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National Diabetes Awareness Month -- November 1995
     November is National Diabetes Awareness Month. In the United
States, approximately half of the 16 million persons with diabetes
are believed to be aware that they have this condition. This year,
efforts will emphasize increasing awareness among health
professionals and the public about scientific findings that confirm
the benefit of glycemic control and comprehensive strategies in
preventing several complications of diabetes. Special materials are
available from a consortium of federal agencies and private
organizations (1). These materials include information about
diabetes and its preventable complications (i.e., amputations,
blindness, cardiovascular disease, and renal disease).
     Additional information about diabetes is available from
diabetes-control programs in state and territorial health
departments, and a Diabetes Home Page is now available through the
CDC home page on the Internet World Wide Web
(http://www.cdc.gov/nccdphp/ddt/ddthome.htm).
Reference
1. CDC. Availability of information on diabetes awareness. MMWR
1995;44:821-2.


Cardiovascular Disease Risk Factors and Related Preventive
Health Practices Among Adults With and Without Diabetes -- Utah,
1988-1993
     The risk for cardiovascular disease (CVD) among persons with
diabetes is two to three times higher than among persons without
diabetes, and CVD accounts for 48% of all deaths among persons with
diabetes (1,2). To estimate the prevalence of CVD risk factors
among and related preventive health practices of the adult
population with diabetes in Utah, the Utah Diabetes Control Program
(UDCP) previously had relied primarily on data from national
surveys. To guide in planning and decision-making about future
activities of the UDCP and to assess CVD-related behaviors and
health practices among persons with diabetes, UDCP analyzed data
from Utah's Behavioral Risk Factor Surveillance System (BRFSS) for
1988-1993. This report presents the findings of this analysis.
     Data were available for 10,388 adults who participated in the
Utah BRFSS during 1988-1993. The BRFSS is a state-specific,
population-based, random-digit-dialed telephone survey of the
civilian, noninstitutionalized population aged greater than or
equal to 18 years. The analysis examined sociodemographic
characteristics, CVD risk factors, and related preventive health
practices of all BRFSS respondents. SUDAAN was used to weight the
results to reflect the age and sex distributions of the Utah
population aged greater than or equal to 18 years and to control
for potential confounding by age and sex using logistic regression
(3).
     Of the 10,388 respondents, 405 (3.4% [95% confidence interval
(CI)=3.0%-3.8%]) reported having been told by a physician they have
diabetes. The unadjusted results indicated that persons with
diabetes were more likely than persons without diabetes to be older
and female, to have attained a lower level of education, to be
retired, and to have lower annual incomes (Table 1).
     Among persons with diabetes, risk factors for CVD were highly
prevalent (Table 2): 50% reported having been told by a health-care
professional they have high blood pressure, and 11% reported
current smoking*. After controlling for potential confounding by
age and sex, persons with diabetes were approximately 2.5 times
more likely than persons without diabetes to report having high
blood pressure (odds ratio [OR]=2.7; 95% CI=2.1-3.4) and to be
obese** (OR=2.5; 95% CI=2.0-3.2) and somewhat more likely to report
a sedentary lifestyle*** (OR=1.3; 95% CI=1.0-1.7).
     Persons with diabetes were more likely than persons without
diabetes to report having engaged in health practices to prevent
CVD (Table 2), including having had a routine examination (86%
versus 62%), having had their blood cholesterol checked during the
preceding year (68% versus 39%), and trying to lose weight (41%
versus 32%). However, of persons who reported trying to lose
weight, those with diabetes were less likely to report using
exercise, either alone or in conjunction with diet, than persons
without diabetes (45% versus 71%). Differences in the prevalence of
preventive health behaviors persisted after controlling for age and
sex: routine examination (OR=2.6; 95% CI=1.8-3.8), blood
cholesterol check (OR=2.0; 95% CI=1.5-2.5), trying to lose weight
(OR=1.5; 95% CI=1.1-2.1).
