic control

and compliance in type 2 diabetics.

• Fatty acid changes in blood components as determinants of insulin resistance in the diabetic state.

Significant findings in FY 2000 include: 

(1) moderate alcohol consumption (15-29 g/day) 

was associated with a 36 percent lower risk of 

type 2 diabetes; (2) alcohol feeding disrupts insulinstimulated glucose uptake in rats by impairing 

intracellular translocation of GLUT4 (a glucose

transporter protein) to the plasma membrane and 

by disrupting the ability of GLUT4-containing 

vesicles to dock and fuse with the plasma membrane

of adipocytes; and (3) fetal alcohol exposure in rats

can induce insulin resistance in the muscle tissue 

of adult male offspring, suggesting that fetal alcohol

exposure has a long-term effect on the response 

to insulin.

Future Activities: 

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

In FY 2000, the total amount of funding for the

above-described six research areas was $536,000.
DMICC ANNUAL REPORT 31 FY 2000

The Veterans Health Administration (VHA)

The Veterans Health Administration is the largest

national integrated health care system. VHA’s 

mission is to decrease the prevalence of adverse

health outcomes in veterans with diabetes. This 

will be accomplished through systems-level integration of guidelines, performance measurement, and

data feedback in order to facilitate adherence to 

preventive and treatment measures. VHA reports the

following progress in FY 2000.

Current Activities:

• Performance Measurement (Office of Quality 

and Performance). In FY 1999, independent contractors from the External Peer Review Program

(Headquarters Performance Office) reviewed 

18,882 charts of veterans with diabetes. The mean

percentage of patients having chart documentation

of the following diabetes-specific measures 

within 12 months of chart review is as follows: 

(1) glycosylated hemoglobin test (93%); (2) foot 

ulcer risk screening examination, including visual

examination (96%), palpation of pulses (84%), and 

a sensory examination (78%); (3) dilated retinal

examination (67%); (4) nephropathy screening 

(44%); and (5) LDL-C measured (73%). Based on 

3rd quarter FY 2000 audits, HbA1c was <9.5% in 

87 percent and <8.0% in 63 percent; LDL-C was

<130 mg/dl in 72 percent, and BP was <140/90 in 

51 percent of veterans with diabetes and hypertension. VHA has adopted the Diabetes Quality

Improvement Project Measures.

• National Diabetes Registry (Office of Policy and

Planning). VHA has developed a nationwide 

diabetes registry consisting of all veterans with

diabetes identified through administrative codes,

pharmacy prescriptions, and hemoglobin A1c. A

conservative period prevalence for FY 1999 based

on HEDIS (Health Plan Employer Data and

Information Set) administrative criteria and pharmacy data is 16.3 percent, or 503,000. Based on

analysis of registry data, the mean HbA1c for 

FY 1999 was 7.65; and the mean LDL-C was 111

mg/dl. In addition to cardiovascular disease,

the cohort had a high prevalence of co-morbid 

conditions, including mental health conditions.

• Lower Extremity Amputation Reduction (Office 

of Policy and Planning). In collaboration with 

the Centers for Disease Control and Prevention’s

Division of Diabetes Translation, a 10-year Lower

Extremity Amputation (LEA) Registry has been 

created. From FY 1997 to FY 1999, the age-adjusted

rate of LEA has decreased from 2.61 to 1.65 per

1,000 VHA users (at least one clinical visit). Based

on the cross-sectional identification of individuals

with diabetes, the age-adjusted rate of LEA has

decreased from 8.48 to 7.48 per 1,000 users from 

FY 1998 to FY 1999.

• Guideline Development (Offices of Patient Care

Services and Quality and Performance). VHA, in

partnership with the Department of Defense,

issued a revision (February 2000) of its Diabetes

Clinical Practice Guidelines. The guidelines, covering outpatient management of glycemia, blood

pressure, hyperlipidemia, diabetic retinopathy,

foot care, and renal disease, are explicitly evidencebased in contrast to other existing guidelines.

Version 1.0 was developed in collaboration with 

the executive committee of the National Diabetes

Education Program.

• Research. From a programmatic perspective,

three additional Juvenile Diabetes Foundation/

VHA diabetes Centers of Excellence were funded.

VHA funded a 5-year cooperative study (CSP 465) 

to evaluate the effect of near normal glycemic 

control on cardiovascular outcomes in type 2 

diabetes. The Diabetes Quality Enhancement

Research Initiative has been funded for translational research, including education, foot care,

eye care, case management, and provider feedback. VHA is also a participant in the Department

of Defense Telemedicine Project for Non-Mydriatic

Retinal Examination in partnership with the 

Joslin Vision Center.
• Standardization of Glycated Hemoglobin Testing.

The Under Secretary for Health mandated that all

VHA facilities use methodology traceable to the

Diabetes Control and Complications Trial (DCCT)

standard as recommended by the National Glycosylated Hemoglobin Standardization Program.

• Education. VHA has 30 facilities that have obtained

American Diabetes Association Recognition of 

their patient education programs. VHA hosted the

2nd annual National Diabetes Symposium for 

endocrinologists and primary care providers, as

well as the annual VHA Diabetes Educators

Conference.

Future Activities: 

No additional diabetes-related activities 

were reported.

Funding for Diabetes Research: 

FY 2000 funding information was not provided.

DMICC ANNUAL REPORT 32 FY 2000
33

Diabetes Mellitus Interagency Coordinating

Committee (DMICC) Meeting

Type 2 Diabetes in American Indian and Alaska

Natives: Focus on Children

May 11, 2000

NIH Campus, Building 45 (Natcher), Room E1/E2

45 Center Drive

Bethesda, Maryland

MEETING SUMMARY

Welcome/Introduction/The DMICC: An Overview 

and the Charge for Today — Type 2 Diabetes in

American Indian and Alaska Native Children

Dr. Sanford Garfield, Senior Advisor, Biometrics and

Behavioral Science, National Institute of Diabetes

and Digestive and Kidney Diseases (NIDDK), welcomed all to the meeting and introduced Dr. Allen

Spiegel, the newly appointed Director of NIDDK.

Dr. Spiegel announced his role as chair of the DMICC,

following the departure of Dr. Richard Eastman. The

key to the DMICC, Dr. Spiegel explained, is coordination, which implies communication and partnership.

The Committee is well positioned to respond to a

recent Congressional mandate to address the issue 

of minority health disparities, including a focus on

diabetes in American Indian peoples. The goal of 

the current meeting is to concentrate on the disproportionate prevalence of this condition in American

Indian and Native Alaskan children and young

adults. The DMICC is positioned to play a role in

helping to bring advances in diabetes research,

many of which provide hope for improved diabetes

outcomes, by furthering communication through

established and developing partnerships with 

the Indian Health Service (IHS), Tribes, and 

Tribal leaders.

Tribal Blessing

Mr. Alvin Windy Boy, Sr., of the Chippewa Cree Tribe,

offered a Tribal blessing to guide the meeting 

participants and attendees in their presentations,

discussions, and deliberations.

IHS: Role in Tribal Health and Diabetes

Dr. Kelly Acton, Director, IHS National Diabetes

Program, opened her presentation by noting that 

the American Indian/Alaska Native population is

diverse in many waysæin traditions, cultures,

history, language, food, living environment, and governance, among many other facets. More than 550

Tribal groups are Federally recognized, reside within

34 States, and speak more than 200 different languages. About one-half of the Native American/

Alaska Native population live in urban areas; some

one-third live in poverty, as compared with about 

13 percent for the total U.S. population. As Dr. Acton

pointed out, the Native American/Alaska Native 

population is a growing one, with a 1994 population

of 2.2 million and a projected population of 4.3 

million by 2050. With this diversity and anticipated

growth, Dr. Acton commented, it is important to 

keep in mind that no one method or approach to

health care will work for all.

The Public Health Service (PHS) has overseen 

Indian health care, first through the Bureau of 

Indian Affairs and more recently through the IHS,

since 1955. The IHS is unique among government

health care-related agencies in that its mission is 

to elevate, through direct service mechanisms,

the health status of a specific population; unlike

many other government programs, such as Medicare,

the programs funded by IHS are not entitlements.

Dr. Acton noted that, overall, PHS/IHS has a positive

record in addressing, raising awareness about, and

assisting in ameliorating many serious public health

problems within the American Indian/Native Alaskan

population. However, for diabetes and other health

issues, the IHS is severely underfunded. The limited

budget authority and changing role of the IHS, whose
DMICC ANNUAL REPORT 34 FY 2000

major health-related programs have undergone

reductions with medical inflation and increased

administrative costs, can now meet only 30 to 40 

percent of the health care needs of the populations 

it serves. For example, the per capita health care

resources available for American Indians and Alaska

Natives through IHS is approximately $1,500/year

versus approximately $3,000/ year for Medicare

recipients; the actual annual costs associated with

treating diabetes average $5,000 to $9,000. Thus,

IHS funding for individuals with diabetes falls very

short of what is needed. Because many American

Indians and Alaska Natives live in rural settings,

they are isolated, which presents an additional 

barrier to receiving adequate and appropriate 

health care.

It has long been known that adults in the American

Indian/Alaska Native population have high prevalence rates of diabetes. National data on American

Indian/Alaska Native populations collected by the

IHS between 1991 and 1997 from 151 IHS service

units and analyzed by the Centers for Disease

Control and Prevention (CDC) reveal an increase in

the prevalence of diabetes in all of the age groups

during the time period studied. The greatest 

increases were found in adolescents aged 15 to19 

(up 32 percent), young adults aged 20 to 24 (up 36

percent), and in adults aged 25 to 34 (up 28 percent).

The increase seen in young men was about twice 

that seen among young women. Dividing up the

American Indian/Alaska Native data by region, it 

was apparent that the Alaskan region has the lowest

prevalence of diabetes in children, adolescents, and

young adults. All of the regions showed a steady

increase in diabetes between 1991 and 1997.

Several steps and actions have been taken in the 

past two decades to remedy health care issues 

and problems facing American Indians and Alaska

Natives. In 1979, Congress established the IHS

National Diabetes Program (NDP) in response to

research showing the very high prevalence of 

diabetes and related complications among Pima

Indians. This program, which extends to the entire

American Indian population, is based on standard

clinical and public health models. One key component of the NDP is the Diabetes Care and Outcomes

Audit, an ongoing audit that has been conducted

annually since 1987. The audit now includes 87 

different elements of standard of care, based on 

medical record reviews (e.g., foot exams, eye exams,

blood pressure, glycemic control, kidney function,

etc.). Outcomes measures are used as QA tools and 

as the means to identify gaps in care and outcomes

and practices to improve care. Dr. Acton noted that

lifestyle changes have a big impact on improving 

or at least maintaining the health of diabetics.

At present, the very limited per capita funds available to American Indians and Alaska Natives with 

diabetes are insufficient to provide many of the 

fundamentals, including medications, to stem the

effects and progression of the disease. The growing

number of Indian youth with diabetes is another 

critical issue that must be addressed.

The NDP needs additional staff and resources to

identify and study gaps and implement further

changes to improve outcomes. It is looking to the

NIH, CDC, and other entities to develop, and

strengthen, partnerships to assist in this endeavor.

The Tribes also are considering the 333 grant programs as an alternative resource to fund studies of

diabetes in Indians. Another newer approach that 

the Tribal population has undertaken to have a 

more direct role in the health care of its peoples

stems from the self-governance movement, which

was instituted as a demonstration project in 1989.

This movement has grown in the past decade,

and now more than one-half of all Tribes have contracted to provide their own health care. As this

movement has grown, however, the role of IHS 

has become less clear and less certain. Dr. Acton 

recognized the importance of the joint efforts of 

government agencies and Tribes and pointed to 

the Tribal Leaders Diabetes Committee as a good

example of such partnerships.
DMICC ANNUAL REPORT 35 FY 2000

The Tribal Leaders Diabetes Committee —

Description and Responsibilities

Mr. Windy Boy, Sr., Co-Chair of the Tribal Leaders

Diabetes Committee, echoed many of the points 

put forth by Dr. Acton about the importance of 

partnerships, such as the Tribal Leaders Diabetes

Committee; adequate funding for medical care and

research; self-governance and increased involvement

of Tribal leadership at all levels of Tribal life; and

understanding, retaining, and incorporating traditional ways, beliefs, and values into all aspects of

health care. As the self-governance movement has

grown, Tribal leaders are taking the initiative in

determining the best path for their people, with a 

key messages of “Go back” to traditions and to 

nature to keep mind, body, and spirit in balance.

The messages of the Tribal leaders focus strongly 

on lifestyle, which is known to be critical to 

influencing the development and management of 

type 2 diabetes. Although lifestyle changes must 

be made by an individual, the family, health care

providers, and community can serve as strong

sources of support and information. As with other

chronic diseases, most cases of type 2 diabetes 

have both environmental (e.g., lifestyle) and complex

genetic components. Thus, simpler messages such 

as “eat less, exercise more,” while helpful, will not 

be able to solve the entire problem.

To its credit, Mr. Windy Boy commented, NIH is 

moving forward in including as partners Tribal 

leaders and Tribal communities in discussions to

direct research and improve health and medical 

care of native peoples; this is especially important 

in the area of diabetes, which has been devastating

to Indians of all Tribes. It is important to keep in

mind, however, the different primary missions of 

the various health-related government agencies 

(e.g., NIH, CDC, IHS, FDA, AHRQ) with respect to

research; prevention, screening, and treatment; 

regulation and policy; public health; and 

educational and translation efforts.

Mr. Windy Boy outlined several steps taken by both

the Federal government and Tribal governments 

in the past 25 years to address health care among

Indian peoples. In the mid-1970s, President Nixon

signed a law allowing Tribes to contract health care

services with the IHS. In 1989, the self-governance

demonstration project, which gave Tribes flexibility

to redirect health care monies and services, was

launched. This program has grown and now includes

253 contracts or compacts, each of which is specific

to the contracting Tribe. In 1994, though a Planning

Grant from IHS, the self-governance health care 

contract budget allowances grew from $3.2 to $8 

million per year and expanded to include orthodontic care, pharmaceutical coverage, other health

disciplines, and Tribal health wards. These changes

overall have helped the diverse American Indian 

and Native Alaska populations to start to identify

and fill health care needs specific to each Tribe.

Diabetes in Alaska Natives

In this presentation, Ms. H. Sally Smith, Chair,

Bristol Bay Area Health Corporation; President,

National Indian Health Board; and member, Tribal

Leaders Diabetes Committee, summarized recent

changes in Tribal roles and responsibilities for 

health care systems and delivery, her traditional

upbringing in Alaska, and the dramatic changes in

Alaska Natives’ day-to-day lives that have occurred

in the past few decades.

Ms. Smith noted that the National Indian Health

Board (NIHB) serves 528 Tribal nations while

addressing 12 health areas and upholding all Tribal

government agreements. The initial Board was 

established in 1972 in an effort to improve Indian

health care and medical services. In the 1980s,

the IHS sought Tribal consultations to obtain feedback in continuing these efforts. In the 1990s,

the government elevated the level of these consultations and began to support the movement toward

self-governance. As Ms. Smith explained, Tribal 

sovereignty, through which Tribal nations seek to

protect their interests and engage in treaty making,
DMICC ANNUAL REPORT 36 FY 2000

has long been part of American history. In the 1880s,

the Federal government treated Indian Tribes as

quasi-independent nations, whereas in the 1990s,

the solid shift toward self-governance has allowed

for clear recognition of the many Tribes as 

independent nations that maintain their own constitutionally developed political and legal rights.

Contemporary Indian health problems, such as 

diabetes and kidney disease, which, in many Tribes,

occur at rates that are three to five times higher 

than the general U.S. population, are now being

addressed at a variety of levels through different

agencies (e.g., CDC, NIH, IHS) and private organizations (e.g., Juvenile Diabetes Foundation, American

Diabetes Association [ADA]). However, the lack of 

sufficient funds remains in question, and, as Ms.

Smith noted, the NIHB, among others, seeks a 300- 

to 500-percent increase in Federal health care funds

for Indian programs.

Alaska is home to 171 remote Indian villages, each

with an average of 100 to 400 residents. The location

of most of these villages in isolated, rural areas 

presents unique health care challenges and barriers

that make outreach and delivery of care and follow

up to diabetic patients difficult. Added to these challenges is that, despite their isolation, the villages 

and their residents are not immune to “Western”

influencesæsuch as a high-fat, high-sugar, low-fiber

diet; computer and video games; television; and

increased to exclusive reliance on motorized vehiclesæthat can adversely affect health and reduce 

regular physical activity.

The adoption of “Western” lifestyle is in stark contrast with the traditional lifestyle of Alaska Natives

just one or two generations ago, when farming and

fishing; high levels of physical activity, such as

kayaking, harvesting, and walking; and indigenous

foods of the land and sea, including low-fat caribou

and heart-healthy fishes, were integral to day-to-day

life. Today, Ms. Smith noted, even the smallest towns

have pizza parlors and take-out restaurants, and 

residents use airplanes, sport utility vehicles, and

snowmobiles as the prime modes of transportation,

which contribute to a sedentary lifestyle.

These lifestyle changes have had pronounced effects

on the physical attributes and health of many 

Alaska Natives. Through a series of slides, Ms. Smith

showed Natives of previous generations, who were

slender, lean, fit, and strong, even among the elderly,

in contrast with current generations of young and

older alike, who tend to be heavier and less fit. She

noted that the rate of diabetes among some Alaskan

Tribes in the 12 regions of the State has increased 

by 200 percent over the 13-year period between 1985

and 1998; type 2 diabetes in preteen Native Alaskans

is on the rise; and more diabetes cases are being

reported in outpatient clinics. As a regular service 

of the Indian health care system, community health

aides, including educators, nurses, and advocates,

supplement doctors’ care by meeting with diabetic

patients 2 weeks before the doctors’ visits to collect

blood and urine, answer questions, and provide 

other support as needed. With resources stretched 

to the limit, the Alaska Native compact as well as 

the NIHB welcome thoughtful input, support, and

resources, and encourage the continued growth 

of new and established partnerships.

Questions/Comments

In a brief break following the previous presentations,

Ms. Smith noted that 1993 was a key time for health

care for Alaska Natives. During this year, all Tribes 

in the State were brought together under the Alaska

Tribal Health Compact, which oversees the entire

Tribal health care system in Alaska. Through this

Compact, each Tribe can opt in or out of the Statewide system, giving each Tribe flexibility and the

opportunity to join in on local, State, and national

partnerships and collaborations. Many of the

changes made in health care in Alaska were initiated

in light of the positives associated with the selfgovernance movement and following nationalization

of the IHS budget, in which the Service’s shares 

and funds were divided among all Tribes.
DMICC ANNUAL REPORT 37 FY 2000

Currently, Dr. Yvette Roubideaux noted, approximately 47 percent of the IHS budget is under Tribal

control. However, in recent years, the IHS has experienced major program reductions and absorptions

and reductions in funds to support the remaining

programs. The level of funding has become very 

critical, especially when these program and financial

changes are considered in conjunction with medical

inflation, increased health care administrative costs,

and the growing importance of preventive care. As

noted by previous speakers, annual per capita diabetes funds through IHS are approximately one-half

of Medicare funds and only one-fifth of per capita

funds available through the VA system. Thus, not

only are funds insufficient for adequate diabetesrelated clinical health care but also providers interested in conducting even the simplest of research

studies must look elsewhere. Ms. Smith added that

many Tribes already have maximized alternative

financial resources, with the bulk of funds needed 

for staff time and patient treatment.

Dr. Spiegel acknowledged the importance and 

success of the shift in the role of IHS governance to

self-governance and agreed that, given the factors

cited, the IHS has had to severely ration health care

services and is able to meet only 30 to 40 percent 

of the current health care needs of American Indians

and Alaska Natives. An important next step is determining the effectiveness, including a cost-benefit

analysis, of primary prevention, which likely will 

be key in childhood diabetes. Dr. Spiegel noted the

recently appropriated diabetes seed money of $30

million for 5 years includes $2 million for prevention

and $11 million for treatment. Some attendees suggested using some of these funds to identify an inexpensive, simple, and practical screening test that

could replace the “gold standard,” the oral glucose

tolerance test. Others suggested using a portion 

of these funds to develop a plan to identify the 

messages, resources, and treatment and prevention

strategies to implement.

The Tribal Role in Research: 

Impact on Diabetes

The Honorable Malcolm Bowekaty, Governor, Pueblo

Zuni Nation, challenged the research community to

rethink its strategy, infrastructure, and agenda for

diabetes in general and Indian populations specifically. He noted the wealth of data already available

from the many descriptive, epidemiologic, basic,

and clinical research studies conducted over the 

past decades. These data should be sufficient to 

provide the fundamental ideas for a cure or, at the

very least, the tools and information necessary to

make significant progress to stem the epidemic of

diabetes (and related conditions, such as kidney 

disease) among American Indians, Alaska Natives,

other high-risk groups, and the population at large

as well. These tools include best practices and 

standards for clinical care and home-based care;

requiring higher standards for hospitals and 

service units; an increase in the number of available

dialysis machines; and the training of caring, knowledgeable, and culturally sensitive professionals.

He emphasized the need for NIH, in conjunction 

with Indian communities and leaders, to develop a

definitive diabetes research agenda with clear and

defined goals. To achieve this, Tribes should be

involved in all phases of the research engine, from

planning and design to implementation of a study 

to translation or research results into practice; 

Tribal input should be required before approval of

any projects that use Native peoples as participants.

The government and Tribes must work together to

foster a relationship based on deep trust and prosperity. The Zuni Tribe, a nation of approximately

9,200, have participated in numerous studies, Gov.

Bowekaty commented, sometimes at a high cost to

the participants or the community.

Gov. Bowekaty identified several strategies and

issues to consider for future projects and endeavors.

For example, funding should be increased for the

recruitment and training of minority researchers 

and to support minority research centers. For sample

size and data analysis and evaluations, researchers
DMICC ANNUAL REPORT 38 FY 2000

should strongly consider pooling data or establishing

collective data centers to increase statistical power

to obtain meaningful results. Educational efforts 

and materials should reflect competence, advocacy,

and cultural understanding, while being scientifically

accurate. Interagency coordination is key to ensuring

success.

Gov. Bowekaty pointed to a set of critical and interconnected issues associated with treating and 

curing diabetes among Indians of all ages. Reaching

youth should be a priority, with a primary focus 

on primary prevention and cure; ensuring a future 

of healthy adults benefits both individuals and the

community in many ways. The focus for adults,

who serve as role models, should be on quality of

life, prevention, and standards of care. For the 

elderly diabetic population, areas of concern are

maintaining quality of life, which, at this time,

includes dialysis. The roles of different agencies,

including the NIH, IHS, CDC, BIA, and Tribes, are 

varied. All agencies should be called on to provide

funding and to seek the best approach within the

agency infrastructure to reach a cure. Other primary

roles include the conduct of basic and clinical

research, establishing or enforcing standards of 

care, setting policy, and public health outreach and

education.

The ultimate goal of diabetes research and care

should focus on cure and treatment; tangible 

benefits can be achieved through revising standards

of care that will improve individuals’ quality of 

life as well as their medical condition per se. Gov.

Bowekaty stated that Tribes will support the moving

forward of research with merits for a cure and 

are highly motivated to participate in the review of

proposed research projects.

Navajo Nation Special Diabetes Project 

(Focus on Navajo Children)

Ms. Marla Jasperse, Executive Director, Navajo

Nation Division of Health, described this project,

which uses a collaborative, holistic model to better

understand the diabetic patient, that includes a 

focus on Navajo children. The “total health concept”

model that forms the basis of the Navajo Nation

Special Diabetes Project incorporates family, community, and traditional approaches to treatment 

and education using the components of spirituality,

knowledge, physical needs, emotion, and society.

