1. The National Diabetes Management Strategy: Diabetes Facts and Figures By using these slides, you agree to the terms on the next slide. The development of these slides was made possible by through financial support by Merck.

2. Terms of Use By using this web site and/or these slides and/or requesting and receiving the information on this site, you are accepting these terms of use. These slides and the related information on the The National Diabetes Management Strategy website synthesize publicly available information in a convenient format. This information is intended for use by policymakers, managers, media, planners, clinicians and researchers. All information provided on this site and in these slides is publicly available from the original sources. All information is attributed to the original source. All information in these slides is copyrighted by other parties. As a visitor to this site, you are granted a limited license to use the information contained within for non-commercial use only, provided the information is not modified and all copyright and other proprietary notices are retained. The National Diabetes Management Strategy and The University of Western Ontario resides in Ontario, Canada and this site and any transactions which you enter into through this site are governed by the laws of Ontario, Canada and the federal laws of Canada applicable therein. The faculty and staff of The National Diabetes Management Strategy The University of Western Ontario shall not be liable for any damages, claims, liabilities, costs or obligations arising from the use or misuse of the material contained on this web site, whether such obligations arise in contract, negligence, equity or statute law. The National Diabetes Management Strategy and The University of Western Ontario do not guarantee or warrant the quality, accuracy, completeness, timeliness, appropriateness or suitability of the information provided. Links to other sites are provided as a reference to assist you in identifying and locating other Internet resources that may be of interest. The National Diabetes Management Strategy and The University of Western Ontario does not assume responsibility for the accuracy or appropriateness of the information contained on other sites, nor do we endorse the viewpoints expressed on other sites.

3. Diabetes is a Worldwide Problem

4. Diabetes is a Worldwide Epidemic 20112030 Total world population (billions)7.08.3 Adult population (20–79 years, billions)4.45.6 Diabetes Global prevalence (%)8.39.9 Number of people with diabetes (millions)366552 In 2011, there were an estimated 366 million people with diabetes (8.3% of the world’s population) By 2030, the prevalence is projected to rise to 522 million (9.9%) International Diabetes Federation. Global burden. IDF Diabetes Atlas. 5 th edition 2011.

5. Leading Causes of Global Death: 2004 and 2030 20042030 DiseaseDeathsRank Deaths Heart disease12.21114.2 CVD9.72212.1 Pneumonia7.0343.8 HIV/AIDS3.56101.8 Lung cancer2.3863.4 Diabetes1.91273.3 Malaria1.713410.4 Breast cancer0.923191.1 Chronic conditions have overtaken infectious diseases as the leading causes of global death. World Health Statistics. World Health Organization; 2008.

6. Global Diabetes Statistics Since 1980, the number of adults with diabetes worldwide has doubled. (1) There will be an estimated 70% increase in the number of adults with diabetes in the developing world, and a 20% increase in the developed world between 2010 and 2030. (2) Each year, approximately 78,000 children worldwide develop type 1 diabetes. (3) 1.Danaei G, et al. Lancet. 2011;378(9785):31-40. 2.Shaw JE, et al. Diabetes Res Clin Pract. 2010;87:8-14. 3.IDF Diabetes Atlas. 5 th Edition. 2011

7. US Diabetes Statistics 25.8 million Americans (8.3% of the US population) have diabetes: –Diagnosed: 18.8 million people –Undiagnosed: 7.0 million people –Prediabetes: 79 million people One in every 400 American children is currently diagnosed with diabetes. National Diabetes Fact Sheet 2011. Centers for Disease Control and Prevention.

8. Diabetes is a Canadian Problem

9. Prevalence of Diagnosed Diabetes Overall prevalence: 6.2% (N=2,086,212) –Males: 6.6% (n=1,092,407) –Females: 5.9% (n=993,805) Age-standardized prevalence: –Overall: 5.2% –Males: 5.8% –Females: 5.2% The prevalence of diagnosed diabetes in Canada in 2006–2007 was 6.2% (approximately 2.0 million people aged 1 year or older). Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

10. Diabetes Prevalence Increases With Age 35-39 years: 2.4% 50-54 years: 8.0% (note sharp increase in middle age) 75-79 years: 23.4% Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

11. Increase in Prevalence of Diagnosed Diabetes After adjusting for differences in age distributions among the provinces over time, the prevalence of diagnosed diabetes increased by 21% from 2002/03 to 2006/07. Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