Reported by: B Larsen, MPH, M Friedrichs, MS, Diabetes Control
Program, R Giles, Bur of Health Promotion, Div of Community and
Family Health Svcs; Bur of Surveillance and Analysis, Office of
Public Health Data, Utah Dept of Health. Epidemiology and
Statistics Br, Div of Diabetes Translation, National Center for
Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: In Utah, characteristics of persons with and
without diabetes are similar to national patterns: among persons
with diabetes, higher proportions are older, have lower incomes,
and are less educated (4). Based on these patterns, UDCP is
collaborating with the state Medicare program to address the need
for providers caring for patients with diabetes to receive
reimbursement for outpatient education and nutrition counseling,
and to ensure access to diabetes education and counseling for
Medicaid recipients. In addition, UDCP is adapting current diabetes
educational materials for selected groups, including persons who
attained low education levels.
     Although the prevalences of major CVD risk factors in the
adult population of Utah were lower than national prevalences
(5,6), the BRFSS findings documented substantially higher
prevalences among persons with diabetes. Based on these findings,
UDCP will initiate efforts to increase patient and community
awareness about CVD risk factors by 1) educating community members
through outreach activities; 2) training local health department
staff to emphasize the importance of diabetes education and the
reduction of CVD risk factors (e.g., smoking and sedentary
lifestyle); and 3) implementing a statewide media campaign with the
Utah Diabetes Awareness Partnership about CVD risk factors. The
BRFSS findings also will be used to increase awareness and improve
care practices among health-care providers through 1) professional
education seminars for primary-care physicians in rural areas,
geriatric nurses working in home health, and mid-level
practitioners; 2) development of office reminder systems to improve
the quality of care in the primary-care setting, and 3)
collaboration with the state Medicaid program to develop statewide
standards of care for persons with diabetes.
     Beginning in 1994, CDC-funded cooperative agreements
facilitated the restructuring of state diabetes-control programs to
emphasize quality of care and monitoring of behavioral risk factors
and preventive health practices (7). Based on the findings in this
report, the Utah Department of Health will emphasize development of
strategies to increase awareness about CVD risk factors and related
preventive health behaviors and to improve medical care for persons
with diabetes. In 1994, UDCP expanded surveillance efforts to
include the use of the new BRFSS diabetes module recently developed
by CDC to collect additional information from persons with diabetes
about diabetes education, glycemic control, the frequency of
screening for diabetic complications, and impaired visual acuity.
These data are not available from other state-specific data
sources and will enable the UDCP to evaluate the impact of efforts
to improve the health status of persons with diabetes.
References
1. CDC. The prevention and treatment of complications of diabetes
mellitus: a guide for primary care practitioners. Atlanta, Georgia:
US Department of Health and Human Services, Public Health Service,
CDC, 1991.
2. CDC. Diabetes surveillance, 1993. Atlanta, Georgia: US
Department of Health and Human Services, Public Health Service,
CDC, 1993.
3. Shah BV. SUDAAN. Professional software for survey data analysis
for multistage sample designs. Research Triangle Park, North
Carolina: Research Triangle Institute, 1992.
4. Cowie CC, Eberhardt MS. Sociodemographic characteristics of
persons with diabetes. In: National Diabetes Data Group, National
Institutes of Health. Diabetes in America. 2nd ed. Bethesda,
Maryland: US Department of Health and Human Services, Public Health
Service, National Institutes of Health, 1995:85-116; DHHS
publication no. (NIH)95-1468.
5. Siegel PZ, Brackbill RM, Frazier EL, et al. Behavioral risk
factor surveillance, 1986-1990. In: CDC Surveillance Summaries
(December). MMWR 1991;40(no. SS-4).
6. CDC. Prevalence of adults with no known major risk factors for
coronary heart disease--Behavioral Risk Factor Surveillance System,
1992. MMWR 1994;43:61-63,69.
7. CDC. State-based programs to reduce the burden of diabetes:
guidelines for program design, implementation, and evaluation.
Atlanta, Georgia: US Department of Health and Human Services,
Public Health Service, CDC, 1994.

* Persons who smoked at least 100 cigarettes during their lifetime
and who reported smoking at the time of the interview.
** Body mass index (kg/m2) greater than or equal to 27.8 for men
and greater than or equal to 27.3 for women.
*** Fewer than three 20-minute sessions of leisure-time physical
activity per week.