It recognizes the importance of ascertaining the

existing habits of a Tribal community, how those

habits are linked to each other, what functions they

serve within the community, and what they mean.

This model provides for a better understanding of

the diabetic patient; increases collaborations

between health care providers, patients, the family,

and the community; maximizes resources; and allows

for an increased role for traditional treatment and

education. Under the spiritual component, the model

encourages the use of prayer and daily thanks for

well being; incorporates traditional therapies such 

as herbs and ceremonies; and emphasizes traditional

values, beliefs, spiritual teachings, and respect for

self and others. The knowledge component focuses 

on incorporating traditional teachings and education, defining diabetes and related conditions in the

Navajo language (e.g., “sugar disease”), and developing culturally appropriate educational materials.

Physical needs include a variety of aspects of daily

living, such as nutritious food, exercise, availability

of running water and electricity, and other physical

supports associated with a diabetes diagnosis. The

emotional feature of the model addresses an individual’s ability to accept or deny diagnosis, provides

for support groups, and recognizes the importance 

of family. Ms. Jasperse noted that the societal component is often the most difficult to develop and 

implement because it moves into and seeks support

through a variety of community venues, such as

supermarkets and restaurants (e.g., to help disseminate nutrition and health information), Tribal leader-
DMICC ANNUAL REPORT 39 FY 2000

ship involvement (e.g., coordinating regular walks

with the President of a Tribe, promoting an outreach

and health message), border town support, schools

(e.g., health promotion and disease prevention), and

different types of support groups.

Ms. Jasperse noted that the model, which has many

benefits to individuals and the Tribe at large, has

been introduced to and has seen great success 

within schools and communities as a preventive 

and educational strategy.

The IHS Diabetes Program: 

Special Program for Indians and Epidemiology 

of Type 2 Diabetes in Indian Children

During this presentation, Dr. Acton focused on two

key issues: the Balanced Budget Act (BBA) Grants

Fund and the extent of the IHS’s knowledge about

type 2 diabetes mellitus in children. The BBA Grants

Funds provides for a total of $33 million/year

(including a $3-million/year Interior Department

appropriation) over a 5-year period beginning in

FY98. The legislative intent of this program was to

establish a special diabetes program for Indians.

The program established a work group, the Tribal

Leaders Diabetes Committee, to advise the IHS and

other organizations about diabetes-related issues.

National efforts targeted toward American Indians

before the BBA Grants Fund consisted of a network

of 13 area diabetes consultants, 19 model diabetes

programs, and 333 diabetes grant sites that have

evolved and developed over 21 years.

The IHS recently surveyed grantees to evaluate its

diabetes programs, with a focus on new components

and results of these programs. In programs for the

target age groups, the survey found that approximately 50 percent of the programs target young

adults, 40 percent are geared toward adolescents,

30 percent focus on elementary school children,

20 percent are designed for Headstart or preschool

children, 50 percent focus on family members with

diabetes, and 40 percent target overweight youth.

Additional programs focus on providing nutritional

information to specific target groups; developing 

and implementing methods to increase physical

activity using BBA Grants Fund monies; and tracking screening, referrals, and treatment modes for 

diabetes complications associated with the feet,

eyes, dental/oral health, blood pressure, urine,

and protein metabolism. The IHS survey identified

several new or improved facets used to develop 

diabetes programs, including a diabetes team,

diabetes registry, diabetes clinic, chart audits, and

flow charts or flow sheets. Many IHS-supported 

diabetes programs also incorporate traditional

approaches, such as story telling and talking circles,

and 60 percent of the programs provide education,

outreach, and training to health professionals.

Survey respondents indicated that the two most 

significant barriers to implementing programs are

lack of space and difficulties in hiring new staff.

Expanding on her earlier presentation, Dr. Acton

summarized trends of IHS’s ongoing Diabetes Care

and Outcomes Audits, which have been conducted

annually since 1987 and now include 87 different 

elements for which data are collected using manual

medical record reviews (e.g., foot exams, eye exams,

blood pressure, glycemic control, kidney function,

and other measures). The audits use a systematic

random sampling of records from various IHS and

Tribal registries across the country; elements are

tracked by age of patients and follow the population

over time. One favorable outcome observed in all age

groups was improvement in hemoglobin A1c (HgbA1c), which serves as a measure of glycemic control.

Overall, however, the youngest persons had the worst

HgbA1c levels. The audits also demonstrate that the

prevalence of diabetes has increased across all age

groups since they began, with the greatest increase

in prevalence seen in youngest persons (ages 15 to

34) between 1991 and 1997. During this time, the

prevalence of diabetes increased by 32 percent, 36

percent, and 28 percent among those 15 to 19 years

old, 20 to 24 years old, and 25 to 34 years old, respectively. Among children under 15 years old, the prevalence of diabetes mellitus increased by 6 percent.

As Dr. Acton noted, these data clearly demonstrate

that diabetes is a growing problem among American

Indians, particularly in younger persons.
DMICC ANNUAL REPORT 40 FY 2000

National Indian Council on Aging: 

The Role of Elders

Mr. David Baldridge, Executive Director, National

Indian Council on Aging, provided background and

demographic information on Indian elders in this

country. Currently there are approximately 236,000

Indian elders and 550 Federally recognized Indian

Tribes in the United States. Some 80 percent of 

the Indian elders live west of the Mississippi River,

and 50 percent live in a rural setting. Ten percent 

of older Indians have no formal education, and 26

percent are high school graduates. Overall, Indian

elders are more likely to live in poverty than older

persons in other populations. The life expectancy 

for older American Indians also is less than that 

for other Americans; for example, Indians born in

1941 have a life expectancy of 51 years, compared

with a life expectancy of 65 years for white

Americans. This gap appears to be closing, however,

for younger persons. Indians born in 1989 or 1994

have a life expectancy of 71 and 72 years, respectively, compared with a life expectancy of 75 years

for whites born in either 1989 or 1994.

In continuing his presentation, Mr. Baldridge noted

that most Indian Tribes place high value and importance on family and community life and recognize

the integral role of elders in their communities.

He explained that there are many different ways of

“defining” or identifying elders within the Indian 

culture. Elders may be spiritual leaders of a Tribe,

possessing characteristics such as connectedness

and selflessness and following traditional ways.

Elders also may be cultural guardians who are a 

living history for a Tribe and who protect values 

and carry knowledge and the history of their ancestors. Tribal elders serve as role models who teach 

by example, who often have overcome significant

adversities, and who are self-reliant. A holistic

approach to medicine and health within Tribal life

recognizes and incorporates the physical, mental,

and spiritual aspects of an individual, family, and

community; supports strong family involvement in

home care; and stresses the importance of caregivers.

The IHS supports 145 health service units and 40

clinics that serve 350 Tribes. Although there are 12

Indian nursing homes, more than 90 percent of longterm care for Indians is done by family members.

Data show that more than one in five Indian elders

have type 2 diabetes and that in some communities,

more than one-half of Indian elders have this 

disease. Thus, Mr. Baldridge commented, the prevalence of diabetes among older Indians has reached

epidemic proportions. Efforts to increase awareness

and educate the general Indian population and

health professionals about this problem ideally

should focus on developing simple, clear, and culturally appropriate messages; using known and trusted

persons, such as family members and elder role 

models, to deliver messages and incorporate visual

learning into outreach programs. The IHS’s 5-year

diabetes education initiative involves developing a

comprehensive education program, training, pilot

testing the program, evaluating the results of the

pilot testing, and expanding the program to accommodate a larger audience.

To reverse the trend of increased prevalence of 

diabetes among Indian elders, and among Indians

overall, programs need to engage a variety of partners, including insurance providers, researchers,

Federal agencies, advocates, and families/communities. These partnerships can help create a holistic

approach that incorporates families, in-home care,

patient education, and benefits counseling.

Diabetes Research: The Pima Indians

Dr. Robert Nelson, Staff Clinician, NIDDK, described

the history and findings of the longitudinal population study in the Pima Indians of the Gila River

Indian Community in Arizona. He described past

studies and some current research issues, including

the extent of diabetes mellitus in children.

In the mid-1960’s, at the start of the longitudinal

study, Pima Indians lived in primitive conditions;

many did not have access to running water. At that

time, researchers found high levels of obesity and 
DMICC ANNUAL REPORT 41 FY 2000

a high rate of diabetes mellitus in the population.

Oral glucose tolerance testing (OGTT) revealed that

the prevalence of diabetes among the Pima was 

related to age and sex, with the greatest proportion

of affected persons (40 percent of men, 65 percent 

of women) over the age of 35 years. The overall prevalence of diabetes mellitus in the adult population

(about 50 percent for those 35 to 64 years old) is

higher than in other American Indian populations

(e.g., 29 percent among adult Navajo), and the prevalence of type 2 diabetes is increasing even in the

children. Increased exposure to diabetes in utero

appears to be at least partly responsible for the 

rising prevalence in Pima children.

The longitudinal population study includes anthropometric measurements, a medical history, EKG,

physical examination, and numerous lab tests (e.g.,

OGTT/glucose, lipids). Major accomplishments of 

the study include establishment of the criteria for

diagnosing diabetes mellitus, identification of insulin

resistance as specific to type 2 diabetes, and demonstration that infants who are breast fed are less 

likely to develop diabetes than those that are not

breast fed.

This study demonstrated that development of 

diabetes is a two-step process. The first step is transition from normal to impaired glucose tolerance,

for which insulin resistance is the main determinant. The second and later step is worsening from

impaired glucose tolerance to diabetes, in which 

the pancreas becomes unable to keep up with the

insulin demand. In addition, the study showed a 

significantly higher prevalence of type 2 diabetes in

children of mothers with diabetes during pregnancy.

The children not only developed diabetes more 

frequently but did so at an earlier age than those

whose mothers were not diabetic during pregnancy.

The study also found that exposure to maternal 

diabetes is on the rise.

Researchers found that the prevalence of end-stage

renal disease in Pima Indians was 75 times that in

U.S. whites, and the rate of kidney failure is rising.

In addition, detailed studies of kidney function

demonstrated high rates of glomerular filtration 

in those with diabetes. Intrauterine exposure to 

diabetes was associated with a twofold increase in

the risk of kidney disease.

American Indian Community Intervention

Dr. Jeanette Carter, Associate Professor, University of

New Mexico School of Medicine, was joined by two

other researchers from the University of New Mexico

(UNM), Ms. Marla Pardilla and Ms. Jackie Two

Feathers, in discussing the Native American Diabetes

Project, conducted by investigators at the UNM

School of Medicine. The study, which included adult

women in the state aged 18 to 88 years was initiated

after the discovery that mortality rates among 

Indian and Hispanic women with diabetes increased

markedly between 1958 and 1994, while rates for 

diabetic white women remained relatively stable.

In an effort to address and counter this trend, a 

comprehensive, multifaceted intervention program

was developed. The initial phase of the project

included holding community meetings, focus groups,

and in-person interviews (to collect baseline information) and producing a draft curriculum; the 

proposed program components were reviewed by

bilingual community members and pilot tested,

which resulted in additional changes to the program.

The key messages of the program and curriculum

were “Get more exercise,” “Eat less fat,” “Eat less

sugar,” “Together we can,” and “Stay on the path.”

The curriculum developed incorporated stories (e.g.,

“through the eyes of an eagle”), hands-on activities,

local and community functions, role-playing, and

prayers. The program was implemented using 

community members as “mentors” who taught the

various elements of the curriculum at neutral sites.

The study included three intervention arms: group

participation, one-on-one intervention, and “usual

care” (delayed intervention). Evaluation measures

included reviewing COOP charts, tracking food 

intake and level of physical activity, monitoring

HgbA1c levels, and following changes in exercise 

and diet and related factors (e.g., weight, height).
DMICC ANNUAL REPORT 42 FY 2000

A total of 206 persons were interviewed at baseline,

which was 1 year before the intervention phase

began. Study participants were matched according 

to age, duration of diabetes, and other relevant 

factors. Retention to the study was high (89 percent

following intervention), and 95 percent of participants reported high satisfaction with both the oneon-one and group interventions and expressed 

interested in having the program continue after the

study ended. Weight and glycemic control improved

among those in the focused intervention groups 

(one-on-one, group) but worsened or did not improve

among those receiving usual care. An unexpected

finding was that, among all participants, HgbA1c

decreased steadily with age, from 10.1 percent

among those 18 to 39 years old to 7.7 percent for

those over 70 years old. BMI (body mass index) 

also dropped as age increased; thus, the youngest

participants were the most obese and most out of

control. Findings from the study have been disseminated to local communities and nationally through 

a grant from the Bristol Myers Squibb Foundation.

The national ADA has incorporated the intervention

program into their Awakening the Spirit program,

an outreach to Native American Communities. To

date, 94 Tribal community teams have been trained

with 60% implementing the program. Future 

research includes evaluation of facilitating factors

and barriers to implementation.

NHLBI: Strong Heart Study

In her presentation, Dr. Barbara Howard, President,

MedStar Research Institute, outlined key points of

the Strong Heart Study (SHS), whose objectives are 

to measure rates of cardiovascular disease (CVD),

measure levels of risk factors for CVD, evaluate the

effect of diabetes on CVD, and follow up on and 

evaluate the determinants of CVD. Participants

include approximately 4,500 persons from 13 communities in Arizona, North Dakota, Oklahoma, and

South Dakota. Men and women 45 to 74 years old 

at the time of enrollment were eligible to participate.

Communities are involved in all phases of the study:

planning, recruitment, conduct of exams, and use 

of data. The participating communities receive 

several benefits from the study such as referrals for

health care, feedback to individuals on results and

educational materials, training, and updated

progress and status reports.

Phase I of the study ran from 1988 through 1991 

and included physical examinations and a

Community Mortality Study based on information

from death certificates. Phase II ran from 1991

through 1996 and included physical examinations

and surveillance for CVD and risk factors for all

Phase I participants using medical records reviews.

Phase II also continued the Mortality Study. Phase 

III began in 1996 and is slated to run through 2000;

it continued physical examinations and CVD 

surveillance on Phase I participants and initiated 

a Family Study, in which 30 families with at least 

30 members over the age of 18 years are studied

more extensively with respect to the other components of the larger investigation.

Participation rates overall have been good, with at

least 90 percent of the initial enrollees who are 

still alive still active in the protocol. Surveillance

results show that CVD and total mortality rates,

CVD incidence, and prevalence of atherosclerotic

plaques were higher among SHS participants than

whites and blacks combined from comparable NIHfunded population studies. The study found that 

cholesterol levels among American Indians are lower

than levels in whites and the general population,

but data indicate that LDL cholesterol is one of the

strongest predictors of CVD. For American Indians,

as LDL levels increased, the increase in risk for CVD

was higher than that for whites and the general 

population with the same LDL values. Rates for 

heart disease in Indians with diabetes were very

high and the greatest risk for CVD was for diabetics

with kidney disease. In addition, the study found 

that heart disease starts very early in life; because

risk for CVD and diabetes appear to be closely 

related, it is important to consider both diseases in

tandem for investigating, preventing, screening,

and treating these conditions, even in children.
DMICC ANNUAL REPORT 43 FY 2000

NIDDK: Type 2 Diabetes in Children Conference

and Future Directions

Dr. Barbara Linder, Program Director, Clinical

Endocrinology and Diabetes Complications Program,

NIDDK, provided an overview of the July 1999 July

DMICC meeting, which focused on type 2 diabetes 

in children, with an emphasis on African American,

Hispanic American, and American Indian youth.

Results of descriptive epidemiology studies indicate

that type 2 diabetes (T2D) in the pediatric population

is increasing at alarming rates in the three groups 

of interest. In contrast, the prevalence of type 1 

diabetes (insulin dependent diabetes mellitus) in

children has remained relatively stable over time.

Several presentations at the July 1999 DMICC meeting focused on diabetes in North American Indian

children. Dr. Kelly Moore, Acting Chief Medical

Officer/Area Diabetes Consultant at the Billings Area

IHS, described Canadian aboriginal data from Dr.

Heather Dean’s studies, in which the average age at

diagnosis of type 2 diabetes was shown to be 10 to

14 years, similar to other populations. These data

also show that the BMI for diabetic males is nearly

always above the 95 percentile and that type 2 

diabetes tends to be more common in females in 

this population, whereas type 1 diabetes tends to

occur equally in males and females. Another statistic 

indicated that 76 percent of Canadian aboriginal

children with type 2 diabetes have mothers with

diagnosed diabetes. Dr. Moore also compared the

Canadian data on diabetes with data collected from

the Pima Indians in Arizona. Most cases are first

diagnosed in Pima children between 10 to 19 years 

of age, with the gender ratio for type 2 diabetes

favoring females; recent data show relative increases

in male incidence of type 2 diabetes, however. In

addition, the Pima diabetes population shows a high

percentage of exposure to diabetes in utero, which 

is proposed to be a major risk factor in this population for the development of type 2 diabetes.

In a discussion of fasting insulin levels, Dr. Moore

presented data from the Canadian study showing

that about 62 of 103 (60 percent) study participants

have increased insulin levels. Hyperinsulinemia 

has been shown to be a good predictor for the 

development of type 2 diabetes in Pima children; 

the 10-year diabetes incidence rate is much higher 

in those children with elevated fasting insulin.

Frequency distribution data of fasting insulin and

fasting glucose levels show that Pima children have

markedly higher levels than do white children, with 

a marked rightward shift of the distribution curves.

Dr. William Knowler, Chief, Diabetes and Arthritis

Epidemiology Section, NIDDK, remarked during the

July 1999 meeting that diabetes prevalence in Pima

Indian adolescents, which is historically high, has

dramatically increased between 1976 and 1996. The

type 2 diabetes prevalence rate is now 8 to 10 times

higher than rates in comparable reference white 

populations from Rochester, Minnesota. Risk factors

for type 2 diabetes in the Pima population include

family history of diabetes; if only one parent has 

diabetes, the risk for the child is greater if the mother, rather than the father, has diabetes. The strongest

family risk factor, in fact, is in utero exposure to a

diabetic mother, rather than simply inheritance of

diabetes susceptibility genes. Dr. Knowler showed

that much of the recent increase in type 2 diabetes

prevalence is attributable to the increase in the 

proportion of Pima women who are diabetic while

pregnant. Another risk factor for type 2 diabetes 

is birth weight. Either very low or very high birth

weight markedly increases the risk for diabetes.

An independent risk factor for type 2 diabetes is 

bottle feeding.

Also during the July 1999 meeting, Dr. Heather Dean,

Professor of Pediatric Endocrinology and Metabolism

at the University of Manitoba, discussed several

regional studies on diabetes prevalence in aboriginal

populations in Canada (also known as First Nation).

The largest language grouping is the Algonquin,

which is Cree-Ojibwa; they also have the highest 

rate of diabetes. Diabetes prevalence is lowest in 

the Haida community in the west and in the Inuit

communities in the north. In contrast to the U.S.

Native American community, 70 percent of the First

Nation inhabitants live on reserves, not in urban
DMICC ANNUAL REPORT 44 FY 2000

areas. In Manitoba, there are 60,000 First Nation

inhabitants, 70 percent of whom live in small 

isolated villages in the north. Prevalence data from

the 1990s from three regional diabetes registries 

all show type 2 diabetes prevalence between 1.7 

per 1000 and 2.5 per 1000. Among three youth 

populations screened in the mid-1990s, prevalence

rates averaged around 16 per 1000, that is, about 

10 times higher than the prevalence rates from the

registry data.

Dr. Dean identified four research priorities for 

future investigations: (1) Development of standard

diagnostic criteria; (2) use of standard age groups

(e.g., 0–4, 5–9, 10–14, 15–19); (3) universal differentiation between type 1 and type 2 diabetes in 

registry databases; and (4) acceptance of standardized, uniform methods for large-scale, populationbased screening. She stressed that in screening 

initiatives in large populations, the protocols may

have to be more practical (e.g., capillary blood 

glucose vs. drawn blood, random blood glucose

instead of fasting blood glucose).

Dr. Linder also cited clinical reports from Dr. Dan

Hale, Associate Professor of Pediatrics at the

University of Texas Health Science Center at San

Antonio, Texas. Of 669 pediatric patients seen by 

Dr. Hale and another practitioner between 1990 

and 1998, 512 (77 percent) had type 1 diabetes; 123

(18 percent) had type 2 diabetes; and 34 (5 percent)

had other types, such as unclassified, atypical, and

maturity-onset diabetes of youth. During this time,

there was been a steady rise in the number of

Mexican American type 2 diabetes pediatric patients,

from approximately 2 per year to up to 30 per year.

A similar rise in type 2 incidence in the African

American and, only most recently, in the white communities has occurred. For the past 3 years, about 

40 percent of the new pediatric diabetes diagnoses

have been type 2, a substantial increase. Dr. Hale’s

data also show that although 100 percent of diabetic

Mexican American children aged 5 or under have

type 1 diabetes, 74 percent of all new diagnoses

among Mexican American children over 15 years 

old are for type 2 diabetes. A similar type 1/type 2

distribution is seen among African American 

children; a lesser trend is seen among whites.

Another small survey conducted by Dr. Hale was

based on data obtained through screening of about

1,500 children at three public middle schools in 

San Antonio. Nearly 60 percent of children surveyed

had a family history of diabetes; 40 percent of the

boys and 27 percent of the girls had a BMI greater

than the 95 percentile; 29 percent had fasting hyperinsulinemia; 19 percent had acanthosis nigricans; 

7 percent had impaired fasting glucose; and 1 percent had undiagnosed diabetes (presumably type 2).

These children also had an adverse risk profile for

coronary artery disease. Approximately 50 percent

had elevated total cholesterol; 29 percent had a 

family history of hyperlipidemia; 27 percent had 

elevated triglyceride levels; 11 percent had a family

history of myocardial infarction under the age of 

50 in a parent or grandparent; 8 percent had low

HDL cholesterol; 7 percent had high LDL cholesterol;

and 3 percent of the girls and 15 percent of the boys

had diastolic blood pressures greater than the 95

percentile for their age.

Dr. Linder summarized findings of a study by Dr.

Lawrence Dolan, of the Children’s Hospital Medical

Center of Cincinnati, which included data on 128

pediatric patients diagnosed with type 2 diabetes

between 1992 and 1998; the study population is 

predominantly African American and female. As of

December 1998, the overall prevalence of type 2 

diabetes for the greater Cincinnati area was 0.14 per

1,000 (0.014 percent) for children up to 19 years old;

the children with type 2 diabetes tend to be female,

African American, and in older adolescence (aged 15

to19). The overall incidence rate of type 2 diabetes

increased greatly during 1992 and 1994; since then,

the incidence rate has been relatively stable. Overall,

Dr. Dolan’s data show the average age for children

with type 2 diabetes is 15.1 years, which does not

vary much by gender or race. The average BMI is 

36.3 (again no real difference by gender or race).

Acanthosis nigricans is present in 71 percent of the

population (African Americans, 82 percent; whites,

54 percent).
DMICC ANNUAL REPORT 45 FY 2000

Many of these children exhibit complications common to type 2 diabetes, including blood pressure

above the 90 percentile (corrected for age and height)

in a fair number of the 66 patients for whom data

were available; a statistically significant relationship

between systolic pressure and BMI was observed.