12. Prevalence of Diagnosed Diabetes Varies by Province Highest age-adjusted prevalence in: –MB (5.6%) –ON (5.6%) –NS (5.8%) –NB (5.6%) –NL (5.9%) –YK (5.5%) –NT (5.2%) Lowest age-adjusted prevalence in: –QC (4.7%) –AB (4.7%) –BC (4.9%) Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

13. Implications of Variable Provincial Diabetes Prevalence Rates Implications for provincially specific: –human and financial resource planning –population-based prevention strategies –individual risk factor reduction –screening for diabetes and pre-diabetes, and –management

14. The Prevalence of Diabetes in Canada is Increasing The prevalence of diabetes in Canada is expected to increase by ~6% per year. By 2012, ~2.8 million Canadians will have diagnosed diabetes. This will represent a 25% increase in prevalence from 2007. Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

15. Diabetes in Canada: 2007 to 2017 Between 2007 and 2017, an estimated 1.9 million Canadians (aged 20 years and older) will be newly diagnosed with diabetes. This means that about nine out of every 100 Canadians are predicted to be newly diagnosed with diabetes during the 10-year period. Manuel DG, et al. Toronto, ON: Institute for Clinical Evaluative Sciences; 2010.

16. Incidence of Diabetes (2006–2007) Among people aged 1 year or older, 211,168 individuals were given a new diagnosis of diabetes: –6.7 per 1,000 individuals –6.1 per 1,000 girls/women –7.3 per 1,000 boys/men Rates of new diagnosis of diabetes show a similar trend as prevalence with rates that rise steeply after age 45 and peak among those aged 70–74 for both men and women. After adjusting for differences in age distributions among the provinces over time, the incidence rate increased by 9% between 2002/03 and 2006/07. Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

17. Diabetes in Ontario In Ontario from 1995 to 2005, the number of adults with diabetes increased by 113%, while the population grew by only 17%. 1 The prevalence of diabetes is increasing in Ontario at a rate of approximately 6% per year. 1 There are currently an estimated 1.2 million people (8.2% of the population) diagnosed with diabetes in Ontario. 2 This is projected to increase to more than 1.9 million people (11.9% of the population) by 2020. 2 Lipscombe LL, Hux JE. Lancet. 2007;369:750-756. Canadian Diabetes Association. The Burden of Diabetes in Ontario. http://www.diabetes.ca/get-involved/news/diabetes-cost- model-released-in-ontario/http://www.diabetes.ca/get-involved/news/diabetes-cost- model-released-in-ontario/

18. Incidence of Diabetes in Ontario Factors that may have affected prevalence in Ontario from 1995–2005: –Longevity: People with and without diabetes are living longer: 25% reduction in standardized mortality from 1995 to 2005. –Obesity: In Canada alone, rates have increased by 20 to 30% in the last decade. WHO diabetes prevalence estimates were based on the unwarranted assumption that obesity rates would remain constant. Lipscombe LL, Hux JE. Lancet. 2007;369:750-756.

19. Incidence of Diabetes in Ontario (cont’d) Other factors that may have affected prevalence in Ontario from 1995–2005: –Immigration: Ontario had a 51% increase in immigrants from South Asia from 1995 to 2001. –Incidence: Record rise of 31% from 1997 to 2003. –Guidelines: Publication of diabetes guidelines may have enhanced screening and detection rates. The implications... The size of the diabetes epidemic is far greater than was anticipated. Lipscombe LL, Hux JE. Lancet. 2007;369:750–756.

20. Factors Affecting the Prevalence and Incidence of Diabetes in Canada

21. An Aging Population The prevalence of diabetes begins to increase steadily after age 40. The proportion of senior citizens in Canada’s overall population is increasing. 1 –In 2006, seniors accounted for 13.7% of the total population. 2 –By 2031, seniors will account for approximately 24% (almost double 2006 levels). 2 1.Canadian Diabetes Association Clinical Practices Guidelines Expert Committee. Can J Diabetes. 2008;32(suppl 1) :S1–S201. 2.Statistics Canada. Population projections 2005–2031. 3.Statistics Canada. 2006 Census: Age and Sex.