Progress Toward Poliomyelitis Eradication -- Eastern Mediterranean
Region, 1988-1994
     In 1988, the Regional Committee of the Eastern Mediterranean
Region (EMR) of the World Health Organization* (WHO) adopted a
resolution to eradicate poliomyelitis from the region by the year
2000 (1). Since this goal was established, substantial progress
toward polio eradication has been achieved using three major
strategies: 1) achieving and maintaining high coverage with at
least three doses of oral poliovirus vaccine (OPV3); 2)
implementing supplementary vaccination activities, including
National Immunization Days (NIDs)**, to rapidly interrupt
poliovirus transmission; and 3) developing sensitive systems of
epidemiologic and laboratory surveillance, including use of the
standard WHO case definition (2).*** This report summarizes
progress toward polio eradication in EMR countries from 1988
through 1994 and is based on reports received through August 1,
1995.
Incidence of Polio
     From 1988 through 1994, the number of confirmed polio cases
reported in the region decreased 57%, from 2342 to 1015 (Figure 1).
The sharp decline in reported cases from 1993 (2451 cases) to 1994
(1015 cases) especially reflected improved control of polio in
Pakistan and Sudan, both of which experienced large outbreaks in
1993. Both countries conducted NIDs for the first time in 1994.
Despite the substantial decrease in the number of cases reported
from 1993 to 1994, Pakistan continues to report more cases than any
other country in the region; the 527 cases reported in 1994
represent 52% of the regional total. During 1994, nine other
countries reported polio cases, including Yemen (173 [17%]), Egypt
(120 [10%]), Iran (93 [9%]), Iraq (63 [6%]), Sudan (25 [2%]), Saudi
Arabia (six [0.5%]), Jordan (four [0.3%]), and Lebanon and Syria
(one each [0.1%]). Eleven countries reported no cases. Five
countries (Cyprus, Kuwait, Libya, Morocco, and Qatar) have reported
no cases for at least 3 years.
Vaccination Coverage
     From 1990 through 1993, routine coverage with OPV3 among
children aged less than 1 year in EMR was greater than or equal to
80%; coverage decreased in 1994 to 78% (Figure 1). Of 20 countries
reporting OPV3 coverage in 1994, a total of 16 reported coverage
greater than 80%. Of these, 12 reported OPV3 coverage greater than
90%. The decrease in coverage in 1994 primarily reflected declining
coverage in four countries (Djibouti, Pakistan, Sudan, and Yemen).
In conjunction with declining routine vaccination coverage,
Pakistan experienced an outbreak of paralytic polio in the second
and third quarters of 1995 in its most populous province (Punjab).
     NIDs were conducted in two countries (Egypt and Syria) in 1993
and in five countries (Egypt, Iran, Pakistan, Sudan, and Syria) in
1994. By the end of 1995, a total of 19 (82%) countries,
representing 93% of the estimated population in the region, will
have conducted NIDs (Figure 2). Cyprus, Djibouti, Somalia, and
Yemen will not conduct NIDs in 1995.
Surveillance
     By 1992, a total of 21 of the 23 countries in EMR had
developed surveillance for polio; surveillance could not be
established in Afghanistan and Somalia because of civil conflict.
By 1994, a total of 19 countries had established systems for
reporting and monitoring the occurrence of acute flaccid paralysis
(AFP), compared with six countries in 1992. Four countries
(Afghanistan, Pakistan, Somalia, and Yemen) are not reporting cases
of AFP. By 1994, AFP or polio cases were being investigated
clinically and epidemiologically in 21 countries, compared with
eight in 1992. An important indicator of the sensitivity of
surveillance that has been consistent in many countries throughout
the world is the rate of nonpolio AFP among children aged less than
15 years (greater than or equal to 1 case per 100,000); by 1994,
five EMR countries had achieved this rate.
Laboratory Support
     By 1994, laboratory surveillance for polioviruses had been
initiated in 14 countries, compared with six in 1992. In 1994, the
EMR laboratory network was involved in the investigation of 717 AFP
cases. Of these, two stool specimens were available for 495 (69%).