Further, among 27 patients tested, 23 (85 percent)

had at least one lipid abnormality (elevated LDL,

triglycerides, or cholesterol; or low HDL): 14 among

17 of the African Americans (82 percent) and 9 

among 10 (90 percent) of the non-Hispanic whites.

Among the 11 children with type 2 diabetes whose

albumin excretion rate was checked to screen for 

diabetic nephropathy, 3 (27 percent) had elevated

excretion rates (greater than 20 g/min as measured

by timed overnight urine collection), signaling 

possible incipient nephropathy. Ophthalmologic

abnormalities, such as retinopathy, were not seen 

in this population.

Dr. Dolan reported during the July 1999 DMICC 

meeting that within the diabetes center at the

Cincinnati Children’s Hospital, there has been no

change over time in the diagnostic criteria for type 2

diabetes, the ethnic pattern of referrals, or the referral patterns by the practicing physicians. However,

Dr. Dolan asserted that the hospital’s patient database is probably a significant underestimate of the

overall type 2 pediatric diabetes disease process.

Evidence for this statement included Dr. Dolan’s

review of the chief complaint of patients on hospitalization: only 59 percent had the classic symptoms 

of polyuria and polydipsia; 40 percent had nonclassic

symptoms, and 13 percent presented only with a 

positive urinalysis for glucose, obtained during a

routine physical examination.

Dr. Linder similarly highlighted results of studies

conducted by Dr. Silva Arslanian, Professor of

Pediatrics at Children’s Hospital of Pittsburgh. In 

one series of experiments, a hyperglycemic clamp

was used to compare the amount of insulin secreted

over 120 minutes while blood glucose was clamped

at a constant, hyperglycemic level of 225 mg/dL 

in a group of healthy African American and white 

adolescent volunteers. Data showed that for the 

same glucose level, African Americans on average

secrete significantly more insulin than do whites.

From these experiments, Dr. Arslanian derived an

insulin sensitivity index for each of the volunteers;

insulin sensitivity was approximately 35 to 40 

percent lower in the African American adolescents

than in their matched white peers.

Additional experiments using CAT scans revealed

that insulin sensitivity (controlling for BMI) is less 

in girls than in boys and is inversely proportional

both to BMI and to total percent body fat. Fasting

insulin levels, a marker of insulin resistance, also as

expected, increase with increasing BMI, even when

measured in normal nondiabetic children. Further

data showed that insulin sensitivity declines (and

fasting insulin levels increase) with increasing 

percentages of either visceral or subcutaneous fat 

(as a proportion of total body fat); however, the

impact of excessive visceral fat was more deleterious

than the impact of subcutaneous fat. Dr. Arslanian’s

findings suggest that the onset of puberty is associated with insulin resistance and that gender differences in insulin sensitivity need further evaluation

with careful attention to body composition differences. For young children (10 years) with a family

history of diabetes, insulin resistance is lower still

and is seen before the onset of puberty, with peak

insulin resistance occurring at 13 to 14 years of age.

Dr. Linder emphasized the collective importance of

these findings, which suggest the need for accurate

population-based screening among children. The 

key research goals identified during the July 1999

DMICC meeting included:

• Gather better population-based incidence and

prevalence data in children and adolescents

• Define initial metabolic abnormalities in 

type 2 diabetes

• Improve our understanding of the basis for racial

and ethnic disparities in diabetes

• Develop effective primary prevention and 

treatment regimens and strategies.
DMICC ANNUAL REPORT 46 FY 2000

In brief, the increasing prevalence of type 2 diabetes

and related complications among young persons

from childhood through their 30s, combined with 

the duration of the disease, signal a significant 

public health issue for this country that must be

addressed aggressively.

CDC: State Programs and Tribal Peoples 

with Diabetes

Dr. JoAnne Pegler, Liaison, National Diabetes

Prevention Center, CDC, provided a brief overview 

of some of the CDC’s activities that relate to diabetes

in children and Tribal peoples. The CDC’s primary

role in health care is to take a lead in addressing

public health issues. The Division of Diabetes Translation, for example, is responsible for translating 

diabetes research findings into practice and disseminating this information as extensively as possible.

Part of the CDC’s role in addressing public health

issues also involves efforts to close gaps in health

disparities. The CDC has a long-standing relationship with IHS and is a partner with IHS in providing health-related services, in the new Diabetes

Prevention Centers (at the University of Mexico,

1 Tribal college, and other locations), and the U.S./

Mexico Border Project. The agency also oversees 

diabetes programs in all 50 States. Dr. Pegler

announced that the CDC, in conjunction with the

NIH, expects to release an RFA focused on type 2 

diabetes in children sometime in late summer or fall

2000. The CDC also is sponsoring a regional conference on type 2 diabetes in children in New Mexico

from August 28 through 31.

NDEP: American Indian and Alaska Native

Programs

As Dr. Yvette Roubideaux, Clinical Assistant

Professor, College of Public Health, University of

Arizona, explained, the National Diabetes Education

Program (NDEP) is a joint program of the CDC and

NIDDK/NIH that includes public and private sector

partners. The initial NDEP was challenged with

developing educational messages that would reach

diverse cultures. In the face of that challenge, the

Program established several special work groups,

including the American Indian Work Group, to 

assist the larger NDEP in disseminating important

research findings and developing culturally appropriate diabetes education messages and products.

Other work groups focus on issues unique to 

African Americans, Hispanic Americans, and Asian

Americans/Pacific Islanders.

The NDEP American Indian Campaign has developed

special messages intended for American Indians 

and Native Alaska populations using a broad-based

media campaign that includes television, radio, print

materials, community partnerships, the Internet,

and toll-free telephone access. Key messages include

“Control your Diabetes. For Life” and “Control your

Diabetes for Future Generations.” The campaign

materials have been distributed to all 333 Indian

health grant programs, and the program has received

awards for the TV spots.

Continuing challenges include the increasing 

burden of diabetes in Indian populations; increasing

demands for educational materials; the increasing

need to reach out to children, families, and communities; continuing development of creative,

informative resources, products, and messages to

disseminate; and identifying resources to evaluate

campaign outcomes.

More immediate future activities of the NDEP

American Indian Campaign are the continued dissemination of current materials and the development

and expansion of a youth focus for children aged 

12 to 18 years.
DMICC ANNUAL REPORT 47 FY 2000

ADA/American Indian Program —

Awakening the Spirit: Pathways to Diabetes

Prevention and Control

Ms. Lorraine Valdez, Nursing Consultant, IHS

National Diabetes Program, described the ADA’s

American Indian Program, “Awakening the Spirit—

Pathways to Diabetes Prevention and Control.”

This program, developed by Native Americans in

partnership with volunteer ADA Diabetes Educators

and the ADA Native American Program Design Team,

was established in 1997 and launched in 1999 with 

a Powwow attended by more than 200. The main 

messages of the program are “Strong in Body and

Spirit” and hope that diabetes mellitus can be

delayed or prevented. The program’s primary goals

and objectives include disseminating messages,

providing interventions to ADA staff and Tribal 

communities, developing working relationships with

ADA and others, and increasing awareness among

Tribes of ADA as a resource and partner. Ms. Valdez

noted that early stages of the program were

described through a series of articles in the ADA

magazine, Diabetes Forecast.

Future Directions: Type 2 Diabetes in American

Indian and Alaska Native Children

Drs. Garfield and Spiegel thanked the presenters 

and attendees for their participation, time, and 

input. Dr. Spiegel then noted several upcoming 

NIH activities, including the July 18th meeting on 

the possibility of developing and implementing a

National Kidney Disease Education Program 

(NKDEP) that would mirror the NDEP and similar

programs; the upcoming release of several RFAs 

for research on type 2 diabetes; and NIH’s development of a strategic plan to reduce health disparities,

of which NIDDK’s plan emphasizing diabetes and

obesity is a significant component.

Mr. Buford Rolin offered concluding remarks on

behalf of the Tribal Leadership Support Group.

Recognizing the integral role of partnerships in

improving health care, he thanked all who attended

the meeting and expressed interest in continued

efforts to work together to eliminate the devastating

effects of diabetes.

Adjournment

Dr. Allen Spiegel adjourned the meeting at 4:20 p.m.

49

PARTICIPANTS

Patricia Bryant, PhD

National Institute of Dental and Craniofacial

Research

Joan Chamberlain

National Institute of Diabetes and 

Digestive and Kidney Diseases

Yen-pin Chiang, PhD

Agency for Healthcare Research and Quality

Richard Eastman, MD

National Institute of Diabetes and 

Digestive and Kidney Diseases

Michael Engelgau, MD, MS

Centers for Disease Control and Prevention

Valerie Gamache, MBA

HealthCare Horizons, Inc.

Sanford Garfield, PhD

National Institute of Diabetes and 

Digestive and Kidney Diseases

N. Krish Krishnan, PhD

Center for Scientific Review

Louis Emmet Mahoney, MD, DrPH

Center for Quality Health Resources 

and Services Administration

Philip Sheridan, MD

National Institute of Neurological 

Disorders and Stroke

Elizabeth Warren Boulton, RN, MSN

Hager Sharp

SPEAKERS

Kelly Acton, MD, MPH

Indian Health Services

John Eisenberg, MD

Agency for Healthcare Research and Quality

Barbara Fleming, MD, PhD

Health Care Financing Administration

Sheldon Greenfield, MD

New England Medical Center

Roland Hiss, MD

University of Michigan Medical School

Richard Kahn, PhD

American Diabetes Association

Leonard Pogach, MD, MBA

Department of Veterans Affairs

Frances Stewart, MD

Department of Defense

Dorothy Tucker, MBA, MSW, MA

National Committee for Quality Assurance

Diabetes Mellitus Interagency Coordinating

Committee (DMICC) Meeting

Federal Implementation of the Diabetes Quality

Improvement Project (DQIP)

January 14, 2000

8:30 am – 4:00 pm

Holiday Inn – Bethesda

Bethesda, Maryland
DMICC ANNUAL REPORT 50 FY 2000

Welcome and Introductions

Richard Eastman, MD, Chairman, Diabetes Mellitus

Interagency Coordinating Committee (DMICC),

and Director, Division of Diabetes, Endocrinology,

and Metabolic Diseases, National Institute of

Diabetes and Digestive and Kidney Diseases (NIDDK),

National Institutes of Health (NIH), welcomed all 

in attendance. He noted that Dr. Nancy Miller from

the NIH Office of the Director and Dr. Allen Spiegel,

the newly appointed NIDDK Director, were unable 

to attend the meeting.

Overview of the Meeting

Barbara Fleming, MD, PhD, Senior Clinical Advisor,

Health Care Financing Administration (HCFA),

provided a brief history of the Diabetes Quality

Improvement Project (DQIP), which has developed

into a collaborative effort to improve the care of 

diabetes and the quality of life for patients with 

diabetes. DQIP’s initial goals in striving to improve

care include the development of a single set of 

comprehensive performance measures for diabetes

from which national standards could be identified,

the ability to compare standards of care across 

multiple health settings, and the identification of

best practices that then could be disseminated

throughout the health care community.

The three key points to understanding DQIP are that

the DQIP measures (1) are not guidelines but rather

performance measures that serve as indicators to

assess care and provide a strategy for accountability,

(2) have more rigorous criteria than do guidelines,

and (3) are in wide use in a variety of health care

plans and settings. Approximately 400 managed care

plans in the commercial and Medicare markets will

be collecting and publicly reporting DQIP measures

data in the year 2000. In addition, HCFA is collecting

data on three of the DQIP measures in fee-for-service

plans that have contracted with Medicare for all 

beneficiaries in all 50 states.

In 1997, HCFA assembled a core group of producers

and users of diabetes performance measures 

and provided funding for DQIP. The DQIP Steering

Committee included HCFA, the Department of

Veterans Affairs (DVA), the American Diabetes

Association (ADA), the American College of 

Physicians (ACP), the American Academy of Family

Physicians (AAFP), the Foundation for Accountability,

and the National Committee for Quality Assurance

(NCQA). The Steering Committee selected 15 experts

in diabetes and measure methodology who, under 

the leadership of Dr. Sheldon Greenfield of the 

New England Medical Center, produced the DQIP

measures for diabetes care for patients aged 18 to 

75 years. These measures, developed using three

major criteria—evidence to support the measure;

ability to collect the measures feasibly, accurately,

and reliably; and existing variability among 

physicians and practices in performance of the 

measures — include:

• Hemoglobin A1c (HbA1c) tested

• Poor control (HbA1c>9.5)

• Eye exam performed

• Lipid profile performed

• Lipids controlled (LDL <130 mg/dL)

• Kidney status monitored

• Blood pressure controlled

• Foot exam performed

More than 200 individuals or groups provided comments on this set of eight measures, which were

released in August 1998. Dr. Fleming re-emphasized

that the performance measures developed by the

DQIP panel are just that — measures, not guidelines.

They are based on both the state of evidence and 

the state of practice. DQIP provides a conceptual

framework for the development of future measurement systems both in its approach to content and

partnerships. The existence of a single set of broadly

accepted performance measures allows for valid

comparison of diabetes care across diverse health

care settings for the first time for any disease.

This strategy provides opportunities for meaningful

benchmarking and accountability and enhanced

quality improvement (QI) while simultaneously
DMICC ANNUAL REPORT 51 FY 2000

reducing burdens on physicians and providers.

Growing interest in DQIP has led to the expansion 

of the initial DQIP partnership base, which now

includes several Federal and private sector partners.

Dr. Fleming noted that Health and Human Services

(HHS) Secretary Dr. Donna Shalala has asked Federal

agencies to commit to these measures and implement

ways to collaborate on DQIP as Federal agencies.

The current meeting is part of that commitment.

Six of the eight measures have been incorporated

into Health Plan Employer Data and Information 

Set (HEDIS) 2000 and will be reported publicly for

Medicare, Medicaid, and commercial plans during

2000. HCFA is using claims data to generate three

measures that can be obtained for all beneficiaries 

in the fee-for-service setting. A variety of other

organizations and agencies also are using the DQIP

measures. In addition, HCFA, the ADA, and the

American Association of Health Plans have developed

extensive materials in support of DQIP, including

standardized software and paper collection tools,

a data analysis package, training materials, and 

QI tools.

Results of the New York State PRO Pilot Study, which

is examining the performance of measures in different health care settings, found that an average of 37

percent of diabetics had their blood pressure under

control, 42 percent received foot exams, 41 percent

received eye exams, and 34 percent were monitored

regularly for nephropathological changes. The overall results of this pilot study indicate that there 

are many opportunities for improvement in delivery

and receipt of care and that care varies considerably across HMOs and fee-for-service vendors.

The Minnesota PRO, which covers older Medicaid

patients in eight plans within the state, also is 

monitoring DQIP measures. One interesting finding

was that a relatively high proportion of diabetics

(mean of 72 percent) received an A1c test during 

the reporting period. However, data also show that

approximately 39 percent of diabetics tested had 

an A1c level greater than 9.5.

DQIP is an ongoing process that will continue to

evolve and develop as changes and advances in 

evidence and practice occur. Data collected thus far

show room for improvement in all measures. HCFA 

is funding DQIP 2.0, which includes a re-evaluation

of the current DQIP measure set that will accommodate changes based on new, compelling data and

the state of practice for diabetes care.

DQIP: A Translation of Research into Practice

John Eisenberg, MD, Director, Agency for Healthcare

Research and Quality (AHRQ, formerly the Agency 

for Health Care Policy and Research/AHCPR), and

Operating Chair, Quality Interagency Coordination

(QuIC) Task Force, opened his presentation by 

recognizing that historically there have been few

standardized, validated performance measures 

for diabetes. However, DQIP has helped to address

this gap by using a “bench to benchmarking”

approach in developing a set of standards for practice. The DQIP program represents the translation 

of research into practice. Biomedical research and

clinical trials sponsored by NIH led to outcomes 

and effectiveness research sponsored by AHCPR,

including the Diabetes Patient Outcome Research

Team (PORT) at New England Medical Center.

These studies documented the relationship between

process of care and outcomes in diabetes, and led 

to the design of performance measures that were

tested by HCFA’s PRO program.

As stewards of public money, HCFA and other 

Federal agencies are using DQIP to bring together

and establish new partnerships to amplify the program’s message and as leverage to move the health

care system and, thus, patient care forward. The 

various Federal agencies involved in DQIP have 

different roles in this and other health care efforts.

The Federal Government plays many roles in 

health care quality that are exemplified by DQIP —

conducting and sponsoring basic and clinical

research (e.g., NIH), sponsoring and conducting

health services research (AHRQ), delivering services

(e.g., DVA), purchasing services (e.g., HCFA, Office 
DMICC ANNUAL REPORT 52 FY 2000

of Personnel Management, Indian Health Service

[IHS]), regulation (Food and Drug Administration

[FDA]), and surveillance and public health (Centers

for Disease Control and Prevention [CDC]). DQIP 

provides a mechanism to bring together these 

activities not only within the Federal system but 

also across the private sector.

The QuIC was established by President Clinton to

enable Federal agencies with health care responsibilities to coordinate their activities to:

• Measure and improve quality of patient care

• Provide beneficiaries with information to assist 

in making choices regarding care

• Develop the infrastructure needed to improve 

the health care system

QuIC participants include DVA, Department of

Defense (DoD), several divisions of HHS, the

Department of Labor (which regulates OSHA and

ERISA), OPM, the Office of Management and 

Budget (OBM), the Coast Guard, the Federal Bureau

of Prisons, the Federal Trade Commission, the

Commerce Department, and the National Highway

Transportation and Safety Board (NHTSB).

Interagency coordination is expected to assist in

identifying and implementing evidence-based,

validated performance measures, including measures for diabetes care, and eliminating redundancy

and overlap across agencies. To that end, the 

QuIC Task Force has focused on efforts to improve

quality care among patients, emphasizing performance practice measures in the following areas:

• Diabetes care (QuIC’s first major project for 

interagency collaboration)

– Evaluation of common guidelines for care 

between DVA and DoD

– Conferences to identify successful strategies

– Agreement among Federal agencies to collect,

compare, and report the performance of 

providers with respect to DQIP measures

• Depression diagnosis and care

• Reduction in medical errors

• Evaluation of the effects of working conditions 

on quality of care provided by health care workers

The QuIC Task Force will continue to take steps to

demonstrate how DQIP improves patient care and

quality of care.

DQIP: A History and the Measures

Sheldon Greenfield, MD, Professor of Medicine, Tufts

University School of Medicine, New England Medical

Center, provided a “case study” of DQIP as a collaborative effort — involving HCFA, ADA, AAFP, DVA,

CDC, NCQA, and ACP — to develop a comprehensive

set of measures for diabetes. He emphasized the

importance of gathering data and support for 

DQIP before the project was formally launched by

multiple agencies and the private sector. He cited

Drs. Eastman, Fleming, and Kahn as instrumental 

in this effort.

The primary features of DQIP measures were 

outlined by Dr. Greenfield. As he explained,

the measures and DQIP itself:

• Are comprehensive and cover all aspects of 

diabetes and diabetes care

• Emphasize both process and outcome and strive 

to identify the optimum process to achieve the 

best patient outcomes

• Identify risk according to case mix and subgroups,

based on both frequency of a measure within a 

certain population and threshold variation

• Address accountability (i.e., for what can physicians fairly be held responsible) and improvement

(i.e., seek continuous improvement in patient care

and status by setting goals higher)

• Are “politically” sensitive within the context of

diverse clinical setting, practices, and health care

delivery systems
DMICC ANNUAL REPORT 53 FY 2000

DQIP measures may be used as potential predictors,

or as a gradient, of risk for adverse conditions associated with diabetes. Following this general background, Dr. Greenfield provided data and applications

of several of the eight DQIP measures. For example,

for the HbA1c test, which indicates glycemic control,

providers are expected to report the percentage of

patients receiving at least one test during the reporting year, the percentage of patients whose most recent

HbA1c level is greater than 9.5 percent, and the mean

and distribution of patients with HbA1c levels in 

five categories (<7.0 percent, 7.0–7.9 percent, 8.0–8.9

percent, 9.0–9.9 percent, >10 percent). The first two

reporting values allow for accountability, whereas 

the third serves as a mechanism to track internal QI.

Another DQIP measure involves tracking the percentage of patients receiving an eye exam (as a proxy 

for a dilated eye exam) by an eye care professional

(i.e., optometrist or ophthalmologist) in the reporting

year, or in the year prior to the reporting year if the

patient meets two of the following criteria: is not

taking insulin, has an HbA1c less than 8.0 percent,

and/or has no evidence of retinopathy in the previous

year. Implementing this measure should improve

patient outcome and provider accountability as well.

Monitoring serum lipids involves collecting information on the percentage of patients receiving a 

lipid profile test during the reporting year or prior

year and the percentage of low-risk patients whose

most recent LDL is less than 130 mg/dL; these 

measures allow for accountability.

Urine proteins are used to monitor diabetic nephropathy based on either the microalbuminuria test or

medical recognition of nephropathy, which requires

certain criteria to be met. These measures are

designed to promote accountability among providers.

The DQIP accountability measure for blood pressure

involves tracking the percentage of patients whose

most recent blood pressure reading is <140/90.

Tracking foot care and foot examinations remains a

challenge in large part because such aspects of care

of diabetic patients are not documented regularly by

doctors in patients’ charts. In addition, controlled

studies of foot care in diabetics are absent. A patient

survey is being field tested to evaluate the DQIP

measure of a regular foot examination.

In summary, eight DQIP measures were finalized in

1998; the complement of patient-derived measures 

is expected to be finalized in 2000. These measures

may be revised, and other measures (e.g., immunizations, education, functional status, satisfaction) may

be added over time, pending new evidence and/or

improved practices. The current DQIP measures are

comprehensive and continued success and improved

quality will require collaborations among agencies

and between the public and private sectors.

DQIP and the Private Sector (Part 1)

Richard Kahn, PhD, Chief Scientific and Medical

Officer, ADA, highlighted the ADA’s Recognition

Programs, which have served as vehicles for the

development and implementation of standards of

care and measures for diabetes care. In the early

80’s, the diabetes community began efforts to develop “National Standards for Diabetes Education.”

This effort received its primary support through the

now-defunct National Diabetes Advisory Board. In

1986, the ADA launched its “Education Recognition

Program.” Over the next 1 to 2 years, the ADA began

development of clinical practice recommendations,

and in 1988, released the first standards of medical

care for persons with diabetes.

In 1993, the Association convened a task force to

determine whether diabetes quality care could be

assessed in a doctor’s office. The task force decided

that such an assessment was possible, by reviewing

medical records from physicians’ offices to determine adherence to the standards of care. The task

force also recommended that the ADA establish a

program to recognize professionals who were 

meeting the medical standards.

The issue of assessing delivery of care within a 

practice was revisited in 1995, when the Association
DMICC ANNUAL REPORT 54 FY 2000

distilled the somewhat lengthy, narrative standards

into a list of approximately 150 action items. The 150

bulleted items were distilled further into 12 measures, and ADA evaluated the measures by conducting

a study at 29 difference practice sites around the

country. An evaluation of the study data resulted in 

a total of 11 measures being adopted as part of a

newly implemented “Provider Recognition Program.”

As Dr. Kahn noted, there is considerable overlap

between the original 11 ADA measures and the current DQIP measures. The original 11 ADA measures

(annual unless noted otherwise, depending on

patient-specific criteria) include Hb1Ac (proportion 

of patients at <8 percent or > 9.5 percent), eye exam

within the past year, annual foot exam, blood pressure (proportion < 140/90), nephropathy assessment

within the past year, lipid profile (proportion with

LDL <130 mg/dL) within the past year, tobacco 

status and counseling, self-management education,

medical nutrition therapy, self-monitoring of blood

glucose, and patient satisfaction. The first seven 

of these measures were similar to the current

Diabetes Quality Improvement Project measures.