22. An Aging Population (cont’d) By the year 2056, the median age of Canadians will be 45–50 years. 1 Guidelines recommend screening starting at age 40. Therefore… over half the population will have at least one risk factor (age >40) and should be regularly screened for diabetes. 2 1.Statistics Canada. 2006 Census: Age and Sex. 2.Canadian Diabetes Association Clinical Practices Guidelines Expert Committee. Can J Diabetes. 2008;32(suppl 1) :S1–S201.

23. An Aging Population (cont’d) Aging trends vary by province, with important implications for regional healthcare planning and policy. Proportion of seniors according to the 2006 Census: –National average: 13.5% –Saskatchewan: 15.4% (highest) –Alberta: 10.7% (lowest) Statistics Canada. 2006 Census: Age and Sex.

24. Increasing Immigration From High-risk Populations Most recent immigrants come from populations at high risk for developing diabetes Of immigrants who came to Canada from 2001– 2006, approximately 80% were from populations at increased risk of developing diabetes: –58.3% came from Asia –10.6% came from Africa –10.8% came from Central/South America and the Caribbean Statistics Canada. 2006 Census: Immigration, citizenship, language, mobility and migration.

25. Implications of Immigration Patterns for Diabetes Prevalence and Incidence Healthcare system will need to respond to the specific healthcare needs of these populations with culturally and linguistically relevant prevention, screening and management practices. Major cities (Toronto, Vancouver, Montreal) are home to the majority of recent immigrants (69%), with implications for local healthcare planning. Statistics Canada. 2006 Census: Immigration, citizenship, language, mobility and migration.

26. Percentage of Foreign-born Canadians is Increasing By 2031, between 25% and 28% of the population could be foreign-born. Between 29% and 32% of the population could belong to a visible minority group, as defined in the Employment Equity Act. This would be nearly double the proportion reported by the 2006 Census. Statistics Canada. Study: Projections of the diversity of the Canadian population, 2006 to 2031.

27. The Percentage of Foreign-born Canadians Is Increasing (cont’d) About 55% of this population would be born in Asian countries, which have a very high incidence and prevalence of type 2 diabetes. In addition, Canada’s Black and Filipino populations could double, and Arab and West Asian groups could more than triple. Statistics Canada. Study: Projections of the diversity of the Canadian population, 2006 to 2031.

28. Aboriginal Population Growth Type 2 diabetes has reached epidemic proportions among Canadian Aboriginal peoples. The national age-adjusted prevalence is 2.5 to 5 times higher than that of the general population, and age-adjusted prevalence rates as high as 26% have been found in individual communities. 1-3 Aboriginal peoples are diagnosed with type 2 diabetes at a much younger age, with high rates of diabetes in children and adolescents. 4 Due primarily to a high birth rate, from 1996 to 2003, the Aboriginal population grew by 45%, nearly 6 times the growth rate of non-Aboriginals. 5 1. Dyck R, et al. CMAJ. 2010; 182(3):249-256. 2. Green C, et al. Diabetes Care. 2003;26:1993–1998. 3. Harris SB, et al. Diabetes Care. 1997;20:185–187. 4. Fagot-Campagna A, et al. J Pediatr. 2000;136:664–672. 5. Statistics Canada. Aboriginal population in 2017.

29. Diabetes Surveillance System for First Nations Communities The First Nations Diabetes Surveillance System is a web-based surveillance application that will track type 2 diabetes and complication rates over time in First Nations communities. This information will allow the monitoring of the diabetes burden in each partnering community and can be used to inform and evaluate new quality improvement initiatives in communities. The goal of the Surveillance System is to monitor and track diabetes rates so that informed decisions can be made to improve community care. First Nations Surveillance System Newsletter. November 2010.

30. Diabetes Surveillance System for First Nations Communities Similar programs in Aboriginal settings in the United States and Australia have been associated with sustained improvements in quality of care for people diagnosed with diabetes. Although this program is currently a 2-year pilot program, it is hoped that in the future the system will be expanded to include other communities, and that ongoing financial support will help sustain the program. The Surveillance System has been generously funded by the Aboriginal Diabetes Initiative, First Nations and Inuit Health Branch at Health Canada. First Nations Surveillance System Newsletter. November 2010.