Of 422 cases with onset and collection data available, 354 (84%)
had stool specimens collected within 14 days of onset of paralysis.
Reported by: Regional Office for the Eastern Mediterranean Region,
Alexandria, Egypt; Global Program for Vaccines and Immunization,
World Health Organization, Geneva. Respiratory and Enterovirus Br,
National Center for Infectious Diseases; Polio Eradication
Activity, National Immunization Program, CDC.
Editorial Note: The findings in this report document substantial
progress toward polio eradication in EMR during 1988-1994. In
addition to providing member countries with technical support to
implement global polio eradication strategies, the EMR has
initiated three major regional initiatives to accelerate polio
eradication. First, during 1993-1994, WHO collaborated with Rotary
International and the United Nations Children's Fund (UNICEF) and
used teams of national and international laboratory and
epidemiology experts to conduct rapid surveillance assessments in
19 countries. Second, WHO coordinated efforts (including NIDs) to
detect and prevent cases in three geographically contiguous and
epidemiologically similar countries (the Mahgreb Union in Northern
Africa; the Arab Gulf states; and the Middle Eastern and Asian
states of Jordan, Lebanon, Palestine, Syria, Afghanistan, Iran,
Iraq, and Pakistan) to foster the emergence of polio-free zones
within the region. Third, a monthly newsletter ("Poliofax") is sent
to all ministries of health in the region to provide feedback and
to encourage complete and timely disease reporting.
     Despite progress toward polio eradication, some barriers
persist and underscore the need to 1) increase vaccination levels
in unvaccinated subpopulations; 2) maintain high routine
vaccination coverage in all member countries; 3) translate
political commitment into action, including the provision of
sufficient funds for the purchase of oral polio vaccine (both for
routine and supplementary vaccination) by governments of all member
countries; 4) encourage all member countries to establish polio
eradication as a priority activity, including the initiation of AFP
surveillance and implementation of NIDs; 5) overcome the
impediments to the regional polio eradication initiative as the
result of war and civil strife in some countries; and 6) strengthen
the timely exchange of information among countries and with WHO,
UNICEF, Rotary International, and other partner organizations to
enable coordination and enhanced support of regional polio
eradication activities.
References
1. Regional Committee for the Eastern Mediterranean Region, World
Health Organization. Poliomyelitis eradication in the Eastern
Mediterranean Region. Alexandria, Egypt: World Health Organization,
1988. (Resolution EM/RC35/R.14).
2. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C. Paralytic
poliomyelitis: seasoned strategies, disappearing disease. Lancet
1994;343:1331-7.

* Member countries are Djibouti, Egypt, Libya, Morocco, Somalia,
Sudan, and Tunisia in northern and eastern Africa; the Arab Gulf
states of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab
Emirates, and Yemen; Iraq, Jordan, Lebanon, Syria, and the
Palestinian people in the Middle East; Afghanistan, Iran, and
Pakistan in Asia; and Cyprus.
** Mass campaigns over a short period (days to weeks) in which two
doses of OPV are administered to all children in the target age
group (usually age less than 5 years) regardless of prior
vaccination history, with an interval of 4-6 weeks between doses.
*** A confirmed case of polio is defined as acute flaccid paralysis
and at least one of the following: 1) laboratory-confirmed wild
poliovirus infection, 2) residual paralysis at 60 days, 3) death,
or 4) no follow-up investigation at 60 days.


Hospitalization for Epilepsy -- United States, 1988-1992
     Epilepsy is a chronic neurologic condition manifested by
repeated unprovoked seizures that affects approximately 1% of the
U.S. population (1). Although effective treatment can prevent
seizures in most persons with epilepsy, some persons have frequent
seizures, which can lead to brain damage, disability, and
diminished quality of life (2,3). To assist in characterizing the
public health impact of epilepsy in the United States, CDC analyzed
data from the National Hospital Discharge Survey (NHDS) for
1988-1992 to estimate the number of hospitalizations for which
epilepsy
was the first-listed diagnosis.