All measures are weighted, for a total possible 

maximum score of 110 points; a score of 82 or 

better is needed to achieve ADA recognition.

Recently, however, ADA modified its measure to 

be entirely consistent with DQIP’s measures.

The ADA’s Provider Recognition Program (PRP) was

launched in February 1997. Approximately 1,400 

doctors at 200 sites across the country have been 

recognized by ADA; about 35 percent of the physicians are generalists, and 65 percent are specialists.

An additional 2,000 plus practices have requested

applications for the PRP. The program is voluntary

and offers no financial incentives to participate or

achieve recognition. The future goal of the PRP is to

provide a “carrot” for provider QI. Dr. Fleming stated

that HCFA will be assessing thousands of practices

based on HEDIS and DQIP measures; the PRP is 

an advantage for those who follow measures. HCFA

is also looking to develop a reward or incentive 

program through Medicare. Dr. Kahn estimates that

some 5,000–10,000 physicians across the country

could qualify for PRP.

DQIP and the Private Sector (Part 2)

Dorothy Tucker, MBA, MSW, MA, Senior Health Care

Analyst, NCQA, reported on NCQA’s accountability

program regarding DQIP measures. As Dr. Fleming

noted, NCQA has played, and continues to play, an

important role in encouraging private health care

vendors and providers to implement DQIP measures

and to establish an accountability system using

these measures to improve patient care. NCQAæa

partnership of managed care plans, public health

professionals, patient advocates, and othersæalso

monitors and tracks improvements and problems

within the health care system. The Committee is 

part of the Performance Measurement Coordinating

Council, which is involved in collaborative efforts 

to reconcile clinical guidelines and recommendations. This Council includes NCQA, the Joint

Commission on Accreditation of Healthcare

Organizations, and the American Medical

Accreditation Program and started out in the area 

of diabetes on the strength of DQIP. Application 

of DQIP in practice, in health plans, and in the 

acute care setting are among the Council’s goals 

for guiding and improving diabetes care.

NCQA’s two core products include accreditation,

defined as an assessment of the core systems within

managed care plans on which high-quality care and

services depend, and HEDIS, through which NCQA

uses six of the eight DQIP measures to assess actual

results achieved by health plans. Accreditation

includes onsite reviews and surveys of health plans

based on specific criteria and expectations around

standards, infrastructure, processes, and systems.

Through recent initiatives and the addition of new

measures, NCQA can now assign plans with commendable and excellent accreditation. Accountability,

as measured, for example, through public health 

statistics and comparisons across health care plans,

is the key foundation of NCQA’s activities in its 

interactions with private health care providers.

NCQA has found wide variations in performance and

measures, often on a regional basis. The Committee

currently is focusing on understanding the factors

driving these differences (e.g., provider education,
DMICC ANNUAL REPORT 55 FY 2000

standard practice, socioeconomic issues) and 

identifying and developing policies that address 

and would reconcile such disparities.

NCQA’s accreditation and accountability are integrated with HEDIS measures and statistics. Ms. Tucker

pointed out the NCQA currently is the only accrediting body that incorporates performance measures

and plan performance as part of the accreditation.

Before implementation of the comprehensive DQIP

measures, NCQA included eye examinations for 

diabetics, among other measures not specific to 

diabetes care (e.g., breast/cervical cancer screening,

childhood immunization), in its accreditation

process.

Ms. Tucker explained that assessment of HEDIS is a

continual process in that NCQA and others examine

and re-examine HEDIS data to determine the feasibility and ease in obtaining data, assess a plan’s

past and current performance, and identify changes

in clinical practice and, where possible, patient 

outcome. Ms. Tucker noted that HEDIS improves

accountability and makes accountability more 

efficient, allows health plans to track performance

over time, is informative regarding health care 

contracting, and helps purchasers work with plans

with a focus on internal QI efforts.

NCQA’s scoring for accreditation includes three main

factors: clinical performance (i.e., effectiveness of

care/HEDIS measures) plus results of member satisfaction surveys (i.e., the “CAP” survey) account for 

25 percent of the final score, and the health plan 

system accounts for the remaining 75 percent. Ms.

Tucker noted that the contribution of the clinical

care/patient satisfaction component is expected to

increase in the future.

In addition to clinical evidence, feasibility studies,

and data collection, NCQA conducts field tests of 

several health plans over a period of 12 to 18 months

to assess how well specific measures actually perform. NCQA also has produced a first-year reporting

measure, which serves as a beta-test of six of the

DQIP measures; in brief, a measure is released in one

year, and the comprehensive diabetes care assessment is conducted as data are collected and analyzed

in the following years. Using these data, NCQA then

revisits and revises its own testing, outreach, and

evaluation efforts. The Committee’s first-year reporting measures for six DQIP were released in 1999;

reporting to this point in time has been largely 

voluntary, Ms. Tucker pointed out.

NCQA’s State of Managed Care Quality Report

indicates that health plans that report measures

publicly, that are accredited, and that report over 

a period of time (e.g., 3 years or more) consistently 

outperform plans that do not meet these specifications. These data suggest that accountability 

does influence outcome and performance.

For more information about NCQA, interested parties

can access the Committee’s Website (www.ncqa.org)

or contact its Customer Support Line (1-202-955-

5697), Accreditation Status Line (1-888-275-7585),

or Publications Center Line (1-800-839-6487).

Ms. Tucker can be contacted directly via e-mail at

<tucker@ncqa.org>.

DQIP and the Public Sector

DoD

Frances Stewart, MD, CAPT, MC, USN, Program

Director, Patient Advocacy and Medical Ethics,

Office of the Assistant Secretary of Defense, Health

Affairs, summarized how DQIP is being utilized 

within DoD. One of the key components in the 

delivery of diabetes care by DoD is the clinical 

practice guidelines for primary care providers,

developed in collaboration with DVA. The final draft

of the diabetes guidelines was released in December

1999. Guidelines for diseases that are comorbid 

with diabetes, such as hyperlipidemia, tobacco use,

and hypertension, have been published or are 

nearing completion.
DMICC ANNUAL REPORT 56 FY 2000

Each guideline includes evidence-based metrics,

and medical treatment facilities are accountable for

their results on the metrics that are included in the

guidelines. Dr. Stewart noted that DQIP measures

serve as the metrics in the joint DoD-DVA guidelines

for diabetes.

Dr. Stewart explained that medical informatics is a

rapidly changing area within DoD; further, information systems are not consistent across DoD and

may not be for several years. Thus, implementing 

the new metrics in a changing environment is a 

challenge for the Department, which seeks to provide timely feedback regarding new metrics to its

providers and providers. The Department is moving

to place all patient records on one computer system,

the CHCS II; pilot testing of this system began in

February 2000. The agency expects implementation 

of this system will improve many features of 

delivery of care, including provider feedback and

tracking patient care and testing.

DoD has developed a Diabetes Toolkit to improve 

the quality of patient care. A prototype informatics/

database system was developed that would allow 

for metrics to be included in the doctor’s progress

notes, patient report cards and progress, interpretation of results, and advice for improvement.

DQIP would be incorporated into this system.

DoD anticipates that the entire informatics structure, with DQIP as a component of that system, will

improve performance through the process of measurement and track improvement in patient care.

DVA/Veterans Health Administration

Leonard Pogach, MD, MBA, National Program

Director, Diabetes, DVA, reported on use of the DQIP

measures in the Veterans Health Administration.

He reported on the following major areas: how DVA

currently uses DQIP measures, how DVA plans to 

use DQIP measures, and opportunities envisioned 

for the Federal sector. Since FY97, the measures 

have been used to track performance in each of the

DVA’s 22 networks. Network directors are held

accountable for results of all clinical performance

measures in their performance contracts. Data are

collected quarterly through independent external

peer review. Other data, to evaluate demographic factors and assess QI, are automatically collected and

then published in electronic reports. DVA also has

incorporated the measures in the Diabetes Quality

Enhancement Research Initiative, funded in FY99.

DVA plans to use DQIP measures to evaluate demographic factors and racial disparities and to influence major national translational programs of

research into practice. DVA also plans to continue 

to use the measures in its research efforts (FY00–

FY02). Efforts include cross-validation of chart

audits, electronic data, and surveys; additional 

validation of the DQIP Survey in the veteran population; longitudinal analysis of DQIP data; provider

profiling; and case mix adjustment models.

Dr. Pogach reported that for the Federal sector DVA

envisions a leadership role in improving clinical 

care through benchmarking of data, sharing of successful practices, and continuing commitment to

DQIP; advancing DQIP through collaborative efforts

to pilot test new measures; implementing internal

and external research initiatives; and making a 

correlation between DQIP and outcomes in longer

term longitudinal analyses.

DVA sees potential for data sharing through MOAs,

collaborative QI multiagency demonstration projects,

and shared research initiatives.

Dr. Pogach pointed out that using, collecting, and

tracking DQIP measures have led to improvements 

in all DQIP domains among VHA diabetic patients,

except for blood pressure.

IHS 

Kelly Acton, MD, MPH, Director, IHS National

Diabetes Program, opened her presentation by noting

that IHS has been measuring quality indicators of

diabetes care through its annual Diabetes Care and

Outcome Audit since 1986. Most of the 87 measures

have been tracked since 1992, and all have been

included in the audit since 1994.
DMICC ANNUAL REPORT 57 FY 2000

Some of the results of record audits conducted

between 1992 and 1998 are presented here:

• As the prevalence of diabetes has increased, the

number of records audited has increased, from

approximately 7,000 in 1992 to 11,518 in 1998.

• Between 20 and 27 percent of diabetic persons

diagnosed with hypertension have their blood 

pressure under control.

• Glycemic control, measured by HbA1c, varies by

age. HbA1c levels are consistently higher among

younger persons; however, a downward trend in

this measure over time has been reported for 

all age groups. Approximately 25 percent of the 

diabetic population have good control (< 7.5 

percent). Previously, reports simply indicated 

good, fair, or poor glycemic control. Starting this

year, detailed results will be published and presented to providers.

• Eighty percent or more of diabetic patients are

tested for proteinuria annually.

• Eye exam rates have stayed consistently at 53 to 

55 percent during the several years, despite a 

variety of interventions.

The findings of the annual audits are being benchmarked against DQIP measures to reinforce and 

validate the recommendations of the IHS National

Diabetes Program to perform the 87 elements and to

compare and validate regional differences and

national data.

HCFA 

In adding to her earlier presentation, Dr. Fleming

noted that HCFA is focused on the areas of measurement and improvement and is also in the process 

of developing a rewards and incentives package.

HCFA continues to work on DQIP-based QI with the

plans and PROs in all 50 states. Under one scenario,

a plan is directed to develop a QI program using one

DQIP measure; the plan must then show significant

improvement in that measure over a 3-year period to

retain its contract with HCFA. PROs are directed to

track three DQIP measures among their beneficiaries,

with retention of the contract tied to the QI of the

measures. Comments and suggestions on DQIP 

activities at HCFA should be forwarded to 

Dr. Fleming via e-mail (bfleming@hcfa.gov) or 

phone (1-410-786-6863).

Dr. Stewart then asked that attendees representing

other government agencies step forward and present

a summary of the status or relevance of DQIP within

their organizations.

CDC

Michael Engelgau, MD, MS, Division of Diabetes

Translation, CDC, stated that the CDC is interested 

in diabetes and DQIP for several reasons, and that

CDC was involved in the early versions of HEDIS as

well as in DQIP 1.0 and now DQIP 2.0 and assisted

the measures subcommittee in the development of

eye, foot, glycemic control (HbA1c), and kidney 

quality indicators and DQIP measurement sets by

providing a public health perspective.

CDC has been tracking self-care, education, and eye

exam measures on a state-by-state basis since 1994

through its Behavioral Risk Factor Surveillance

System (BRFSS).

Other CDC-related activities or collaborations

include the Diabetes Control Programs, the development of model contract language that Medicaid 

programs can use in negotiating with managed 

care companies for plans to include diabetes programs, the Association of States and Territorial

Chronic Disease Program Directors, the National

Diabetes Education Program, and partnerships 

with several non-government organizations to promote diabetes awareness and QI.

In the future, the CDC, in collaboration with NIDDK

and DVA, will be focusing on TRIAD (Translating

Research Into Action for Diabetes), a multicenter

project initiated approximately 1 year ago. This project will include at least 10 health plans, 40 provider

groups, and 15,000 patients with diabetes. Findings

from TRIAD are likely to contribute to the future

development of DQIP.
DMICC ANNUAL REPORT 58 FY 2000

QuIC

Dr. Stewart explained that thus far, QuIC has focused

primarily on disseminating the current DQIP-related

information and bringing new partners to the 

table (e.g., ADA, DVA, HCFA, DoD). Funding for QuIC

efforts is very limited. QuIC’s five working groups —

Consumer and Patient Information, Key Opportunities for Clinical Quality Improvement, Measures,

Developing the Workforce, and Information

Systems — meet on an as-needed basis. The Steering

Committee meets every 6 weeks. Dr. Stewart noted

that the QI working group has been charged with

three task areas: clinical guidelines (in the areas 

of diabetes, depression, and substance abuse),

patient safety, and formulary issues. Once clinical

guidelines are approved, they will be available to 

the public. QuIC meetings are open but limited to

Federal employees and partners; however, the group

welcomes input and feedback from the private sector.

NIH 

Philip Sheridan, MD, Program Director, Developmental Neurobiology Program, NIDDK, commented

briefly on NIH’s role in advancing and improving

health care. In just 15 years, QI and delivery of care

has moved beyond the bench-to-bedside paradigm

and now includes benchmarking, implementing

results of clinical trials, and increasing emphasis on

clinical research training. Recent years also have

seen increased interactions and collaborations

among agencies regarding overall research planning

and setting of strategic goals, participation in 

consensus conferences, and development of strategic

and long-range plans with input from patient 

advocacy and professional organizations. The importance of multidisciplinary and multiorganizational

collaborations underscores these efforts.

Dr. Sheridan continued by noting that NIH has

become a more active player in the QI “movement”

with departmental and Presidential initiatives on

quality in place. NIH has been approached by the

National Center for Health Statistics and AHRQ to

solicit assistance in developing data for a report on

the national quality of health care, which is due to

the President in 2002.

Afternoon Session: Brainstorming

Roland Hiss, MD, Chair, Department of Medical

Education, and Director, Demonstration and

Education Division, Michigan Diabetes Research 

and Training Center, University of Michigan 

Medical School, facilitated this brainstorming 

session, during which attendees were asked to 

suggest issues that should be considered further

with respect to DQIP collaborations. The following

list includes those suggestions.

• Benchmarking.

• Symposium on “Profiling” planned for June 2000,

sponsored by Federal agencies with an interest 

in diabetes and to occur in association with the

annual convention of the ADA.

• State-level (Diabetes Control Program) 

collaboration with the PROs.

• The CDC publication Diabetes Surveillance, last

published in 1997, is available at http://www.cdc.

gov/diabetes/survl/surveill.htm. The results of 

the BRFSS, which assesses preventive care practices, are published periodically in MMWR. This

will probably also be the case for TRIAD.

• Ongoing DCCT followup, which includes the 

DQIP measures.

• Translational research on DQIP implementation.

• DQIP use within Federal agencies to highlight 

successes and problems.

• Data sets from agencies who have them made 

available for study.

• CDC publication of state and regional data.

• Continuous sharing of DQIP data between Federal

agencies. (The subsequent discussion suggested

that this be accomplished by periodic additions 

to the DMICC Webpage.)

• Each agency should prepare its own “report card.”
DMICC ANNUAL REPORT 59 FY 2000

• DQIP Operating Committee continually look at the

experience of DQIP implementation and change or

add to the DQIP measures as indicated.

• DMICC Website posting of Federal agency 

DQIP data.

• QuIC continuous analyses of DQIP data.

• NCHS develop a QI model and include it in 

national surveys such as NHANES III or IV.

• This number was inadvertently skipped over by 

the facilitator (i.e., no item/activity is assigned 

to this number).

• Commonly shared purposes:

• Documenting racial disparities

• Common tools for database collection (demographics, minorities, etc.). Responsibility for 

conducting this activity was initially assigned 

to the QuIC, but subsequent discussion, noted

below, assigned this to a public/private sector 

collaboration.

• Reward systems that provide good care.

• Continue to hold “best practices” conferences 

about every 18 months.

• Annual submission of “best practices” to the combination of HCFA, ADA, and AAFP (as was done 

in association with the Millennium Conference of

August 1999), with HCFA taking the lead.

• Increase the role of other Federal agencies in the

research agenda beyond the “usual suspects.”

• Benchmark the U.S. population through 

NHANES III.

• DQIP update at each DMICC meeting and integrate

DQIP activities into whatever the main topic for

discussion is at each meeting.

Summary and Next Steps

Recommendations and Their Implementation

First-Tier (Top) Activities

The meeting attendees were asked to place a checkmark (vote) next to four items from the discussion

list that they thought were the most important.

The list below contains the items that received 

either four or five votes and notes the subsequent

discussion at the summary session concerning

responsibility for followup or implementation of

these activities.

• DCCT followup (former #5). This has been under

way for some time and will continue. It is an 

activity of the NIDDK.

• DMICC Website, for posting of DQIP data from

Federal agencies (former #13). The DMICC is 

organized and directed by the NIDDK and that

agency will establish DQIP data on its Web site

http://www.niddk.nih.gov/federal/dmicc.htm.

• Common database tools (former #17b). This was

thought to be the most important “next step”

activity, as currently each agency has its own 

rules and format for its database and a common

merging of DQIP data, or data from any other 

categorical diseases, would be problematic without a common understanding of definitions,

scope, format, and other relevant information.

During the discussion, a public/private sector 

collaboration was established that would involve

the DMICC, QuIC and the ADA, with the ADA 

taking the lead responsibility.

• Benchmark the U.S. population during NHANES

III and beyond (former #21). Responsibility for

NHANES rests with the NIDDK, CDC, and CHS.
DMICC ANNUAL REPORT 60 FY 2000

Second-Tier Activities

The following activities received three votes from

meeting participants.

• Translational research concerning DQIP issues

(former #6). Discussion of this item bogged down

with confusion over definition as to whether this

meant establishing a research agenda or funding

and conducting such research. Resolution of 

this question was postponed to the next DMICC

meeting, where it will be placed on the agenda.

• DQIP Operating Committee followup (former #12).

This activity is already being done with recommendations made to the QUIC.

• DQIP update at each DMICC meeting and also at

each QuIC meeting (former #22). Minutes of these

meetings will be posted on the DMICC Website 

for the benefit of all interested parties.

• Documenting racial disparities (former #17a). The

NIDDK indicated that data concerning hemoglobin

A1c and blood pressure would be obtained through

future NHANES activities. The definition of minority status and agreement on how to report racial

disparity information was assigned to the “database” project to be undertaken by the public/

private sector collaboration (see above).

A ranking of pertinent barriers and opportunities

facing DQIP collaborations can be found below.

Next Steps

In sum, attendees agreed that the basic overarching,

guiding principle for implementing these strategies

and recommendations is a basic commitment across

the health care system to use DQIP measures for 

the assessment of diabetes care.

It was suggested that progress reports on DQIP top

priorities be presented at a future DMICC meeting;

data and progress reports also might be placed 

on the DMICC Website, possibly in spreadsheet 

format. Attendees also requested that DMICCrelated progress reports be presented to the QuIC

Executive Committee.

Issues Concerning DQIP Collaborations

Ranking value of:

1 = 3 points, 2 = 2 points, 3 = 1 point

Points BARRIERS 

12 Insufficient staff and related resources

Ranking: 1+1+1+1

4 Lack of single easily accessible database

Ranking: 3+2+3

2 Concerns about value/validity of DQIP

Ranking: 2

5 Variable support/interest within agency

Ranking: 2+2+3

Diabetes not a high priority within agency

2 Tradition of agency independence

Ranking: 3+3

Waiting for rest of package before 

implementing

Concerns re “report card” effect

4 Lack of communication mechanism

between agencies

Ranking: 2+2

Lack of communication within agency

3 Write in: Sustainable effort

Ranking: 1

1 Write in: “Quality improvement” not 

traditionally within NIH mission.

NIH does not deliver health care

Ranking: 3
DMICC ANNUAL REPORT 61 FY 2000

Points OPPORTUNITIES

3 To learn of the successes/problems 

other agencies are experiencing

Ranking: 1

17 To promote better diabetes care 

within agency and the country

Ranking: 1+1+1+1+1+2

5 To define and quantify racial disparities

Ranking: 1+2

3 To map geographic variation

Ranking: 3+2

1 To collaborate on DQIP-related projects

Ranking: 3

1 To demonstrate agency commitment 

to diabetes

Ranking: 3

1 To acknowledge/reward exemplary 

care within agency

Ranking: 3 

3 To identify need for improvements 

within agency

Ranking: 2+3 

5 To work collaboratively with other 

federal agencies

Ranking: 3+2+2

To work collaboratively with private

health plans

2 Write in: Develop methods

Ranking: 2 

1 Write in: Develop information system

Ranking: 3

2 Write in: To understand basis of low 

quality, develop interaction strategy

Ranking: 2

1 Write in: Prioritize a research agenda

Ranking: 3

DMICC ANNUAL REPORT 63 FY 2000

A PROGRESS REPORT FROM THE 

NATIONAL DIABETES EDUCATION PROGRAM

Prepared for the Diabetes Mellitus Interagency Coordinating Committee

INTRODUCING THE NATIONAL DIABETES EDUCATION PROGRAM

The National Diabetes Education Program (NDEP) conducts nationwide education and awareness

activities to help reduce the morbidity and mortality from diabetes and its complications. The 

program was launched in June 1997 in response to scientific evidence that improved management 

of diabetes can significantly reduce the toll of the disease.

The NDEP is cosponsored by the two leading Federal agencies with responsibilities in the area of 

diabetes: the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the

National Institutes of Health and the Division of Diabetes Translation, Centers for Disease Control 

and Prevention (CDC). The NDEP functions as part of the Diabetes Mellitus Interagency Coordinating

Committee (DMICC), which includes representatives of other Federal Government agencies involved 

in diabetes-related activities.

The NDEP supports two major Federal Government initiatives: the President’s Initiative on Race,

which aims to eliminate racial disparities in health access and outcomes; and the Healthy People 

2010 initiative, which establishes health objectives for the Nation in the 21st century. Diabetes is a

priority health problem in both of these programs and NDEP strategies support their objectives.

The NDEP aims to change the way diabetes is treated — by the media, by the public, and by the 

health care system. Program audiences include people with diabetes and their families, health care

providers, payers and purchasers of health care, health care system policy makers, and the general

public. More than 200 public and private sector organizations participate as NDEP partners by 

helping to plan and implement diabetes education activities. In three short years since its inception,

NDEP messages have reached more than 180 million people through nationwide campaigns and 

community awareness strategies. This report recounts the development of NDEP and highlights its

many accomplishments in support of its goal.
DMICC ANNUAL REPORT 64 FY 2000

WHY A NATIONAL DIABETES EDUCATION 

PROGRAM?

Diabetes Is a Serious and Growing 

Health Problem

Diabetes is universally recognized as a major public

health problem in the United States — and an 

emerging epidemic that threatens to worsen during

the 21st century. The sixth leading cause of death 

by disease, diabetes exacts a severe toll as the 

leading cause of adult blindness, kidney failure,

and non-traumatic lower limb amputations and as 

a major contributor to premature heart disease 

and stroke.1 Statistics from 1998 listed below attest

to diabetes’ impact on the health of our Nation 

and the drain on our health resources.