31. Canada Has a National Diabetes Surveillance System In each province and territory, the health insurance registry database is linked to physician billing and hospitalization databases An individual is identified as having diagnosed diabetes, if: –At least one hospitalization with diagnosis of diabetes; or –At least two physician visits with a diagnosis of diabetes within a 2-year period. –Gestational diabetes mellitus excluded. Current national database includes summary data on individuals 1 year or older at time of diabetes diagnosis from all provinces and territories from 1995/96 to 2004/2005. Age-standardized data are adjusted to 1991 Census data. Can’t distinguish between type 1 and type 2 diabetes. Validated methodology. Public Health Agency of Canada; 2009. Available at: http://www.phac-aspc.gc.ca.

32. Increasing Prevalence of Adult and Childhood Obesity In 2008, of adult Canadians: –51% being overweight –17% reported being obese. 1 From 2003 to 2008, obesity rates rose: –from 16% to 18% in men –from 15% to 16% in women The highest rate of obesity (22%) was among 55 to 64 year olds –24% of men –21% of women 1 In boys and girls aged 2–17 years, prevalence of obesity from 1978/1979 to 2004 increased from 3% to 8%. 2 1. Statistics Canada. Canadian Community Health Survey, 2008. 2. Lau DCW, et al. CMAJ. 2007;176(8 Suppl):S1–13.

33. Overweight, Obesity and Diabetes Between 2007 and 2017, it is estimated that people who are overweight (BMI 25–30 kg/m 2 ) will comprise the greatest number of new cases of diabetes (712,000) While those who are overweight have lower baseline risk than those who are obese (BMI 30–35 kg/m 2 ) or morbidly obese (BMI >35 kg/m 2 ), there are more more Canadians who are overweight than obese Manuel DG, et al. Toronto, ON: Institute for Clinical Evaluative Sciences; 2010.

34. Low Levels of Physical Activity In 2008, only 51% of Canadians reported being at least moderately active during their leisure time. “Moderately active” is equivalent to walking at least 30 minutes a day or taking an hour-long exercise class at least 3 times a week. Statistics Canada. Canadian Community Health Survey, 2008.

35. Socioeconomic & Environmental Impact on Health: Canadians Living in Poverty Health follows a social gradient: populations in a lower position in the social hierarchy experience the worst health More than 12% of the working-age population lives in poverty. 1 People who live in poverty are: –often unable to meet basic housing, food and security needs –have a greater risk of health problems than people who do not live in poverty Compared to those in the highest-income neighbourhoods, life expectancy in the lowest-income quintile neighbourhoods in Canada is: –5 years shorter for men –1.6 years shorter for women 2 1.Canada’s Record on Poverty Among The Worst of Developed Countries−And Slipping. Available at: http://www.conferenceboard.ca. 2.Ontario Medical Review. 2008;May:32-37.

36. Socioeconomic & Environmental Factors Diabetes Disproportionately Affects the Poor Diabetes is disproportionately clustered: 1 –in the lower socioeconomic status quintiles –in neighbourhoods with: lower average household incomes high proportions of visible minorities and/or recent immigrants In 2007, the self-reported age-standardized diabetes prevalence rate was highest among adults with a household income of <$20,000 (8%) This rate was double that of the group with an income of  $60,000 (4%). 2 1.Hux JE, et al. In: Diabetes in Ontario: An ICES Practice Atlas: Institute for Clinical and Evaluative Sciences. 2.Canadian Institute for Health Information. Diabetes Care Gaps and Disparities in Canada December 2009.

37. Socioeconomic & Environmental Factors Diabetes Disproportionately Affects the Poor People in lower income brackets and with fewer years of education also report the following (all of which are risk factors for diabetes): –Higher rates of smoking –Less physical activity; and –Higher rates of overweight Statistics Canada. National Population Health Survey – Household Component Longitudinal, 1998–1999.

38. Socioeconomic Status Also Affects Diabetes Care In 2007, people with higher household incomes were more likely to receive: –an A1C test –a urine test for protein –a dilated eye exam –a foot exam –all 4 recommended tests The age-standardized percentage of adults with diabetes receiving all 4 recommended tests was: –highest in the highest household income group (42%) –lowest in the lowest household income group (21%) Canadian Institute for Health Information. Diabetes Care Gaps and Disparities in Canada; December 2009.

39. Diabetes is a Serious Disease

40. Diabetes is a Frequent Reason for Physician Visits Top 10 reasons* for patient visits ¶ to physicians in Canada, 2009 1. Hypertension 2. Health check-up (Routine Child Health Check-up [V20.2] and Routine General Medical Exam and Health Check-up [V70.0]) 3. Diabetes (without complications) 4. Depression 5. Anxiety 6. Acute upper respiratory infection 7. Normal pregnancy supervision 8. Hyperlipidemia 9. Surveillance of contraceptive methods 10. Hypothyroidism * Based on ICD-9 classifications ¶ Visits made to Canadian office-based physicians – physicians maintaining an office outside hospitals

41. Diabetes is the Sixth Leading Cause of Death in Canada Cause of deathRankNumber All causes of death−226,584 Cancer166,947 Heart diseases252,000 Stroke314,626 Chronic lower respiratory diseases410,041 Accidents (unintentional injuries)58,986 Diabetes67,823 Influenza and pneumonia75,729 Alzheimer’s disease85,536 Suicide93,613 Kidney diseases103,541 All other causes−47,742 Statistics Canada. Leading causes of death in Canada, 2000 to 2004.

42. Diabetes is Associated with Serious Complications Diabetes is associated with significant morbidity Among people with diabetes: –40% have diabetic retinopathy –15% have foot ulcers –80–90% have obesity –34–45% have erectile dysfunction –40–50% have neuropathy –40% have anxiety and 15% have depression –75% of deaths will be due to coronary or cerebrovascular event –Have a 2- to 3-fold increased risk of CAD Public Health Agency of Canada. Diabetes in Canada: Highlights from the National Diabetes Surveillance System 2004–2005.. Canadian Diabetes Association Clinical Practice Guideline Expert Committee. Can J Diabetes. 2008;32 (suppl 1): S1-S201. Statistics Canada. Sequelae of diabetes. Diabetic foot, chronic ICD-9 250.7.

43. Diabetes is the Leading Cause of End-stage Renal Disease Diabetes is the predominant cause of ESRD in Canada –identified in 35% of new cases in 2008 The most significant factors associated with less favourable outcomes in dialysis patients and mortality after a kidney transplant are: –advancing age, and –the diagnosis of diabetes Canadian Institute for Health Information. 2010.

44. Worldwide, diabetic retinopathy is responsible for 4.8% of cases of blindness due to eye disease Diabetic retinopathy is responsible for 4.8% of the 37 million cases of blindness due to eye diseases throughout the world (i.e. 1.8 million persons). After 15 years of having diabetes, about 2.0% of individuals will become blind, while about 10% will suffer severe visual loss. After 20 years, over 75% of people with diabetes will have some form of diabetic retinopathy. This eye disease can seriously compromise people's ability to work and live productive lives. VISION 20/20 The Right to Sight. Diabetic Retinopathy.

45. Diabetes is Associated with Higher Mortality After Cancer Surgery People with diabetes who undergo cancer surgery are more likely to die in the month following their operation than people who have cancer, but do not have diabetes. People with newly diagnosed cancers – especially colorectal or esophageal tumours – who also have type 2 diabetes have an approximately 50% greater risk of dying following surgery. While the reasons for this are not clear, possible explanations include: –increased risk of infection and infection-related mortality associated with diabetes –increased risk of cardiovascular death associated with diabetes. Barone BB, et al. Diabetes Care. 2010;33:931-939.

46. Diabetes is a Strain on Out-patient and In-patient Resources Compared to people without diabetes, adults with diabetes in Canada have: –Twice as many visits to family physicians –3 to 4 times as many visits to specialists Compared to people without diabetes, people with diabetes were hospitalized at higher rates for: –Heart failure: 4-fold increase –Stroke: 3-fold increase –Heart attack: 3-fold increase –Chronic kidney disease: 6-fold increase –Lower limb amputation: 19-fold increase Public Health Agency of Canada. Report from the National Diabetes Surveillance: Diabetes in Canada 2009.

47. Diabetes Shortens Life Expectancy For All Ages Compared to people without diabetes, people with diabetes have higher mortality rates: –20–44 years: 4 to 6 times higher –45–79 years: 2 to 3 times higher Public Health Agency of Canada. Report from the National Diabetes Surveillance: Diabetes in Canada 2009.