Diabetes in the United States:

Serious, Common, and Costly2

Diagnosed: 10.3 million 

Undiagnosed: 5.4 million 

Incidence: 800,000 year 

Complications:

Adult Blindness: 12,000-24,000 new cases each year 

Kidney Failure: 36.3 percent of new cases3

Heart Disease: 2-4 times higher 

Non-traumatic Lower Limb Amputations:

86,600 year4

Cost: $98 billion/year (direct and indirect)

Source: NIDDK Diabetes Fact Sheet, March 1999

Current data show that the prevalence of diabetes

has increased alarmingly in the past decade.

Findings from a survey conducted by the Centers for

Disease Control and Prevention point to a 33 percent

increase in diabetes prevalence between 1990 and

1998. The increase occurred in both sexes and

among all ages, ethnic groups, and educational levels. Persons aged 30 to 39 years and those with higher levels of education had the largest increase.5

Prevalence of diabetes is expected to increase 41% 

in the developed world by the year 2025. A number 

of trends are contributing to the rise in diabetes

prevalence:

• The growing prevalence of obesity in the 

United States. Obesity is a major risk factor for

type 2 diabetes, the most common form of the 

disease. The 1999 National Health and Nutrition

Examination Survey (NHANES) found that 26 

percent of adults are obese, up from 23 percent in

the 1988–1994 NHANES Survey.6 More alarming 

is the increase in obesity in children. An estimated

25 percent of children and adolescents are obese,

an increase of 50 percent in the past 20 years.7

• The higher prevalence of diabetes in racial/

ethnic minority populations. Diabetes 

disproportionately affects African Americans,

Hispanic and Latino Americans, American 

Indians and Alaska Natives, and Asian 

Americans and Pacific Islanders. Compared to 

non-Hispanic whites, rates of diabetes are 1.7 

times higher in African Americans, 1.9 times 

higher in Mexican Americans, and 2.8 times 

higher in American Indians and Alaska Natives.1

In some American Indian tribes, notably the 

Pima Indians in Arizona, up to half of adults 

have diabetes. Ethnic minority populations also

experience higher rates of complications and,

often, have limited access to quality health care.

Some minority populations, especially Hispanic

Americans are among the fastest growing 

segments of our society.

• The aging of the U.S. population. Type 2 diabetes

typically develops in people ages 40 years and

older, and it is especially common in persons 

over 65 years. More than 18 percent of persons 

over age 65 (6.3 million people) have diabetes.1

This population segment is expected to increase 

dramatically in the coming years with the aging 

of the baby boomers.
DMICC ANNUAL REPORT 65 FY 2000

• The increasing prevalence of type 2 diabetes 

in children. Normally a disease of adults, type 2

diabetes is becoming more common in children 

and adolescents.8 The National Institutes of Health

estimates that the percentage of children diagnosed

with type 2 diabetes has risen from less than 5 

percent prior to 1994 to 20 to 30 percent today.9

Minority children, especially American Indian,

African American, and Hispanic/Latino American

children, appear to be at greater risk, particularly 

if they are overweight.10 

Better Care Is Available and Makes a Difference

In June 1993, the NIDDK announced the long-awaited

results of the Diabetes Control and Complications

Trial (DCCT). This landmark study proved conclusively that improved control of blood glucose levels

reduced and delayed microvascular complications

affecting the eyes, kidneys, and nerves in people with

type 1 diabetes.11 The United Kingdom Prospective

Diabetes Study (UKPDS), completed in 1998, reported

similar results for people with type 2 diabetes.12

These two major studies form the scientific basis for

the NDEP.

Fortunately, the means to achieve improved control 

of blood glucose levels is now available to people

with diabetes and their health care providers.

Advances in medical research and technology have

produced an array of treatment and management

tools to improve and monitor blood glucose control:

• Self-monitoring of blood glucose (SMBG) 

and the hemoglobin Alc test (A1c). These two

tests have revolutionized diabetes management.

SMBG enables people with diabetes to test their

blood sugar on a daily basis and ascertain with a

great deal of accuracy the current level of glucose

in their blood. Likewise, the A1c test, which 

measures the average level of blood glucose over 

a 3-month period, allows health care providers 

and people with diabetes to evaluate the success 

of the treatment plan and work together to make

adjustments as necessary.

• Development of new oral drugs and new 

forms of insulin. In previous years, only one 

class of drugs, the sulfonylureas, was available 

to treat type 2 diabetes. Now, physicians may

choose from a variety of drugs that act in 

different ways to lower blood glucose and 

improve insulin usage.

Researchers have also developed new and purer

forms of insulin that act more synergistically with

the body and provide better day-to-day coverage.

Insulin pumps, insulin pens, and other devices 

to improve insulin delivery make it easier and 

less painful for people with diabetes to manage 

the disease.

• New and more effective diagnostic and treatment approaches for diabetes complications.

Major advances have been made in diagnosing 

and treating diabetic eye disease. Studies have

demonstrated the value of angiotensin-converting

enzyme (ACE) inhibitors, a drug used to treat 

hypertension, in slowing the progression of 

diabetic kidney disease. New drugs to treat high

blood pressure and to control blood lipids allow

physicians to be more aggressive in treating 

these conditions, both of which contribute to

excess mortality from heart disease in people 

with diabetes. In addition, management of 

diabetes in pregnancy (gestational diabetes) is 

vastly improved. Many women with diabetes are

now able to have successful pregnancies with 

minimum risk to themselves and their babies.

• New guidelines for diagnosis of type 2 diabetes.

New guidelines for diagnosing diabetes, adopted 

in 1997, make it easier to identify people with 

undiagnosed diabetes and bring them into the 

medical system earlier. Currently, an estimated 5.4

million people have undiagnosed diabetes. Early

identification and treatment of these patients will

lessen the damage caused by uncontrolled high

blood glucose levels.
DMICC ANNUAL REPORT 66 FY 2000

• Advances in Care Are Not Being Applied.

Unfortunately, surveys show that many of these

advances in knowledge are not being applied in

current diabetes care. More than half of people

with diabetes have hemoglobin A1c levels above 

7 percent, the level above which the risk for

microvascular complications increases significantly, and more than one third have values 

greater than 8 percent. The hemoglobin A1c test 

is not widely used in clinical practice, despite 

its proven value in assessing the level of diabetes

control.13 A recent study of 345,253 Medicare

patients aged 65 years and older showed that 

less than half of those with diabetes had annual

eye examinations and less than a third had a 

hemoglobin A1c test every 6 months.14

A number of studies document that current care

often does not meet the recommended standards

for treating diabetes, screening for complications,

referrals to specialists, blood glucose self-monitoring, dietary counseling, and patient education.xve

People with diabetes themselves often neglect selfcare practices because of lack of time or resources,

lack of education in diabetes management, or lack

of appreciation of the seriousness of diabetes.

PLANNING THE NATIONAL DIABETES 

EDUCATION PROGRAM

The results of the Diabetes Control Complication

Trial (DCCT) set the stage for a national diabetes

education program. The DCCT message — good blood

glucose control matters — needed to be disseminated

to people with diabetes and those responsible for

their care. A series of planning meetings in 1996 and

1997 laid the groundwork for the National Diabetes

Education Program (NDEP).

From the outset, program planning involved a wide

variety of organizations, government agencies, and

professional groups with an interest in diabetes that

represented each of the program’s target audiences:

health care professionals, payers and purchasers of

health care, public health officials, and organizations

and advocacy groups serving the general public and

people with diabetes and their families, including a

large number of organizations representing minority

populations. The planning meetings resulted in the

following key strategies for program implementation:

• Developing and disseminating guiding principles

that promote quality diabetes care.

• Creating program partnerships with other 

organizations concerned about diabetes.

• Developing and implementing ongoing awareness

and education activities.

• Identifying, developing, and disseminating 

educational tools and resources, including those

that address the needs of special populations.

• Promoting policies and activities to improve the

quality of and access to diabetes care.
DMICC ANNUAL REPORT 67 FY 2000

The National Diabetes Education Program is truly 

a national effort, involving both national leadership

and grassroots input in all phases of planning and

development. The program’s sponsorship by the two

major health agencies of the Federal Government,

NIH and CDC, provides a firm basis of credibility,

commitment, resources, links to public health 

agencies nationwide, and the scientific basis for the

program. The program’s partnerships with community and consumer groups and health-related organizations in the private sector ensure broad and 

meaningful input in its design, effective implementation, wide dissemination of its messages, and 

continued growth.

The program involves representatives from national,

state, and local level organizations on its Executive

and Steering Committees and on work groups 

that help plan and implement program strategies.

(See NDEP Organizational Chart on next page.) 

The NDEP work groups assist in developing,

implementing, and/or evaluating specific program

components. Work group participants include

Steering Committee members and representatives

from the Partnership Network who have the 

necessary expertise, experience and organizational

linkages to address the work group’s tasks.

The NDEP Work Groups include:

• Guiding Principles of Diabetes Care Work Group

• Community Interventions Work Group, including:

– African American Work Group

– Hispanic/Latino American Work Group

– American Indian Work Group

– Asian American/Pacific Islander Work Group

• Health Care Providers Work Group

• Podiatry, Pharmacy, Optometry, and Dentistry

(PPOD) Work Group

• Team Approach to Care Work Group

• Diabetes in Children and Adolescents Work Group

• Business and Managed Care Work Group

• Medicare Benefits Work Group

• Evaluation Work Group
DMICC ANNUAL REPORT 68 FY 2000

THE NDEP ORGANIZATIONAL STRUCTURE

NDEP Executive Committee

Establish and implement 

program vision, goal, objectives,

policies, and activities

NDEP Steering Committee

Coordination, collaboration, and guidance 

on program vision, goal objectives,

policies and development

Ad Hoc 

Work 

Groups*

Ad Hoc 

Work 

Groups*

NDEP Partnership Network

Dissemination, information sharing, networking,

mass media, special population interventions,

community-based interventions, and 

health systems improvement activities.

*Ad hoc work groups of the NDEP assist in the development, implementation,

and/or evaluation of specific program components.
DMICC ANNUAL REPORT 69 FY 2000

ACCOMPLISHMENTS OF THE NDEP: 1997-2000

The NDEP was introduced to the diabetes community

in June 1997 at the American Diabetes Association’s

Annual Scientific Meeting. In the three years since 

its inception, the program has:

• developed guiding principles for diabetes care;

• built a strong Partnership Network;

• reached millions with its Control Your Diabetes.

For Life. mass media campaign messages;

• developed tools and resources for people with 

diabetes, health care providers, and partners;

• laid the groundwork for improving access to 

quality health care services.

Guiding Principles of Diabetes Care

One of the first priorities of the new NDEP was to

define broad elements of good diabetes care to meet

the need for consensus in the medical and health

insurance communities. The NDEP convened a work

group of diabetes experts to help develop the program’s Guiding Principles of Diabetes Care. The 

guiding principles were developed in English and

Spanish and in two versions: a professional 

version for health care providers, managed care,

and employers; and a lay version for people with 

diabetes and their families. Released in 1998,

the guiding principles describe seven overarching 

essential components of quality diabetes care 

that form the basis for the NDEP’s public and 

professional awareness program.

The Guiding Principles for Diabetes Care are intentionally broad. They are flexible enough to adapt to

different practice settings and they accommodate 

the needs of individual patients. They may be used 

as a guide for physicians and their patients in 

making decisions about the diabetes management

plan and they may be used by managed care 

organizations and employers to determine diabetes

care and treatment, service options, assess quality,

and establish diabetes care principles.

Building the Partnership Network

The Partners

The core of NDEP is its Partnership Network. The

program’s first Partnership Network meeting in

March 1998 brought together about 100 potential

partners, many of whom had participated in the

planning meetings. Today, the network has doubled

in size and is still growing. The diversity of the

Partnership Network reflects the pervasive impact 

of diabetes and its complications on the individual

with diabetes, the family, the community, the work

environment, and the health care system.

The Role of Partners

Partners play a crucial role in the success of the 

program. They help create messages and activities

and disseminate them to their constituencies 

through local and constituent media and in community-based interventions. Partners serve on the

NDEP Steering Committee and on work groups 

where they participate in setting priorities, identifying program needs, and developing new projects.

Partners often advise program staff on special 

needs and are available to lend their expertise in

developing materials or programs for special populations. Drawing on their contacts, they work in 

their communities to improve health care systems.

And they seek to expand the NDEP Partnership

Network by forming their own networks and 

encouraging others to become a part of NDEP.

Communicating with Partners 

Partners network with each other at partnership

meetings, through work group calls, and via the 

electronic media, sharing information about effective

approaches and new ideas. NDEP program staff 

communicates with partners in a number of ways:

• Partnership Network Meetings include technical

assistance sessions, forums for exchanging 

information, and workshops on using new NDEP

products;
DMICC ANNUAL REPORT 70 FY 2000

• NDEP Program Update, the NDEP newsletter,

highlights new program and partner activities 

and resources; and

• The NDEP Website (at http://ndep.nih.gov)

posts up-to-date information and resources and

provides links to other related organizations 

and programs.

NDEP Resources for Partners

NDEP has developed a variety of resources for 

partners such as media materials, community 

intervention resources, materials for businesses 

and employers to support diabetes control, and 

various tools and educational materials for health

care providers and patients. All materials are 

copyright-free and may be duplicated as needed.

The NDEP Campaign Guide for Partners includes 

an array of media materials designed to be adapted

by partner organizations for multiple purposes,

depending on individual needs and situations.

There are reproducible print ads and educational

brochures, press releases and fact sheets, as well 

as ideas on how to work with the media. Partners 

are encouraged to add their own logos to materials

and use them in creative ways.

A major resource for partners is NDEP’s Diabetes

Community Partnership Guide. The guide provides 

a blueprint for conducting a diabetes awareness 

program, with tips for enlisting potential partners,

planning events, suggested activities for raising 

and maintaining diabetes awareness in the 

community, reaching goals, and evaluating the 

success of the program.

All NDEP materials are readily available from the

National Diabetes Information Clearinghouse (NDIC)

and also may be downloaded from the NDEP website.

A complete list of materials and other resources 

produced by NDEP is included in Appendix 2.

Highlights of Partner Activities 

NDEP partners have engaged in a wide range of

activities to promote NDEP messages. Activities

include disseminating NDEP materials through 

state and local health departments, placing NDEP

messages on local radio and television stations,

promoting NDEP at local and national healthrelated meetings, adapting NDEP materials into 

other languages, supporting a website and toll-free 

telephone service, helping in printing and disseminating NDEP materials, and incorporating NDEP

messages and strategies into ongoing programs of

their organization. Brief descriptions of partner

activities are presented in Appendix 3.

To help support partner activities, six minority

organizations have been awarded grants from CDC 

to work with the NDEP’s minority work groups to

help disseminate culturally appropriate diabetes

education messages through community and media

channels. The grantees include: the Association 

of American Indian Physicians, the Association of

Asian Pacific Community Health Organizations,

the National Asian Women’s Health Organization

(NAWHO), the National Council of La Raza, the

National Hispanic Council on Aging, and the Urban

League of Nebraska. See Appendix 3 for highlights 

of these organizations’ activities.

Raising Awareness About the Importance 

of Diabetes Control

People with diabetes play a major role in controlling their disease and helping to prevent serious 

complications. Making people with diabetes aware 

of this important fact has been the key objective 

of the NDEP’s awareness campaign. Launched in 

June of 1998, the Control Your Diabetes. For Life.

awareness campaign has been designed to achieve 

maximum impact through targeted, efficient use 

of the mass media.
DMICC ANNUAL REPORT 71 FY 2000

The campaign has reached over 180 million

Americans with radio and television public service

announcements (PSAs), print ads, and newspaper stories carrying the program’s messages. The ability of

the campaign to achieve such national prominence

within a two-year period reflects both the commitment to this effort by NDEP’s many partners and 

the principles of effective public health education 

on which it is based.

• Research was conducted to assess educational

needs and set priorities, and gain an understanding of the primary audiences for the campaign.

• Minority groups at high risk for developing 

diabetes participated in planning the campaign.

• Strategies were tailored to the intended campaign

audiences.

• Campaign promotion and distribution mechanisms

were selected based on their potential for reaching

specific segments of the campaign’s ethnically 

and culturally diverse audiences.

Conducting Audience Research

To help ensure the success of the awareness 

campaign, the NDEP sought the help of the people 

it hoped to reach. Focus groups were conducted

around the country with diabetes patients 

representing the various ethnic, racial, and senior 

audiences for the campaign. The focus groups

explored attitudes about diabetes, the language

patients use to discuss diabetes, and reactions 

to promising educational strategies for helping

patients control their disease.

Milestones in the NDEP Awareness Campaign, 1998-2000

• Campaign launch, including release of Many Faces of Diabetes TV PSA and first wave of 

Hispanic/Latino Rayos y Truenos PSAs, June 1998

• Launch of the African American campaign, September 1998

• Medicare Expanded Benefits campaign launched, April 1999

• Launch of Phase Two of the Hispanic/Latino Thunder and Lightning campaign, May 1999

• Release of TV PSAs: Family Reunion (African Americans), Taking Control (General Audience),

Future Generations (American Indians), Thunder and Lightning (Hispanics/Latinos), June 1999

• Launch of the American Indian campaign, including Future Generations radio and print PSAs,

November 1999.

• Launch of the Asian American and Pacific Islander (AAPI) campaign, including print media 

and radio PSAs, November 1999.

• National Association of Broadcasters disseminates TV PSAs on behalf of NDEP, June 2000
DMICC ANNUAL REPORT 72 FY 2000

Minority Group Participation in Designing 

the Campaign

NDEP formed Work Groups comprised of representatives of each of the race/ethnic minorities disproportionately affected by diabetes. The Work Groups’

involvement was crucial to ensuring that the 

campaign messages were culturally sensitive and 

resonated with the audiences they were designed 

to inform and influence. The Work Groups also 

played a role in promoting the campaign messages 

to the constituencies they represent through 

targeted placement in local media and trusted 

community-based communication channels.

Crafting the Campaign Messages

The use of mass media is a proven strategy for 

raising broad public awareness of an issue in a 

relatively brief period of time. Mass media campaign

effectiveness depends on a number of factors, none

more important than a compelling and convincing

message. The message “platform” for the NDEP

awareness campaign drives the development of all

campaign messages: Diabetes is serious, common,

costly, yet controllable. The hopeful element in 

that message platfor m— diabetes is controllable —

has become the unifying theme for all campaign

materials directed to people with diabetes: 

Control Your Diabetes. For Life. Implicit in this 

call to action is the recognition that people with 

diabetes play an important, ongoing role in 

managing their disease to protect their health 

and prevent complications.

To reach the broad, general audience of people 

with diabetes, the Control Your Diabetes. For Life.

campaign was launched in 1998 with “The Many

Faces of Diabetes” television PSAs. These PSAs and

companion posters demonstrated that diabetes

affects people of every race and ethnic group.

Targeted to people with diabetes over age 45, the

PSAs emphasize that controlling diabetes makes a

big difference in the way people feel now and in

reducing their chances of complications later on.

Tailoring the Message for Diverse Audiences

Based on focus group research, the central campaign

message has been carefully tailored for each of the

high-risk minority audiences. The result is a set 

of campaign materials reflecting important cultural

considerations that enhance their persuasiveness

with a particular audience and help motivate 

people with diabetes to practice good diabetes 

self-management.

The “Family Reunion” theme for African American

audiences, for example, speaks to the importance 

of family support and inter-generational ties within

this community. The “Future Generations” theme,

designed for American Indians, emphasizes the need

to protect and pass along culture and traditions.

The program message to the multi-cultural Asian

American/Pacific Islander audience, “Manage Your

Diabetes,” has been translated into eleven different

languages. To reach Hispanic/Latino audiences, the

NDEP developed the “Rayos Y Truenos” PSAs. These

messages address the cultural barrier of fatalism

and put diabetes control in context with the message

that “There are certain things in life that cannot be

controlled, but diabetes is not one of them.”

The Balanced Budget Act of 1997 mandated new 

benefits for all Medicare-eligible people with 

diabetes. The NDEP joined forces with the Health

Care Financing Administration (HCFA) to promote 

the new benefits and help people learn how to 

control diabetes. The Medicare Benefits & 

Controlling Your Diabetes campaign, launched in

1999, was developed to meet those objectives.

NDEP Awareness Campaign Materials

• Brochures for people with diabetes

• Campaign guide to encourage participation 

by state and local groups

• Media kits, press releases, and fact sheets

• Print ads

• Posters

• Radio and television PSAs
DMICC ANNUAL REPORT 73 FY 2000

Delivering the Message

In the same way that the NDEP has tailored campaign materials to particular audiences, the Program

has used targeted, highly efficient and cost-effective

strategies to promote and distribute campaign messages to target audiences. Campaign dissemination

strategies employ selective distribution of PSAs and

print materials to media outlets most likely to reach

campaign audiences. Campaigns are also timed to

coincide with events of importance to key audiences.

• Campaign PSAs were distributed to media markets

that have the highest concentrations of the minority audiences and the seniors for whom the PSAs

were designed.

• Distribution of radio PSAs was even more targeted:

stations were identified that geared their programming to specific minority groups. The “Family

Reunion” radio PSA, for example, was distributed

primarily to radio stations airing programs geared

to the African American community.

• The American Indian campaign was kicked off 

in November 1999 — Native American Heritage 

Month as well as National Diabetes Month.

“Future Generations” radio PSAs were distributed

to American Indian radio stations and print public

service ads were distributed to American Indian

newspapers. In addition, general audience media

outlets in markets with the highest concentrations

of American Indians received the campaign ads.

• Latino communications firms were used to distribute the Hispanic/Latino campaign materials,

ensuring that they reached appropriate media 

outlets such as Univision and Telemundo, two

Hispanic/Latino television networks.

• The National Asian Women’s Health Organization

and the Association of Asian Pacific Community

Health Organizations, two community-based Asian

associations, are conducting outreach to the Asian

and Pacific Islander communities and distributing

campaign materials to appropriate media outlets

and other communication channels.

Control Your Diabetes. For Life. Television PSA Campaign, August 1998 –May 2000

Campaign Phase & Reach/ Total # Dollar

Coverage Period Penetration of Plays Value

Many Faces of Diabetes 274 TV stations, 41,389 $3,959,709

8/98–7/99 48 states,

(General audience PSA) 243 cable systems

Taking Control, Family Reunion, 350 TV stations, 28,293 $5,920,445

Future Generations, Thunder & 50 states,

Lightning, 6/99–5/00 19 cable systems

(4 targeted audience PSAs)

Medicare Benefits & 28 stations, 1,424 $161,278

Controlling Your Diabetes 17 markets,

4/99-6/99 8 states

(Senior Audience PSAs)

Rayos Y Truenos 23 stations 4,423 $447,779

9/99-10/00

(Hispanic/Latino PSA)
DMICC ANNUAL REPORT 74 FY 2000

The success of these efforts can be measured in the

numbers of materials distributed, the airplay given

to the Program’s PSAs, coverage in national and local

print and broadcast media, and personal appearances by campaign spokespersons. Articles on the

campaign, for example, have appeared in 3,360 publications with an estimated readership of over 180 million people. The campaign’s achievements are also

reflected in the numerous awards the NDEP has

received, including the Department of Health and

Human Services’ (DHHS) Distinguished Program

Award in May of 2000.

Role of the Partnership Network in the 

Awareness Campaign

The NDEP Partnership Network has contributed 

significantly to the success of the awareness 

campaign. Partners have helped identify appropriate radio stations, newspapers, and other outlets 

to receive campaign PSAs and other promotional 

materials. Many partners have become active 

participants in the campaign, distributing TV, radio,

and print PSAs with their own local tags to broadcast stations and print media outlets. They have

made presentations about the campaign to their 

state and local networks, obtained private sector

support for reproducing campaign materials,

and adapted campaign messages to reflect their 

communities. They also have helped translate 

media materials such as the news releases and 

print ads for the Asian American and Pacific 

Islander Campaign into 12 languages.

Educational Tools and Resources for People 

with Diabetes and Health Care Providers

Controlling diabetes is a challenge for both people

with diabetes and health care providers. People with

diabetes, and their support system, must assume a

large part of the responsibility for managing their

own care. This self-care includes following dietary

and physical activity guidelines that may require

major lifestyle changes, as well as monitoring blood

sugar levels and taking medications, if needed, on 

a regular basis. The NDEP is responding to the 

educational needs of people with diabetes and

providers, helping to prepare them to meet 

their joint responsibility for diabetes control.

NDEP has developed several brochures for people

with diabetes that present information and tips for

controlling diabetes in simple, easy-to-understand

language and in positive encouraging terms.

In addition to the Guiding Principles of Care for 

health care providers, NDEP has produced a 

quick-reference pocket guide on current standards 

of care and a comprehensive kit for preventing 

diabetes foot problems. See Appendix 2 for a list 

of NDEP tools and resources.

Improving Quality and Access to Diabetes Care

Improving the quality of and access to care for 

people with diabetes is a major objective of the

NDEP. Program strategies include disseminating

information and education to health care providers,

educating employers about quality diabetes care,

and encouraging payers and purchasers to provide

reimbursement for team care approaches that may

improve the quality of diabetes care. NDEP Work

Groups are playing a major role in implementing

these strategies.

Reaching Out to Health Care Providers

One of the keys to improving the quality of diabetes

care is ensuring that health care providers understand how to manage the disease and are aware of

its implications for a variety of other conditions.

Provider education and training is needed to 

improve diabetes outcomes.

In addition to developing educational resources 

such as the Diabetes Numbers At a Glance card and

the Feet Can Last a Lifetime kit, the NDEP conducts 

a variety of other provider awareness-building and

educational activities. The program has presented or

exhibited at meetings of key primary care provider

groups such as the American College of Physicians
DMICC ANNUAL REPORT 75 FY 2000

and the American Association of Family Physicians,

as well as at meetings of diabetes specialists,

diabetes educators, and dietitians. The response 

from these groups has resulted in broad support 

for NDEP educational initiatives.

Articles in professional journals and newsletters

have also proven a highly effective way of promoting

the problem of diabetes to health care providers.

The most prominent example appeared in the

Journal of the American Medical Association 

(JAMA) in July of 2000. Entitled “Promoting Early

Diagnosis and Treatment of Type 2 Diabetes,” this

NDEP commentary argued persuasively for making

diabetes care a national health care priority.

Not only did this article reach the readers of JAMA,

but it also resulted in an Associated Press wire 

service story that reached over 40 million 

newspaper readers.

Business and Managed Care 

Business and managed care organizations are essential partners in NDEP efforts to address issues of

access and quality of care for people with diabetes.

The NDEP Business and Managed Care (BMC) Work

Group seeks to increase awareness of the clinical 

and economic benefits of quality diabetes care

among employers, benefits managers, and managed

care decision makers. It also promotes worksite

strategies for diabetes-related health promotion and

disease prevention.

As its first project, the BMC Work Group developed

Making a Difference: The Business Community 

Takes on Diabetes, an NDEP publication designed 

to build awareness of the economic and health 

consequences of diabetes, and the benefits of 

worksite interventions to prevent diabetes-related

problems. This booklet also outlines specific goals

and action steps that businesses can take to support employees who have diabetes and to encourage

health-promoting lifestyles among all employees.

Making a Difference has been widely distributed

among business groups, corporations and occupational health organizations, including the 

Association for Worksite Health Promotion and 

the American College of Occupational and

Environmental Medicine.

Team Care Approach

People with diabetes need continuous, proactive,

and carefully planned care. The most realistic way 

of achieving such care is through the use of interdisciplinary health care teams trained in diabetes

management. Team care integrates the skills of 

different health care professionals with those of 

people with diabetes and family members into a

comprehensive lifetime diabetes management 

program.

The NDEP Team Care Work Group has generated 

a report, Team Care: Comprehensive Lifetime

Management for Diabetes, which focuses on the

importance of team care and the requirements for

achieving it. Intended for organizational leaders 

in health care systems and purchasers of health 

care, the report provides guidelines for team care

policies that will improve outcomes for people 

with diabetes while minimizing expensive 

procedures and hospitalizations.

Comprehensive Diabetes Care Campaign

A new initiative to promote comprehensive diabetes

care is being developed by the NDEP Health Care

Providers Work Group. The initiative will focus 

on helping primary care providers improve their 

diabetes management skills to attain improved 

blood glucose control as well as better management

of cardiovascular risk factors such as blood 

pressure and blood lipids. Primary care physicians,

nurse practitioners, and physician assistants 

will be targeted by the initiative. Complementary 

messages will be developed for people with 

diabetes.
DMICC ANNUAL REPORT 76 FY 2000

The comprehensive care initiative will be launched 

in Spring 2001. In preparation for that launch,

NDEP has enlisted the support and participation 

of key diabetes and other health care provider 

organizations represented on the NDEP Steering

Committee. Campaign strategies include an educational campaign to promote awareness of the 

importance of comprehensive care and development

of tools and resources to facilitate provider implementation of recommended clinical practices.

Pharmacy, Podiatry, Optometry and 

Dentistry (PPOD)

Pharmacy, podiatry, optometry, and dentistry are

areas of health care with special importance for 

people with diabetes. The NDEP Pharmacy, Podiatry,

Optometry and Dental (PPOD) Work Group was

formed in the spring of 2000 and has moved rapidly

to develop a new NDEP initiative targeting providers

in these areas. A plan is now in place to accomplish

the following:

• Utilize PPOD delivery channels to disseminate

information to increase the awareness of people

with diabetes and their families about the 

importance of glucose control and prevention 

of complications.

• Increase access to and awareness of quality 

diabetes care for the prevention and control of

complications through collaboration between 

PPOD and other health care providers.

PPOD providers, other primary care providers,

and health service delivery systems will work 

collaboratively to implement the plan.

Children and Adolescents with Diabetes

Under the leadership of the Children and Adolescents

with Diabetes Work Group, NDEP is developing a

campaign to decrease morbidity and mortality 

related to diabetes among these younger age groups.

Directed to health care providers, the campaign has 

a number of objectives:

• To increase health care provider awareness of 

the increasing incidence of type 2 diabetes in 

the younger population, and disproportionate

increases among special populations.

• To increase health care provider knowledge of 

the risk factors for type 2 diabetes in children 

and youth.

• To change health care provider behavior to include

testing for type 2 diabetes in high-risk youth.

• To increase early diagnosis of diabetes among 

children and adolescents.

NDEP will partner with a number of health care

provider organizations to disseminate the targeted

messages and materials being developed for the 

campaign. The Work Group is also creating educational materials for schools and day care centers 

to assist them in managing children with diabetes.
DMICC ANNUAL REPORT 77 FY 2000

PRIORITIES FOR THE FUTURE

In the coming years, the NDEP will continue to work

to support the objectives of the President’s Initiative

on Race and Healthy People 2010. To increase awareness about diabetes, the program will continue to

promote and reinforce its message that “Diabetes is

serious, common, costly, yet controllable.” Awareness

campaigns are being planned that focus on offering

social support for people with diabetes, providing

healthy eating tips to Hispanics/Latinos to help control the disease, renewing efforts to reach seniors

with messages about Medicare’s benefits for people

with diabetes, and promoting the importance of

healthy eating and regular physical activity to

American Indian children to help reduce their risk 

of diabetes.

NDEP will continue to support its Partnership

Network with technical assistance tools and training

sessions, meetings, and a new interactive website

designed to promote information sharing. Greater

emphasis will be placed on developing NDEP 

activities with partners and fostering mutually 

beneficial relationships.

As new biomedical research on management of 

diabetes emerges, the NDEP will translate that 

science for primary care providers and people with

diabetes alike. An immediate priority is to expand 

the program’s blood glucose control message to

include rigorous control of the key cardiovascular

risk factors of blood lipids and blood pressure,

as demonstrated by the UKPDS and other recent

studies. In addition, the program will implement its

plans for disseminating important new information

about the emerging problems of type 2 diabetes in

children and adolescents. Data from ongoing NIDDK

clinical trials and research will need to be released

in the near future and will be promoted by NDEP 

to the scientific, health professional, and lay public

communities.

To change the way diabetes is treated, the NDEP will

expand its efforts to change the heath care system.

Plans are in the offing to promote the team approach

to care to the people who make decisions about

health care plans. Similarly, the program will offer

worksite-based diabetes control program tools to

employers, and the people who purchase health care.

Finally, the NDEP plans to begin implementing 

evaluation of the program. The program will gather

measures of partner activities and examine the

minority work group component of the Partnership

Network. In addition, plans will be developed for

measuring the NDEP’s impact on target audience,

knowledge, attitudes practices, and outcomes 

related to diabetes care.

The National Diabetes Education Program has made

its mark as a strong, flexible organization that

responds rapidly to public health needs and to the

needs of its constituents. The program envisions a

promising future that will continue to be shaped 

by its strong leadership and the many partners who

have worked steadfastly to spread the word about

the program and the importance of diabetes control.
DMICC ANNUAL REPORT 78 FY 2000

References

01 Diabetes Statistics, NIDDK, NIH Publication 

No. 99-3892, March 1999.

02 Unless otherwise cited, statistics in this table 

are taken from the NIDDK fact sheet,

Diabetes Statistics, March 1999.

03 Centers for Disease Control and Prevention,

Division of Health Care Statistics. National hospital discharge survey, 1996. Atlanta: Division of

Diabetes Translation. National Center for Chronic

Disease Prevention and Health Promotion, 1996.

04 Mokdad AH, et.al, Diabetes Trends in the U.S.:

1990-98. Diabetes Care Vol. 23, No. 9, September

2000, pp1278-83.

05 National Center for Health Statistics, “Prevalance 

of Overweight and Obesity Among Adults: United

States, 1999”, Health E-Stats, Center for Disease

Control and Prevention, December 15, 2000.

06 Hansen JR, MJ Hunter, MK; Type 2 Diabetes

Mellitus in Youth: A Growing Challenge. Clinical

Diabetes, Vol. 18, No. 2, Spring 2000, pp 52 – 56.

07 American Diabetes Association, Type 2 diabetes in

children and adolescents, Consensus Statement.

Diabetes Care, Vol. 22, No. 12, 381-xxx.

08 Type 2 Diabetes in the Pediatric Population,

RFA DK-00-008, NIDDK, NICHHD, Dec. 1, 1999.

09 Lindner, L. “Child-onset” diabetes. The Washington

Post, Health, Dec. 5, 2000.

10 The Effective 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.

1993 September 30; 239 (14): 977-86.

11 United Kingdom Prospective Diabetes Study 

Group: Intensive blood-glucose control with

sulphonylureas or insulin compared with 

conventional treatment and risk of complications

in patients with type 2 diabetes (UKPDS 33).

Lancet 352: 837 – 853, 1998.

12 Asch SM, et.al, Measuring Underuse of Necessary

Care Among Elderly Medicare Beneficiaries Using

Inpatient and Outpatient Claims, Journal of the

American Medical Association, Vol. 284, No. 18,

Nov. 8, 2000, pp. 2325-33.

13 Clark CM, et. Al, Promoting Early Diagnosis and

Treatment of Type 2 Diabetes, The National

Diabetes Education Program, Journal of the

American Medical Association, Vol. 284, No. 3,

July 19, 2000, pp. 363-65.

14 Asch SM, et.al, Measuring Underuse of Necessary

Care Among Elderly Medicare Beneficiaries Using

Inpatient and Outpatient Claims, Journal of the

American Medical Association, Vol. 284, No. 18,

Nov. 8, 2000, pp. 2325-33.

15 Marshall CL, Bluestein M. Chapin C, et al.

Outpatient management of diabetes mellitus in 

five Arizona Medicare managed care plans.

Am J Med Qual 1996, 11:87-93.

16 Harris MI. Health care and health status and 

outcomes for patients with type 2 diabetes.

Diabetes Care 2000; 23:754-8.

17 Cook, CB, Penman A, Cobb, AB, Miller, D, Murphy,

T, Horn, T. Outpatient diabetes management of

Medicare beneficiaries in four Mississippi feefor-service primary care clinics. J Miss State 

Med Assoc 1999; 40:8-13.

18 Kell SH, Drass J, Bausell RB, Thomas KA, Osborn

MA Gohdes D. Measure of diabetes control in

Medicare beneficiaries with diabetes mellitus.

J Am Geriatr Soc 1999; 47: 417-22.
79

NDEP Executive Committee, Steering Committee, and Work Group Members

NDEP EXECUTIVE COMMITTEE

Charles M. Clark, Jr, MD Regenstrief Institute for Health Care

Judith E. Fradkin, MD NIDDK, National Institutes of Health

Joanne Gallivan, MS, RD NIDDK, National Institutes of Health

Roland Hiss, MD Michigan Diabetes Research and Training Center,

University of Michigan Medical School

Rodney Lorenz, MD University of Illinois, College of Medicine

Frank Vinicor, MD, MPH Centers for Disease Control and Prevention

Faye L. Wong, MPH, RD Centers for Disease Control and Prevention

NDEP STEERING COMMITTEE

Kelly Acton, MD, MPH, FACP Indian Health Service

Ann Albright, PhD, RD California Diabetes Control Program

Gerald Bernstein, MD American Diabetes Association

Lawrence Blonde, MD, FACP American College of Physicians

Valentine Burroughs, MD National Medical Association

Jeff Caballero, MPH Assoc. of Asian/Pacific Community Health Organizations

Mary Clark, MEd The Links, Inc.

Charles M. Clark, Jr, MD Regenstrief Institute for Health Care

James Coan Health Care Financing Administration

P. Michael Conn, PhD Endocrine Society

Judith Dempster, PhD American Academy of Nurse Practitioners

Peter Fitzgerald American Association of Health Plans

Yanira Cruz Gonzalez, MPH National Council of La Raza

Roland Hiss, MD Michigan Diabetes Research and Training Center,

University of Michigan Medical School

Carolyn Leontos, MS, RD, CDE American Dietetic Association

Claresa Levetan, MD American Association of Clinical Endocrinologists

Rodney Lorenz, MD University of Illinois, College of Medicine

Eliana Loveluck, MSW National Alliance for Hispanic Health

David Marrero, PhD Indiana DRTC, Indiana University School of Medicine

Timothy McDonald, MS General Motors Corporation

Robert Moulthrop Juvenile Diabetes Foundation International
DMICC ANNUAL REPORT 80 FY 2000

NDEP STEERING COMMITTEE (continued)

Adolfo Perez-Comas, MD, PhD Puerto Rican Assoc. of Diabetes Educators

Kevin Peterson, MD American Academy of Family Physicians

Leonard M. Pogach, MD NJ Veterans Administration Health Care System

Stephen Popolizio, PhD Lions Clubs International

Jose Rivera, MPH Kaiser Permanente Stockton

Milissa Rock, CDE, RPH American Pharmaceutical Association

Yvette Roubideaux, MD, MPH Association of American Indian Physicians

Daniel Stryer, MD Agency for Health Care Policy and Research

Carolyn Thompson, MA Mississippi Diabetes Control Program

Christine Tobin, RN, CDE American Association of Diabetes Educators

Mark Williams, MD National Kidney Foundation

Violet Woo, MS, MPH Office of Minority Health, DHHS

NDEP STAFF

Larry Agodoa, MD NIDDK, National Institutes of Health

Sanford Garfield, PhD NIDDK, National Institutes of Health

Mimi Lising, MPH NIDDK, National Institutes of Health

Phyllis McGuire Centers for Disease Control and Prevention

Kathy Rufo, MPH Centers for Disease Control and Prevention

Elizabeth Singer, MS NIDDK, National Institutes of Health
DMICC ANNUAL REPORT 81 FY 2000

NDEP WORK GROUPS

Guiding Principles

Kelly Acton, MD, MPH, FACP Indian Health Service

Charles Clark, Jr, MD Regenstrief Institute for Health Care

Claresa Levetan, MD American Association of Clinical Endocrinologists

Adolfo Perez-Comas, MD, PhD Puerto Rican Assoc. of Diabetes Educators

Leonard M. Pogach, MD NJ Veterans Administration Health Care System

Christopher Saudek, MD American Diabetes Association

Stephen Spann, MD American Academy of Family Physicians

Robert E. Stone, MBA American Healthways, Inc.

Daniel Stryer, MD Agency for Health Care Policy and Research

Herbert Young, MD American Academy of Family Physicians

Community Interventions

Jeff Caballero, MPH Assoc. of Asian/Pacific Community Health Organizations

Mary Clark, MEd The Links, Inc.

Diana Nancy DeLeon, MPH White Memorial Medical Center

Steven Edelman, MD University of California at San Diego

Eliana Loveluck, MSW National Alliance for Hispanic Health

Stephen Popolizio, PhD Lions Clubs International

Yvette Roubideaux, MD, MPH Association of American Indian Physicians

Violet Woo, MS, MPH Office of Minority Health, DHHS

African American

James Black, DDS 100 Black Men of America

Eva Bradley, RN, BSN, CDE Independent Practioner

Mary Clark, MEd The Links, Inc.

Caswell Evans, Jr., DDS, MPH NIDCR, National Institutes of Health

Linda Jackson National Caucus and Center on Black Aged

Thomas Joyce, MS Ohio Dept. of Health, DCP

Sara Lomax Reese HealthQuest Magazine

Clifton Mitchell Center for Substance Abuse Treatment, SAMHSA

Carolyn Thompson, MA Mississippi Dept. of Health, DCP

Gladys Gary Vaughn, PhD U.S. Dept. of Agriculture

Stephanie White-Perry, MD Tennessee Dept. of Health, DCP

Frederick Wright The Urban League of Nebraska Inc.
DMICC ANNUAL REPORT 82 FY 2000

Hispanic/Latino American 

Nelva Ancona-Paraison Diabeticos Hispanos Perfil Latino TV Program

Lizia Auger University of Georgia, Cooperative Extension Service

Diana Nancy DeLeon, MPH White Memorial Medical Center

Yanira Cruz Gonzalez, MPH National Council of La Raza

Eliana Loveluck, MSW National Alliance for Hispanic Health

Wanda Montalvo, RN, MS, ANP Diabetes Collaborative, Northeast Cluster

Adolfo Perez-Comas, MD, PhD Puerto Rican Assoc. of Diabetes Educators

Elena Rios, MD, MSPH National Hispanic Medical Association

Betsy Rodriguez, CDE, MSN Puerto Rican Association of Diabetes Educators

Aracely Rosales Health Promotion Council

Marta Sotomayor, PhD National Hispanic Council on Aging

Jaime Torres, MD National Hispanic Medical Association

Elizabeth Valdez, MD Concilio Latino de Salud

Jose Luis Velasco, PhD National Hispanic Council on Aging

American Indian

Kelly Acton, MD, MPH, FACP Indian Health Service

Charlene Avery, MD Assoc. of American Indian Physicians

Dan Burich Bayer Pharmaceuticals

Lorelei De Cora, RN American Indian Talking Circles

Yvette Joseph-Fox, MSW National Indian Health Board

Margaret Knight Assoc. of American Indian Physicians

Gale Marshall Two Feathers Management

Kelly Moore, MD Billings Area Indian Health Service

Ben Muneta, MD Indian Health Service

Georgia Perez Univ. of New Mexico

Yvette Roubideaux, MD, MPH Association of American Indian Physicians

Lorraine Valdez, R.N., M.P.A., C.D.E. Indian Health Service

Tanya Wapskineh Assoc. of American Indian Physicians

Patricia Yarholer Assoc. of American Indian Physicians
DMICC ANNUAL REPORT 83 FY 2000

Asian American/Pacific Islander

Nina Agbayani, R.N. Assoc. of Asian / Pacific Community Health Orgs.

Jeff Caballero, MPH Assoc. of Asian / Pacific Community Health Orgs.

Catherine Cruz-Guzman, MPH, R.D. Guam Memorial Hospital Authority

Aurora Cudal, MPH Council of Phillipine American Orgs. Of San Diego County, Inc.

Tele Frost-Hill, RN, FNP LBJ Hospital

Wilfred Fujimoto, MD University of Washington

Lydia Hsu, RN, PHN, MHS North East Medical Services

Lisa Huang National Asian Women’s Health Organization

Peggy Huang, RN, CDE Diabetes Teaching Center, Dept. of Medicine and Endocrinology

Joseph Humphry, MD Hawaii Medical Service Association

Theanvy Kuoch, MA Connecticut Dept. of Public Health

Man-Ja Lee, RN Parkland Health and Hospital System

Jackie Liro Assoc. of Asian/Pacific Community Health Orgs.

T.G. Patel, MD U.S. Department of Veterans Affairs

Tam Phan Vietnamese Health Care Assoc.

Marcus Samo, MPH Department of Health and Social Affairs, Micronesia

Jennifer Stoll-Hadayia, M.P.A National Asian Women’s Health Organization

Robert Uhrle Advocate Initiatives for Grassroots Access (AIGA)

Violet Woo Office of Minority Health

HCFA Medicare Benefits 

Ann Albright, PhD, RD California Diabetes Control Program

Betty Burrier Health Care Financing Administration

Ashley Burt Ogilvie Public Relations Worldwide

James Coan Health Care Financing Administration

Jane Fletcher Lifescan, Inc.

Glendale Johnson National Council on Aging, Inc.