48. Diabetes Treatments are Among the Top 10 Most Frequently Dispensed Therapeutic Classes in Canada RankTherapeutic class Prescriptions* dispensed in 2009 (in millions) 1Cardiovasculars74,423 2Psychotherapeutics61,202 3Gastrointestinal/genitourinary33,585 4Cholesterol agents31,825 5Hormones26,130 6Analgesics25,232 7Anti-infectives (systemic)24,723 8Diabetes therapies21,348 9Neurological disorders19,994 10Diuretics17,515 *Estimated prescriptions dispensed in Canadian retail pharmacies. Includes new and refills IMS Health Canada; CompuScript, 2010.

49. Diabetes Treatments are Among the Top 10 Therapeutic Classes by Worldwide Sales, 2008 IMS Health, MIDAS, December 2010. RankTherapeutic class Sales (US$ billions) % Sales 1Oncologics52.47.0 2Lipid regulators35.34.7 3Respiratory agents33.64.5 4Anti-diabetics30.44.0 5Anti-ulcerants29.63.9 6Angiotensin-II antagonists25.23.4 7Anti-psychotics23.23.1 8Anti-depressants19.42.6 9Autoimmune agents18.02.4 10Platelet aggregation inhibitors14.61.9 Total top 10 281.737.5 Sales cover direct and indirect pharmaceutical channel purchases in US dollars from pharmaceutical wholesalers and manufacturers. The figures above include prescription and certain over-the-counter data and represent manufacturer prices. Totals may not add up to 100% due to rounding.

50. Diabetes is an Expensive Disease

51. Diabetes is Straining Worldwide Healthcare Budgets In 2011, the estimated global healthcare cost to diagnose and treat diabetes is at least $465 billion USD. International Diabetes Federation. Diabetes Atlas 5 th edition. 2011.

52. Diabetes is Straining Canadian Healthcare Budgets The economic burden of diabetes in Canada is: –currently estimated to be $12.2. billion –expected to increase to $16.9 billion by 2020. The direct costs of diabetes currently account for approximately 3.5% of public healthcare spending. Canadian Diabetes Association. An Economic Tsunami, The Cost Of Diabetes. 2009

53. Diabetes is Straining American Healthcare Budgets It is predicted that in the next 25 years, spending on diabetes in the US will almost triple, increasing from $113 billion in 2009 to $336 billion in 2034. Huang ES, et al. Diabetes Care. 2009;32:2225-2229.

54. Diabetes Management in Canada

55. CDA Publishes Clinical Practice Guidelines The Canadian Diabetes Association Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada are published once every 5 years (most recently in 2008) Represent the best and most current evidence- based clinical practice data for healthcare professionals

56. Many patients not meeting therapeutic targets The goal of treatment is to minimize the risk of complications by aiming for guideline-recommended targets. Studies of Canadian patients with type 2 diabetes in the primary care setting demonstrated: –47% to 49% were above the A1C target <7.0% 1,2 –46% were above the BP target of 130/80 mm Hg 2 –36% were above the LDL-C target of 2.5 mmol/L (2003 CDA guideline-recommended target). In the 2008 CDA guidelines, this target was lowered to 2.0 mmol/L. Had this target been applied, 63% would have been above target 2 –Only 21% achieved all three key targets 1 1. Braga MFB, et al. Can J Cardiol. 2010;26(6):297-302. 2. Harris SB, et al. Diabetes Res Clin Prac. 2005;70(1):90-07.

57. Public Awareness About Diabetes is Low

58. Diabetes Awareness in the US In the US, when asked to rank which disease (diabetes, breast cancer, AIDS) caused the most deaths each year, not even half of respondents chose diabetes (42%). In the US, diabetes causes more deaths per year than breast cancer and AIDS combined. Canadian data on diabetes awareness are not available. As America Earns Failing Grade, American Diabetes Association Launches Movement to Stop Diabetes. Available at: http://www.diabetes.org/for-media/2009/america-earns-failing-adm-sd-2009.html.

59. American Diabetes Association Awareness Survey The American Diabetes Association conducted an online survey to determine what people fear most: –16% feared being in a plane crash –13% feared snake bites –5% feared being hit by lightning –5% feared getting an illness/disease –4% feared a shark attack When asked specifically about diseases: –49% feared cancer –Only 3% cited a fear of diabetes Ironically, 10% of adults reports having been diagnosed with diabetes, while fewer (6%) have been diagnosed with cancer. Further, cancer and diabetes have similar rates of expected new cases each year American Diabetes Association Survey. Available at: http://www.marketwire.com/press-release/American-Diabetes-Association-914002.html.