Carolyn Leontos, MS, RD, CDE American Dietetic Association

Rodney Lorenz, MD University of Illinois, College of Medicine

Jan Norman, RD, CDE Washington State Dept. of Health, DCP

Kathleen Swiger, MS University of North Carolina at Chapel Hill
DMICC ANNUAL REPORT 84 FY 2000

Health Care Provider

Samuel Abbate, MD, CDE American Diabetes Association

Lawrence Blonde, MD, FACP American College of Physicians

Charles Clark, Jr, MD Regenstrief Institute for Health Care

Sam Dagogo-Jack, MD University of Mississippi

Judith Dempster, PhD American Academy of Nurse Practitioners

Carolyn Leontos, M.S., R.D., CDE American Dietetic Association

Claresa Levetan, MD American Association of Clinical Endocrinologists

Bob McNellis, MPH, PA-C American Academy of Physician Assistants

Kevin Peterson, MD American Academy of Family Physicians

Leonard M. Pogach, MD NJ Veterans Administration Health Care System

Christine Tobin, R.N., CDE American Association of Diabetes Educators

Mark Williams, MD National Kidney Foundation

Pharmacy, Podiatry, Optometry, and Dental (PPOD)

Barbara J. Aung, DPM American Podiatric Association

Norma Bowyer, O.D., MPH, FAAO American Optometric Association

Caswell Evans, Jr., D.D.S., MPH National Dental Association

Joann Gurenlian, R.D.H., PhD American Dental Hygienists Association

Stuart Haines, PharMD, CDE University of Maryland, School of Pharmacy

Lawrence Harkless, DPM American Podiatric Association

S. Daniel Kidder National Association of Chain Drug Stores

Kathryn Kuhn, PD National Community Pharmacists Association

Milissa A. Rock, RPh, CDE American Pharmaceutical Association

Ross Taubman, DPM American Podiatric Medial Association

George W. Taylor, III, DMD, DPH School of Dentistry, University of Michigan

Rosie Janiszewski, MS, CHES National Eye Institute

Team Approach to Care

Kris Ernst, RN, CDE American Association of Diabetes Educators

Judith Dempster, DNSc, NP-C American Academy of Nurse Practioners

Martha Funnell, RN, MS, CDE Michigan Diabetes Research and Training Center,

University of Michigan 

Sandy Gillespie, MMSc, RD, LD Independent Practioner

Roland Hiss, MD Michigan Diabetes Research and Training Center,

University of Michigan 

Patricia Kidd, RN, C-FNP CIBA Vision Corp.
DMICC ANNUAL REPORT 85 FY 2000

Children and Adolescents with Diabetes

Charles M. Clark, Jr, MD Regenstrief Institute for Health Care

Anne Fagot-Campagna. MD Centers for Disease Control and Prevention

Leslie Curtis NIDDK, National Institutes of Health

Alison Evert, RD, CDE American Dietetic Association

Sheila Gahagan, MD University of Michigan

Barbara Linder, MD NIDDK, National Institutes of Health

Rodney Lorenz, MD University of Illinois, College of Medicine

Kelly Moore, MD Billings Area Indian Health Service

Robert Moulthrop Juvenile Diabetes Foundation International

Adolfo Perez-Comas, MD, PhD Puerto Rican Assoc. of Diabetes Educators

Judith Robinson, PhD, RN National Association of School Nurses

Stephanie White-Perry Tennessee Department of Health

Cheryl Wilson, MS Indian Health Service

Regan Wright American Diabetes Association

Business/Managed Care

Pamela Allweiss, MD American College of Occupational and Environmental Medicine

Jamie L. Amaral, M.H.A. National Federation of Independent Business

Kristen Birtwhistle, M.A. Stockton Kaiser Permanente Medical Center

Amita Dasmahapatra, MD Merck-Medco Managed Care, L.L.C.

M. Sue Gerson General Motors

Peter Fitzgerald American Association of Health Plans

Synnomon Harrell, MBA United Auto Workers

Pam Kalen Employers Managed Health Care Association

Barbara A. Larsen, MPH, RD Utah Diabetes Control Program Utah Dept. of Health

Timothy McDonald, PA, MHSA General Motors Corporation

Marilyn Park AFL-CIO

José Rivera, MPH Stockton Kaiser Permanente Medical Center

John Semeraro, MD Polaroid Corporation

Patricia Thompson-Reid, MPH Centers for Disease Control and Prevention

Cathy Van Doren, M.S.H., N.P. The Alliance Health Quality Partnership

Marcus G. Wilson, MD General Motors Corporation

DMICC ANNUAL REPORT 87 FY 2000

NDEP Publications

Materials for People with Diabetes 

Single copies free. See each item for pricing of additional copies and limits.

Take Care of Your Feet for a Lifetime (NDEP-4) ★

This illustrated patient booklet provides step-by-step instructions for proper foot care.

Includes a tear-off reminder card and a patient “To Do” list. Package of 25, $5. Limit 2 packages.

Control Your Diabetes. For Life. Tips for Feeling Better and Staying Healthy (NDEP–8) ★

This 2-color patient education booklet provides an action plan for diabetes control that includes tips on 

knowing blood sugar levels, reaching blood sugar goals, and maintaining blood sugar control.

Package of 50, $5. Limit 2 packages.

Control Your Diabetes. For Life. Tips for Feeling Better and Staying Healthy, Photocopy Master (NDEP–8PM)

Camera-ready version of NDEP–8. Limit 1 copy.

Tome su diabetes en serio, para que no se vuelva cosa seria.

Recomendaciones para sentirse mejor y estar mas saludable (NDEP–9) ★

Spanish version of Control Your Diabetes. For Life. Tips for Feeling Better and Staying Healthy.

Package of 50, $5. Limit 2 packages.

If You Have Diabetes, Know Your Blood Sugar Numbers (NDEP–10) ★

This reproducible, black-and-white patient education brochure provides information on measuring blood 

sugar levels using the hemoglobin A1C test and the finger-stick test (with a blood glucose monitor).

Package of 50, $5. Limit 1 package.

Sepa cuánta azúcar tiene en la sangre: Hágase la prueba para controlar el azúcar sanguíneo (NDEP–11) ★

Spanish version of Know Your Blood Sugar Numbers: The ABCs of Testing for Blood Sugar Control.

Package of 50, $5. Limit 1 package.

7 Principles for Controlling Your Diabetes for Life (NDEP–17) ★

This easy-to-read brochure for people with diabetes describes the essential components of quality diabetes 

care in a checklist form. Package of 50, $5. Limit 1 package.

7 Principios para controlar la diabetes para toda la vida (NDEP–18) ❚

Spanish version of 7 Principles for Controlling Your Diabetes for Life. Package of 50, $5. Limit 1 package.
DMICC ANNUAL REPORT 88 FY 2000

Expanded Coverage for Diabetes — Medicare and You (NDEP–19) ★

This brochure provides Medicare beneficiaries who have diabetes with information on expanded benefits 

for diabetes equipment and supplies. Limit 1 copy.

Expanded Coverage for Diabetes — Medicare and You, Photocopy Master (NDEP–19PM)

Camera-ready version of NDEP–19. Limit 1 copy.

Medicare tiene más que ofrecer. Beneficios adicionales para la diabetes (NDEP–30) ★

Spanish version of Expanded Coverage for Diabetes — Medicare and You. Limit 1 copy.

Medicare tiene más que ofrecer. Beneficios adicionales para la diabetes, Photocopy Master

(NDEP–30PM) Camera-ready version of NDEP–30. Limit 1 copy.

★ Commercial printer-ready Zip cartridges available. Call (301) 654–3327

Visit our home page at http://ndep.nih.gov to preview or download these publications.

Materials for Health Care Providers

Single copies free. See each item for pricing of additional copies and limits.

Feet Can Last a Lifetime Kit (NDEP–2) ★

This comprehensive kit for health care providers contains ready-to-use foot exam forms, Medicare certification

forms for therapeutic footwear, a sample disposable sensory testing monofilament, reproducible patient 

education materials, and current resource and reference materials. Single kit free. Each additional kit, $3.

Limit 6 kits.

Feet Can Last a Lifetime Videotape (VHS) (NDEP–6)

This two-part video is designed for both patients and health care providers. Part 1, dedicated to patient 

education, is a comprehensive guide to proper foot care including a sensory foot examination by a health care

provider, self-examination of the foot, daily foot and skin care, footwear selections, and the role of the podiatrist.

Part 2, for health care providers, reviews steps for conducting foot exams, assessing patients’ risk category,

and counseling patients on proper foot care (approximately 22 minutes). ($7)

Diabetes Numbers at-a-Glance (NDEP–12) ★

This quick-reference pocket guide for health care providers lists criteria for diagnosing diabetes and treating

people with diabetes. Package of 10, $5. Limit 5 packages.

Guiding Principles of Diabetes Care (NDEP–16) ★

This booklet describes the essential components of quality diabetes care for people with diabetes,

their families, health care providers, and insurers. Package of 50, $5. Limit 1 package.

Guía de Principios para el Cuidado de la Diabetes (NDEP–20) ★

Spanish version of Guiding Principles of Diabetes Care. Package of 50, $5. Limit 1 package.
DMICC ANNUAL REPORT 89 FY 2000

Materials for Organizations 

The following items are intended for use in public education campaigns, not for individual patients.

See each item for pricing of additional copies and limits.

Control Your Diabetes. For Life. Campaign Guide for Partners (NDEP–15) ★

This 58-page how-to guide is designed to help partner organizations disseminate the Control Your Diabetes.

For Life. campaign messages. Single copy free. Each additional copy, $3. Limit 2 copies.

Control Your Diabetes. For Life. Campaign Videotape 1999 Edition (VHS) (NDEP–23)

Includes: A message to Partners from Miss America; “Taking Control,” 30-second general audience PSA; 

“Family Reunion,” 30-second African-American PSA; “Future Generations,” 30-second American Indian PSA;

“Medicare Benefits,” 30-second Older American PSA (English); “Medicare Benefits,” 30-second Older American 

PSA (Spanish); “Thunder & Lightning,” 30-second Hispanic/Latino PSA (English); “Rayos y Truenos,” 30-second

Hispanic/Latino PSA (Spanish); “Couple in the Rain,” 15-second Hispanic/Latino PSA (Spanish); “Snowstorm,”

15-second Hispanic/Latino PSA (Spanish). ($10)

Control Your Diabetes. For Life. Campaign Videotape 1998 Edition (VHS) (NDEP–14) Includes: 

Many Faces of Diabetes, 60-, 30-, and 15-second general audience PSAs; Rayos y Truenos, 30-second PSA in

Spanish; a message from U.S. Surgeon General Dr. David Satcher; and campaign launch video news release. ($10) 

Changing the Way Diabetes Is Treated (The NDEP Program Video) (NDEP–24)

This video introduces the National Diabetes Education Program and its purpose, goals, and objectives.

It presents information on the devastating effects of diabetes and reasons why organizations should 

participate in the program. ($10) 

★ Commercial printer-ready Zip cartridges available. Call (301) 654–3327

Visit our home page at http://ndep.nih.gov to preview or download these publications.

Diabetes Community Partnership Guide (NDEP–21) 

A how-to kit that includes ideas, tools, and guidelines for community partnerships and diabetes activities.

Single copy free. Each additional copy, $3. Limit 2 copies.

Medicare Benefits and Controlling Your Diabetes Community Kit (NDEP–22)

This kit provides organizations with tools to promote the expanded benefits for Medicare recipients for 

diabetes equipment and supplies. Single copy free. Each additional copy, $2. Limit 2 copies.

How Can Medicare Help You Control Your Diabetes? Poster (NDEP–31)

This poster provides information about Medicare’s expanded coverage for diabetes equipment and 

monitoring supplies. Single copy free. Each additional copy, $1. (Limited quantity available.)

Making a Difference: The Business Community Takes on Diabetes (NDEP–33) ★

This white paper is a call-to-action for business leaders to become involved in workplace and community 

activities to control diabetes-related complications. It provides information on the human and economic 

impact of diabetes and gives suggestions on how businesses can help employees with diabetes achieve 

improved glycemic control. Single copy free. Each additional copy, $1.
DMICC ANNUAL REPORT 90 FY 2000

Media Kits

Single copy free. Limit 1 copy each. Reproducible.

General Audience Campaign Media Kit (NDEP–25) 

Focuses on the seriousness of diabetes and the importance of controlling blood sugar levels. Includes a 

sample news release, diabetes statistics, resources, educational materials for people with diabetes,

print public service ads, and live-read radio scripts.

African-American Media Kit (NDEP–26)

Focuses on the seriousness of diabetes in the African-American population with a “Family Reunion” theme.

Includes a sample news release, diabetes statistics, resources, educational materials for patients, print 

public service ads, and live-read radio scripts.

American Indian Media Kit (NDEP–27)

Focuses on the seriousness of diabetes in the American Indian population. Includes a sample news release,

diabetes statistics, resources, educational materials for patients, print public service ads, and live-read 

radio scripts.

Asian American and Pacific Islander Media Kit—English Version (NDEP–28)

Focuses on the seriousness of diabetes in Asian Americans and Pacific Islanders. Includes a sample news 

release, diabetes statistics, resources, educational materials for patients, print public service ads, and 

live-read radio scripts.

Asian American and Pacific Islander Media Kit—Translated Versions 

The sample news release, diabetes statistics, live-read radio scripts, and print ads from the English kit 

have been translated into 11 Asian American and Pacific Islander languages.

Cambodian (NDEP–28CA) Ilokano (for Filipinos) (NDEP–28IL)

Chinese (NDEP–28CH) Korean (NDEP–28KO)

English (for Asian Indians) (NDEP–28EI) Laotian (NDEP–28LO)

Gujarati (for Asian Indians)(NDEP–28GU) Samoan (NDEP–28SM)

Hindi (for Asian Indians) (NDEP–28HI) Tagalog (for Filipinos) (NDEP–28PI)

Hmong (NDEP–28HM) Vietnamese (NDEP–28VI)

Hispanic and Latino Media Kit (NDEP–29)

Focuses on the seriousness of diabetes in the Hispanic and Latino population. Includes a sample news 

release, diabetes statistics, resources, educational materials for patients, print public service ads,

and live-read radio scripts.

★ Commercial printer-ready Zip cartridges available. Call (301) 654–3327

Visit our home page at http://ndep.nih.gov to preview or download these publications.
DMICC ANNUAL REPORT 91 FY 2000

NDEP partners include State Diabetes Control Programs, minority-focused organizations and agencies,

voluntary and professional groups, and business and media-related groups. Following are highlights of 

NDEP activities implemented by partner organizations.

STATE DIABETES CONTROL PROGRAMS

The CDC supports Diabetes Control Programs (DCPs) in state health departments in all 50 states and U.S.

territories. Their mission is to lessen the burden of diabetes in their states. The DCPs are active partners in

NDEP, promoting the program through their networks. Examples of DCP activities include the following:

Arkansas Diabetes Control Program: Converted the NDEP’s “Family Reunion” print ads into a public transit 

ad, which is being displayed on public transportation vehicles throughout the state; transferred the “Family

Reunion” TV PSA to 35mm format for showing in movie theaters; placed NDEP news releases and public service

ads in Arkansas media outlets; and distributed materials to health care providers and at community events.

California Diabetes Control Program: Contracted with the California Broadcasters Association to add a local

tag to the Control Your Diabetes. For Life. and Spanish-language radio PSAs, which were broadcast throughout

the state.

Connecticut Diabetes Control Program: Worked with the Connecticut Department of Public Health Refugee

Health Program to promote the NDEP’s Asian American and Pacific Islander campaign materials.

Delaware Diabetes Control Program: With the American Diabetes Association (ADA), conducted five community

presentations to promote diabetes and NDEP awareness and distributed NDEP materials to 35 churches that 

participate in ADA’s Diabetes Sunday Program.

Idaho Diabetes Control Program: Incorporated NDEP messages and logo on its fact sheet, “Diabetes in Idaho

and the U.S.: Reducing the Burden of Diabetes,” which is being distributed throughout the state at local health

professional events and to members of the Diabetes Alliance of Idaho; distributes NDEP materials to rural 

health clinics; and developed partnerships with four American Indian tribes and is working with tribal leaders 

to disseminate NDEP’s American Indian campaign.

Indiana Diabetes Control Program: Placed the Control Your Diabetes. For Life. logo on the Indiana State

Department of Health’s diabetes web page and has linked this page to the NDEP web site; the department’s web

page was highlighted during March, Diabetes Awareness Month, and on a video produced by the department.

Highlights of NDEP Partner Activities
DMICC ANNUAL REPORT 92 FY 2000

Kentucky Diabetes Control Program: Trained over 100 members of the Kentucky Diabetes Network and 45 

local health departments, nurses, dietitians, and health educators in using the Community Partnership Guide 

and widely distributed the NDEP Numbers-at-a-Glance cards to health care providers.

Maryland Diabetes Control Program: Held a statewide diabetes partnership meeting based on the NDEP 

partnership model and showcased NDEP campaign messages.

Michigan Diabetes Control Program: Incorporated NDEP messages and materials into presentations to 

the Michigan Diabetes Outreach Network (NDON), which reaches people with diabetes and health care 

professionals throughout the state.

Mississippi Diabetes Control Program: Developed diabetes information pages for telephone directories in 

three cities with large African-American populations, using NDEP African American campaign materials; 

also contracted with the Southern Urban Network, a consortium of 25 African American radio stations across 

the state to broadcast the NDEP campaign PSAs.

New York Diabetes Control Program: Promotes NDEP on state health websites and distributes NDEP materials

through three Diabetes Centers of Excellence and at the state fair, the Senior Games, and the La Salud Hispanic

Health Fair; adapts NDEP material for use by the state’s 14 Community Diabetes Coalitions.

North Carolina Diabetes Control Program: Developed partnerships with rural health centers and hospitals,

HMOs, and veterans hospitals and shared NDEP campaign materials with the state’s 87 local health 

departments; distributed NDEP African American campaign materials via the Baptist Informer, a monthly

newsletter that goes to more than 15,000 African American churches in the state; NDEP general audience 

and American Indian campaign print ads also have appeared in Making a Difference in Diabetes, a magazine

published by the Durham Herald Sun newspapers.

North Dakota Diabetes Control Program: Developed a Leader’s Guide for service organizations to promote 

diabetes education in their communities that lists NDEP materials as resources and is used by nearly 400 

service organizations; also lists NDEP materials on its Department of Health website.

Ohio Diabetes Control Program: In partnership with the Ohio Association of Broadcasters, arranged for 

broadcast of NDEP TV PSA campaign messages throughout the state.

Oregon Diabetes Control Program: Partnered with the horticultural nursery industry to place diabetes print

ads and articles in The Digger Magazine, which reaches growers in Oregon, Washington, Idaho, and British

Columbia; also maintains a web page, including a Spanish version, that has a link to the NDEP web page.

Tennessee Diabetes Control Program: In partnership with the University of Tennessee Extension Service,

included NDEP messages in its statewide health education program and the University’s Center for 

Community-based Health Initiatives; also using NDEP African American campaign materials in communitybased interventions with 18 county health councils and in State Extension Service diabetes cooking schools; 

promoted NDEP PSAs on local radio stations, and disseminated the NDEP Community Partnership Guide to

regional offices and coalitions, primary care providers, insurers, public health workers, and diabetes educators.
DMICC ANNUAL REPORT 93 FY 2000

Texas Diabetes Control Program: Through its partnership with the Texas Association of Broadcasters,

the Texas DCP distributed NDEP PSAs to 143 television stations and 723 radio stations; the DCP also is 

encouraging its 18 community-based organization grantees to become involved in NDEP.

Utah Diabetes Control Program: Distributed the “Guiding Principles of Diabetes Care” to health plan medical

directors and quality assurance staff throughout the state; incorporated NDEP campaign messages into a

statewide media campaign; distributed NDEP materials, using own logo, to health plans, community health 

centers, quality improvement clinics, hospital administrators, diabetes educators, community partners, Indian

tribes, resource line callers, and state Extension Services; used NDEP radio and television PSAs, as well as its

own, in diabetes awareness campaigns directed to American Indians, Hispanics, and older Americans.

Washington Diabetes Control Program: Convened a meeting with representatives of 30 organizations serving

the state’s Asian and Pacific Islander communities to promote NDEP; distributed NDEP information and diabetes

care wallet cards in English and Spanish to more than 7,000 primary care providers in the state and distributed

70,000 diabetes care wallet cards with the NDEP logo to retail pharmacies; shared its Control Your Diabetes.

For Life. wallet cards with DCP programs in Connecticut, Idaho, Mississippi and Montana; sponsors a website 

to communicate with other NDEP partners and health care professionals; provided NDEP materials at healthy

eating classes and at Asian American/Pacific Islander and community-wide health fairs; presented NDEP PSAs 

to the Washington State Diabetes Collaborative.

West Virginia Diabetes Control Program: In partnership with West Virginia Medical Institute and the 

West Virginia Hospital Association, developed a Year 2000 Diabetes Toolkit, featuring the Control Your Diabetes.

For Life theme, which was mailed to more than 800 physicians in the state; also has developed radio and 

television PSAs that feature the NDEP campaign theme.

Wisconsin Diabetes Control Program: Developed the Personal Diabetes Care Record Card for patients,

which includes the NDEP campaign logo and is available in English, Spanish, and Hmong; the cards have been

widely distributed throughout the state; also has distributed the NDEP’s press release, “Nation’s Health Report

Shows Widespread Increase in Diabetes,” to all media outlets in the state in conjunction with the launch of

Healthy People 2010.

Wyoming Diabetes Control Program: The DCP held a NDEP campaign launch event in the state capitol and is

promoting NDEP messages in media outlets throughout the state.
DMICC ANNUAL REPORT 94 FY 2000

Minority-Focused Organizations and Agencies

NDEP has strong support from the many minority organizations that participate as partners in the program.

Representatives from a number of these groups serve on the Steering Committee and on the Work Groups,

including the four Work Groups concerned with minority populations, the African American Work Group, the

Hispanic/Latino Work Group, the Asian American and Pacific Islander Work Group, and the American Indian 

Work Group.

Minority organizations are actively working with NDEP to develop culturally and linguistically appropriate 

campaign and educational materials and disseminate NDEP messages among their constituencies and health

care professionals who provide services to minority patients. Some examples of activities are:

African-American Work Group Members: Participated in a panel on diabetes in the African American 

community at the Lonnie Mitchell Historically Black Colleges and Universities Substance Abuse Conference 

and displayed and distributed NDEP materials.

Association of American Indian Physicians (AAIP): Promotes NDEP on its website, through its toll-free 

telephone service, at meetings, through a speakers bureau; networks with local and tribal health units; 

participated in the NDEP American Indian campaign launch; monitors and evaluates use of NDEP materials; 

promotes NDEP through its network of regional partners and to allied organizations and programs such as 

the Association of Native American Students and Strategies for the Prevention and Control of Diabetes Project;

added the AAIP logo to the NDEP American Indian radio, print, and television PSAs and distributed them to

American Indian media; developed an American Indian Control Your Diabetes. For Life. campaign poster/

calendar that is distributed at conferences, events, and workshops attended by AAIP; distributed Things You 

Can Do to Make a Difference in Diabetes in Your Community to promote the campaign and encourage 

diabetes awareness activities for American Indians throughout the United States; disseminates NDEP patient

education brochures with the AAIP logo at American Indian events and conferences; developed a media kit 

for distribution at Native American events and meetings.

Association of Asian Pacific Community Health Organizations: The organization’s BALANCE Program 

for Diabetes funded centers in California, Hawaii, Massachusetts, and New York using NDEP resources; 

held community discussion groups to profile Asian Americans’ and Pacific Islanders’ knowledge, attitudes,

and beliefs about diabetes; coordinated a review of 150 existing diabetes education materials in Asian 

and Pacific Island languages; and trains media spokespersons for the NDEP’s media campaign.

Black Women’s Agenda (Washington, DC): Showcased the NDEP television PSA, “Family Reunion,” at its 

Annual Luncheon and Workshop held at the Congressional Black Caucus Meeting and made a presentation 

on NDEP.

Center for Substance Abuse Treatment (Washington, DC): Distributed NDEP materials at the “Targeted

Capacity Expansion Conference,” held in Washington, DC, reaching more than 530 SAMHSA grantees and others;

also sponsored a workshop on diabetes in the American Indian community during the conference.

Connecticut Department of Public Health Refugee Health Program: Presented the NDEP message to

Cambodian groups in Western Massachusetts and Connecticut and networked with the Connecticut DCP to 

promote NDEP Asian American and Pacific Islander materials.
DMICC ANNUAL REPORT 95 FY 2000

Diabeticos Hispanos (Millville, NJ): Produces a segment for Perfil Latino, a weekly bilingual cable television

program that airs in New Jersey and reaches more than 14 Hispanic communities.

Indian Health Service: Presented NDEP’s American Indian campaign at meetings with the New Mexico 

Diabetes Advisory Council, Navajo Area Indian Health Service Diabetes Coordinators, and the National Diabetes

Prevention Center; mailed NDEP campaign materials and educational materials to all IHS diabetes grantees; 

and included information about NDEP its newsletter Diabetes News.

Japanese American Community Diabetes Study (JACDS) at the University of Washington: Included an 

article on the NDEP’s importance to Asian Americans and Pacific Islanders on its Spotlight Feature website and

created a link with the NDEP website.

La Voz del Anciano (Dallas, TX): Holds diabetes awareness programs in Spanish at senior centers and churches

and distributes NDEP materials to health care providers, at community events, and in organization mailings.

The Links, Inc: Distributed NDEP’s “Family Reunion” PSA to 240 chapters throughout the country to use in 

community outreach activities; included NDEP materials in the National Eye Institute’s Diabetes Month mailing

to Links chapters throughout the country; and co-authored an editorial with NDEP on African Americans and

diabetes that was placed in African American newspapers across the country.

National Asian Women’s Health Organization: Disseminated the NDEP Asian American and Pacific Islander

media kit to print and media outlets throughout the country serving this population, reaching more than 

750,000 persons; holds regional conferences to distribute diabetes educational materials and NDEP Asianlanguage media kits, which have been translated into 11 different Asian languages; included the NDEP 

print ad, editorial, and feature story on the NDEP’s AAPI awareness campaign in the organization’s Diabetes

Program newsletter, which is distributed to more than 5,000 individuals; developed the NAWHO Diabetes

Program Brochure, which includes information on NDEP and the program’s logo.

National Caucus and Center on Black Aged (Washington, DC): Sponsored a diabetes education workshop 

with the NDEP at the caucus’ “Circle of Friends: Partnerships for Health” program during Older Americans 

Month and distributed NDEP materials at the meeting.

National Coalition of Hispanic Health & Human Service Organizations: Incorporated an article about the

new Medicare benefits for people with diabetes in its newsletter and included a presentation on the NDEP’s

“Rayos Y Truenos” campaign on its annual meeting agenda.

National Council of La Raza: With NDEP funding, established a National Latino Diabetes Initiative that 

supports four community-based organizations that are promoting diabetes education and awareness and 

incorporating NDEP principles; launched a bilingual web site dedicated to providing the latest news and information about diabetes for the Latino community; produces and distributes The Diabetes Alert on a quarterly

basis to NCLR affiliates; produced a children’s storybook about diabetes titled Dia a Dia con la Tia Betes; 

sponsored a diabetes awareness campaign called A Su Salud:Viva Mas, Viva Mejor!, that reached nearly 37 

million people through print, broadcast, radio, and Internet locally and nationally.

National Hispanic Council on Aging: Supports a diabetes awareness project that targets midlife and older

Mexican Americans and Puerto Ricans at risk for or who have diabetes.
DMICC ANNUAL REPORT 96 FY 2000

North East Medical Services (NEMS) (San Francisco, CA): Distributed resource and education materials to

1,000 NEMS patients and 7,000 attendees of San Francisco’s Chinese New Year’s Fair; placed monthly diabetes

PSAs in major San Francisco Bay area Chinese newspapers; developed a press release on diabetes and cardiovascular disease and distributed it to a Chinese newspaper published in several major cities; translated the

Control Your Diabetes. For Life. campaign brochure and Diabetes Numbers at-a-Glance card and distributed 

them to patients and health care providers; distributed translated NDEP materials through Chinese herbalists,

acupuncturists, and Chinese-owned businesses.

Office of Minority Health: Devoted an entire issue of its Closing the Gap newsletter, which reaches more than

7,000 individuals and organizations, to the NDEP and exhibited NDEP materials at its Partnership Summit.

Tennessee African American NDEP Work Group: Promoted diabetes awareness and presented NDEP goals 

to 350 participants at the Fourth Annual Minority Health Summit and partnered with the Tennessee Minority

Health Coalition to exhibit NDEP materials at the meeting.

Urban League of Nebraska Inc.: Spearheading the National Urban League’s program called Lift Every Voice: 

A Community-Based National Diabetes Education and Prevention Program. The League is replicating and

enhancing an effective community organization/education strategy and apply it to diabetes education and 

prevention and is providing technical assistance resources and training in 16 targeted African American 

communities to implement a series of culturally appropriate community intervention strategies.

Urban League of Wichita: Conducts the Urban League’s “Lift Every Voice” diabetes education and awareness

program in Kansas and partners with local organizations to distribute NDEP materials.

Vietnamese American Health Care Association (Madison, WI): Promotes the NDEP campaign to Vietnamese

media in Orange County, San Jose, Houston, Washington, DC, Chicago, and St. Paul; also distributes NDEP 

materials to the Vietnamese Physician Association and 120 community-based organizations.

Voluntary and Professional Groups

A number of voluntary and professional groups are active in NDEP as members of the NDEP Steering Committee

and as members of NDEP Work Groups. As such, they are invaluable partners in developing messages and 

materials designed to reach a wide audience of the general public, patients, health care community, and 

insurance and business industries. Examples of NDEP-related activities carried out by these groups include:

American Academy of Family Physicians: Published news about NDEP and the program’s Guiding 

Principles for Diabetes Care in its journal, American Family Physician, and has linked its website to the 

NDEP’s “Guiding Principles.”

American Academy of Nurse Practitioners: Publishes news of NDEP in its newsletter and invited NDEP 

to exhibit at its annual meeting.

American Association of Clinical Endocrinologists: Announced support for NDEP in a news release about 

its “Patients First” campaign.
DMICC ANNUAL REPORT 97 FY 2000

American Association of Diabetes Educators: Distributes NDEP materials at annual meetings; 

includes NDEP presentations at annual meetings; and features news of NDEP in its publications.

American Diabetes Association: ADA affiliates have partnered with DCPs and other groups to disseminate

NDEP messages; included the NDEP’s “Numbers At-a-Glance” reference cards in a mailing to 15,000 health 

care professionals; added the ADA tag to NDEP’s “Family Reunion” and “Future Generations” TV PSAs and 

distributed them to TV stations across the country; features NDEP presentations at meetings; and has 

representatives on the NDEP Steering Committee and on Work Groups.

American Dietetic Association: Featured presentations on NDEP initiatives at every annual meeting since 

1997; devoted an entire issue of On the Cutting Edge, a monthly newsletter of the association’s Diabetes Care 

and Education (DCE) Practice Group to NDEP; and runs a regular column on NDEP in Newsflash, another 

DCE practice group publication.

Delmarva Foundation for Medical Care (Easton, MD): Distributed a diabetes toolkit containing NDEP 

messages and information to nearly 3,000 providers.

La Joya Senior Citizen Center (La Joya, TX): Gives presentations on diabetes at senior citizen centers and 

distributes NDEP materials in church bulletins and at senior centers, health fairs, community events,

post offices, and stores.

Lions Clubs International: Mailed NDEP kits to district Diabetes Awareness Chairmen across the country;

linked its website to NDEP’s website; promotes NDEP activities and materials in its publications and 

through its CORE 4 Grant Program initiative.

Mt. Sinai Medical Center (Cleveland, OH): Included information on NDEP in presentations at community 

events in the Cleveland, Ohio, area.

National Medical Association (NMA): Announced support for NDEP at the African American campaign 

press briefing in 1998 in Washington, DC.

Northeast Cluster of the Bureau of Primary Health Care Diabetes Collaborative (Staten Island, NY):

Sponsored presentations on NDEP at 20 community health centers and trained health team members in 

using the Community Partnership and Campaign guides.

Southern New Jersey Family Medical Center: Features the NDEP’s Control Your Diabetes. For Life.

campaign theme in print ads distributed to local newspapers and advertising books; included diabetes 

information in The Atlantic County Minority Health Guide; participated in a diabetes telethon on local 

television in Atlantic City, NJ.

U.S. Department of Veterans Affairs: Worked with community leaders in Los Angeles to display the translated

Asian Indian print ads at the festival of Garba, which attracts 3,000 people; also displayed the ads on the 

bulletin board of a Los Angeles temple during the Indian New Year’s festival. In addition, the VA has partnered

with the NDEP on the “Feet Can Last a Lifetime” kit, promoted NDEP materials throughout the VA, linked its 

website to the NDEP site, and invited the NDEP to present at their annual meeting.
DMICC ANNUAL REPORT 98 FY 2000

Business and Media Partners

NDEP partners in the business and media communities are important allies in producing and disseminating

NDEP messages and materials. A number of companies have helped the program and its partners in printing

materials, helping to support meetings, distributing NDEP materials in direct mailings and through their sales

teams, and cosponsoring campaigns. For example:

Bayer Pharmaceuticals: Reprinted 1,000 NDEP American Indian posters for distribution at the National 

Indian Health Board meeting in Anchorage, Alaska; sponsored a luncheon and distributed NDEP materials at

AAIP’s mid-year diabetes conference.

Bristol Meyers Squibb: Sponsored professional golfer Lee Elder’s appearances at NDEP campaign launches.

Eli Lilly and Company: Sponsored a luncheon following the NDEP campaign launch in June 1998; 

provided funding support for NDEP to exhibit the African American campaign at the National Council of 

Negro Women’s Black Family Reunion Celebration in Washington DC in 1999.

HealthQuest Magazine: Publishes NDEP print PSAs to promote diabetes control and features articles about 

diabetes and African Americans in the magazine.

Lifescan: Reprinted and distributed over one million copies of the Diabetes at-a-Glance card to health care

providers and patients.

Merck-Medco: Printed and distributed copies of the Diabetes Numbers At-a-Glance card to 40,000 physicians 

in its diabetes prescription program.

Mutual of Omaha: Teamed up with 100 Black Men of Omaha to initiate a campaign targeted to African

Americans with diabetes in Nebraska using NDEP campaign messages.

National Association of Broadcasters: Transmitted NDEP PSAs on its monthly satellite feed of programming

and PSA messages to its 1,300 member TV stations.

Parke-Davis: Sponsored printing of 70,000 diabetes care wallet cards with the NDEP logo and slogan 

distributed by the Washington Diabetes Control Program to all retail pharmacies in the state.

Pfizer, Inc.: Supported the Wyoming Diabetes Control Program’s efforts to promote NDEP activities across the

state.

WJLA-TV/Parke Davis/Safeway: In partnership with NDEP, the Health Care Financing Administration,

Parke Davis, and pharmacies in local Safeway stores, the ABC affiliate in Washington, DC, promoted diabetes

awareness and Medicare benefits in the metropolitan Washington, DC, area during Diabetes Month in 1998.
99

Interagency Coordinating Committees

Sec.429. [285c—3] (a) For the purpose of —

(1) better coordination of the research activities of all the national research institutes relating to 

diabetes mellitus, digestive diseases, and kidney, urologic, and hematologic diseases; and

(2) coordinating those aspects of all Federal health programs and activities relating to such diseases 

to assure the adequacy and technical soundness of such programs and activities and to provide 

for the full communication and exchange of information necessary to maintain adequate 

coordination of such programs and activities;

the secretary shall establish a Diabetes Mellitus Interagency Coordinating Committee, a Digestive Diseases

Interagency Coordinating Committee, and a Kidney, Urologic, and Hematologic Diseases Coordinating

Committee (hereafter in this section individually referred to as a “Committee”).

(a) Each committee shall be composed of the Directors of each of the national research institutes and 

divisions involved in research with respect to the diseases for which the Committee is established,

the Division Director of the Institute for the diseases for which the Committee is established, the 

Chief Medical Director of the Veterans’ Administration,1 and the Assistant Secretary of Defense for

Health Affairs (or the designees of such officers) and shall include representation from all other

Federal departments and agencies whose programs involve health functions or responsibilities 

relevant to such diseases, as determined by the Secretary. Each Committee shall be chaired by the

Director of NIH (or the designee of the Director). Each committee shall meet at the call of the 

chairman, but not less often than four times a year.

(b) each Committee shall prepare an annual report for —

(1) the Secretary;

(2) the Director of NIH; and

(3) the Advisory Board established under section 430 for the diseases for which the Committee 

was established, detailing the work of the Committee in carrying out paragraphs (1) and 

(2) of subsection (a) in the fiscal year for which the report was prepared. Such report shall be 

submitted not later than 120 days after the end of each fiscal year.

1 The reference is deemed to be a reference to the Under Secretary for Health of the Department of Veteran Affairs.

See section 302 (e)(1) of Public Law 102-405(106) Stat. 1985 and section 10(4) of Public Law 100-527 (102 Stat.2641)

APPENDIX A

101

Diabetes Mellitus Interagency Coordinating Committee

ROSTER OF MEMBERS

CHAIRMAN

Allen Spiegel, MD

Director

National Institute of Diabetes and 

Digestive and Kidney Diseases

National Institutes of Health

Building 31, Room 9A52

9000 Rockville Pike

Bethesda, MD 20892

Phone: (301)496-5877 

Fax: (301) 496-9943

E-mail: allens@amb.niddk.gov

EXECUTIVE SECRETARY

Sanford Garfield, PhD

Senior Advisor, Biometrics and Behavioral Science

National Institute of Diabetes and 

Digestive and Kidney Diseases

National Institutes of Health

6707 Democracy Boulevard, Room 685

Bethesda, MD 20892-5460

Phone: (301) 594-8803

Fax: (301) 480-3503

E-mail: garfields@extra.niddk.nih.gov

MEMBERS

Kelly Acton, MD, MPH

Director, National Diabetes Program

Indian Health Service 

National Institutes of Health

Headquarters Office

5300 Homestead Road, N.E.

Albuquerque, NM 87110-1293

Phone: (505) 248-4182

Fax: (505) 248-4188

E-mail: kelly.acton@mail.ihs.gov

Nell Armstrong, PhD, R.N.

Program Director

National Institute of Nursing Research

Building 45, Room 3AN-12

45 Center Drive, MSC 6300

Bethesda, MD 20892-6300

Phone: (301) 594-5973

Fax: (301) 480-8260

E-mail: nell_armstrong@nih.gov

Kate Berg, MD, MPH (Alternate)

Deputy Scientific Director

National Human Genome Research Institute

National Institutes of Health

31 Center Drive, MSC 2152

Bethesda, MD 20892-0844

Phone: (301) 594-2481

Fax: (301) 402-2040

E-mail: kb22t@nih.gov

Perry Blackshear, MD, D.Phil

Director, Office of Clinical Program 

National Institute of Environmental Health Sciences 

National Institutes of Health

NIEHS, MD A2-05

PO Box 12233

RTP, NC 27709

Phone: (919)-541-4899

Fax: (919) 541-4571

E-mail: black009@niehs.nih.gov

APPENDIX B
DMICC ANNUAL REPORT 102 FY 2000

RADM Susan J. Blumenthal, MD, MPH

U.S. Assistant Surgeon General 

Office of Public Health and Sciences 

Department of Health and Human Services 

5600 Fishers Lane, Room 18-66

Rockville, MD 20857

Phone: (301) 443-2270

Fax: (301) 443-3574

E-mail: sblumenthal@osophs.dhhs.gov

Carl Caspersen, PhD 

Associate Director for Science, DDT (K-10)

Centers for Disease Control and Prevention

4770 Buford Highway

Atlanta, GA 30341

Phone: (770) 488-5326

Fax: (770) 488-5966

E-mail: ccaspersen@cdc.gov

Bethesda, MD 20893

Carolyn Clancy, MD

Director, Center for Outcomes and 

Effectiveness Research

Agency for Health Care Research and Quality

6010 Executive Boulevard, Suite 300

Rockville, MD 20852

Phone: (301) 594-2829

Fax: (301) 594-3211

E-mail: cclancy@ahcpr.gov

Elaine Collier, MD

Centers Program Director

Division of Allergy, Immunology and Transplantation

National Institute of Allergy and Infectious Diseases

National Institutes of Health

Soar Building, Room 4A20

9000 Rockville Pike

Bethesda, MD 20892-7640

Phone: (301) 496-7104

Fax: (301) 402-2571

E-mail: ec5x@nih.gov

Peter Dudley, PhD

Chief, Endocrinology, Nutrition, & Growth 

Senior Science Advisor Program

National Eye Institute

National Institutes of Health

6120 Executive Plaza South

Building 6100, Room 4B11

Rockville, MD 20852-7164

Phone: (301) 496-0484

Fax: (301) 402-0528

E-mail: pad@nei.nih.gov

Chhanda Dutta, PhD

Director, Musculoskeletal Research and

Nutrition Metabolism & Gastrointestinal

Research, Geriatrics Program

National Institute on Aging

Gateway Building, Suite 3E327

7201 Wisconsin Avenue

Bethesda, MD 20814

Phone: (301) 435-3048

Fax: (301) 402-1784

E-mail: duttac@exmur.nia.nih.gov

Mark Eberhardt, PhD

Epidemiologist

National Center for Health Statistics

Centers for Disease Control & Prevention

6525 Belcrest Road, Room 730

Hyattsville, MD 20782

Phone: (301) 436-5979, X142

Fax: (301) 436-8459

E-mail: MSE1@cdc.gov

Julia Freeman, PhD

Chief, Autoimmunity Section

National Institute of Arthritis & Musculoskeletal 

& Skin Diseases

National Institutes of Health

Building 45, Room 5AS-19F

45 Center Drive, MSC 6500

Bethesda, MD 20892-6500

Phone: (301) 594-5052

Fax: (301) 480-4543

Email: freemanbj@exchange.nih.gov
DMICC ANNUAL REPORT 103 FY 2000

Gilman D. Grave, MD

Program Director, Retinal Diseases Branch

Center for Research for Mothers & Children

National Institute of Child Health & 

Human Development

National Institutes of Health

6100 Executive Boulevard

Suite 350, MSC 7510

Bethesda, MD 20892-7510

Phone: (301) 496-5593

Fax: (301) 480-9791

E-mail: gg37v@nih.gov

Judith Greenberg, PhD

Developmental Biology

National Institute of General Medical Sciences

National Institutes of Health

Building 45, Room 2AS-25

45 Center Drive, MSC 6200

Bethesda, MD 20892-6200

Phone: (301) 594-0943

Fax: (301) 480-2228

E-mail: greenbej@nigms.nih.gov

Rachel Greenberg

Senior Project Manager

National Diabetes Education Program

Hager Sharp Inc.

1090 Vermont Avenue NW

3rd Floor

Washington, DC 20005

Phone: (202) 842-3600

E-mail: rgreenbe@hagersharp.com

Joan Jacobs, MPH

Health Policy Analyst

Division of Policy and Data

Office of Public Health and Sciences

Department of Health and Human Services

5515 Security Lane, Rockwall II

Rockville, MD 28052

Phone: (301) 443-9923

Fax: (301) 443-8280

E-mail: jjacobs@osophs.dhhs.gov

Elke Jordan, PhD

Deputy Director

National Human Genome Research Institute

31 Center Drive, MSC 2152

Bethesda, MD 20892-0844

Phone: (301) 496-0844

Fax: (301) 402-0837

E-mail: elkej@od.nhgri.nih.gov

Mary Beth Kester

Director, Division of Genetics & Program Analyst

National Institute of Diabetes and Digestive 

and Kidney Diseases

National Institutes of Health

Building 31, Room 9A07

31 Center Drive MSC 2560

Bethesda, MD 20852

Phone: (301) 496-6623

Fax: (301) 480-6741

E-mail: kesterm@extra.niddk.nih.gov

Richard Knazek, MD

Medical Officer

National Center for Research Resources

Clinical Research

National Institutes of Health

6705 Rockledge Drive

Fax: (202) 842-4032

Rockledge 1, Room 6128

Bethesda, MD 20892

Phone: (301) 435-0790

Fax: (301) 480-3661

E-mail: richardk@ncrr.nih.gov

N. Krish Krishnan, PhD

Scientific Review Administrator

Center for Scientific Review

National Institutes of Health

Two Rockledge Centre

Room 6164

Bethesda, MD 20892

Phone: (301) 435-1041

Fax: (301) 480-2065

E-mail: krishnak@csr.nih.gov
DMICC ANNUAL REPORT 104 FY 2000

John P. Lanigan

Health Insurance Specialist

Office of Professional Relations

Health Care Financing Administration

Hubert Humphrey Building

Room 435H

Washington, DC 20201

Phone: (202) 690-7418

Fax: (202) 401-7438

E-mail: jlanigan@hcfa.gov

Louis Emmett Mahoney, MD, PhD

Senior Medical Advisor

Office of the Administrator

Center for Quality Health Resources

and Services Administration

Department of Health and Human Services

Parklawn Building

5600 Fishers Lane, Room 9-05

Phone: (301) 443-0458

Fax: (301) 443-9795

E-mail: lmahoney@hrsa.gov

Dennis Mangan, PhD

Chief, Infectious Diseases and Immunity Branch

Division of External Research

National Institute of Dental and 

Craniofacial Research

National Institutes of Health

Building 45, Room 4AN-32F

45 Center Drive, MSC 6402

Bethesda, MD 20892

Phone: (301) 594-2421

Fax: (301) 480-8318

E-mail: dennis.mangan@nih.gov

Nancy E. Miller, PhD

Senior Science Policy Analyst

National Institutes of Health

Building 1, Room 218

Bethesda, MD 20892

Phone: (301) 594-7742

Fax: (301) 402-0280

E-mail: nm68k@nih.gov

Peter Muehrer, PhD

Chief, Health and Behavioral Science 

Research Branch

Division of Mental Disorders, Behavioral

Research, and AIDS

National Institute of Mental Health

National Institutes of Health

6001 Executive Boulevard, Room 6189

MSC 9615

Bethesda, MD 20892-9615 

Phone: (301)-443-4708

Fax: (301)480-4415

E-mail: pmuerhrer@mail.nih.gov

Capt. Laura McNally

Office of the Administrator

Center for Quality Health Resources

and Services Administration

Department of Health and Human Services

Parklawn Building, Room 9-05

Rockville, MD 20857

Phone: (301) 443-0458

Fax: (301) 443-9795

E-mail: lmcnally@hrsa.gov
DMICC ANNUAL REPORT 105 FY 2000

Paul L. Nichols, PhD

Program Director, Systems and Cognitive

Neuroscience Program

National Institute of Neurological Disorders 

and Stroke

National Institutes of Health

6001 Executive Boulevard, Room 2118

Rockville, MD 20892

Phone: (301) 496-9964

Fax: (301) 402-2060

E-mail: pn13w@nih.gov

Leonard M. Pogach, MD, MBA

National Program Director, Diabetes

Veterans Health Administration

East Orange Veterans Affairs Medical Center

385 Tremont Avenue

East Orange, NJ 07019-1095

Phone: (973) 676-1000 ext.1095

Fax: (973) 677-4408

E-mail: leonard.pogach@med.va.gov

Peter J. Savage, MD

Acting Director, Division of Epidemiology 

and Clinical Applications

National Heart, Lung and Blood Institute

National Institutes of Health

Rockledge 2, Room 8104

Bethesda, MD 20817

Phone: (301) 435-0421

Fax: (301) 480-1864

E-mail: savagep@nhlbi.nih.gov

Shaio-Wei Shen, MD

Medical Officer, Division of Metabolism 

and Endocrine Drug Products

Food and Drug Administration

Parklawn Building, Room 14B-04

5600 Fishers Lane, HFD-510

Rockville, MD 20857

Phone: (301) 827-6378

Fax: (301) 443-9282

E-mail: shen@cder.fda.gov

Daniel B. Stryer, MD

Medical Officer

Center for Outcomes and Effectiveness Research

Agency for Healthcare Research and Quality

6010 Executive Boulevard

Suite 300

Rockville, MD 20852

Phone: (301) 594-4038

Fax: (301) 594-3211

107

FY2000 BUDGET ACTUALS

APPENDIX C