     The NHDS is conducted annually and collects data from a sample
of inpatient records obtained from a nationally representative
sample of nonfederal general and short-stay specialty hospitals in
the United States (4). Hospitalizations for which the first-listed
diagnosis was epilepsy were selected by using the International
Classification of Diseases, Ninth Revision, Clinical Modification,
codes 345.0-345.9. Age-specific and age-adjusted rates were
estimated for the civilian population; the direct method was used
to age-adjust the estimates to the 1980 U.S. resident population.
Because of differences in the racial designation of the denominator
population in different years, race-specific rates for the total
period could be estimated for whites only and for all other groups
combined. Hospitalizations for persons with race not stated were
included with whites. To increase the stability of the estimates,
data for all 5 survey years were combined. SUDAAN was used to
calculate the estimates and standard errors.
     From 1988 through 1992, epilepsy was the first-listed
diagnosis for an estimated 466,000 hospitalizations; the
age-adjusted hospitalization rate was 37 hospitalizations per
100,000 persons (Table 1). The age-specific rate per 100,000
persons varied by age group and was highest for persons aged
greater than or equal to 65 years (68 per 100,000) and lowest for
persons aged 15-64 years (30).
     The age-adjusted hospitalization rate was higher for males
(40) than females (34); however, age-specific rates for males and
females were similar (Table 1). The age-adjusted hospitalization
rate was higher in the Northeast (49) than in the South (37), North
Central (35), and West (27).*
     Age-adjusted rates were substantially lower for whites (35)
than for all other racial groups combined (51). Age-specific rates
were similar for the youngest age group; however, compared with
whites, rates were higher in other age groups for the other racial
groups combined (Figure 1). The ratio of rates increased directly
by age group--0.9 among persons aged less than 15 years, 1.6 among
those aged 15-64 years, and 1.8 among those aged greater than or
equal to 65 years.
Reported by: Statistics Br, Div of Chronic Disease Control and
Community Intervention, National Center for Chronic Disease
Prevention and Health Promotion, CDC.
Editorial Note: Hospitalizations for epilepsy represent a
potentially preventable complication of this condition. The
findings in this report indicate that, during 1988-1992,
approximately 93,000 hospitalizations each year were attributed to
epilepsy. These rates are similar to those reported for 1973-1976
(5) and to rates based on studies employing rigorous ascertainment
of cases (6).
     Comparing these results with the estimated prevalence of
self-reported epilepsy (7), approximately 8% of persons with
epilepsy are hospitalized each year. The proportion of persons
hospitalized is similar for men and women but varies considerably
with age; an estimated one fourth of persons with epilepsy aged
greater than or equal to 65 years are hospitalized each year with
epilepsy as the first-listed diagnosis. This may be attributable to
either severity of epilepsy, its underlying causes in older age
groups, or underreporting of epilepsy in this population segment.
     Although data characterizing the prevalence of epilepsy by
racial/ethnic group are limited, the prevalence among whites, in
general, has been reported to be lower than for blacks (7,8). In
1992, 20% of NHDS records lacked a designation of race (7). Because
most of these persons were discharged from hospitals that
historically reported most of their patients as white, these
records were included with whites in this analysis, thus resulting
in an overestimate of hospitalization rates for whites. Despite
this bias, however, the hospitalization rate for whites was
different when compared with all other racial groups combined. In
this analysis, this disparity increased directly with age, possibly
reflecting cumulative differences in disease severity or access to
effective therapy.
     The findings in this report are subject to at least two
limitations. First, the hospitalization data could not be linked to
individuals. Persons with particularly refractory seizures may have
been hospitalized multiple times during the study period. Second,
epilepsy may be the underlying factor for hospitalizations
attributed to other causes (e.g., trauma). Therefore, this analysis
probably underestimated the total number of hospitalizations for
epilepsy.
     Although hospitalization accounts for only a small proportion
of the total medical and public health impact of epilepsy, rates of
hospitalization for epilepsy are especially high in some age
groups. In addition, hospitalizations attributable to epilepsy are
preventable with effective outpatient management focusing on proper
diagnosis, treatment, and patient compliance. Patients with
epilepsy refractory to treatment in the primary-care setting or
those experiencing difficulties in compliance or adverse effects of
antiepileptic medication should be referred to appropriate
specialty centers for the diagnosis and treatment of epilepsy (9).
CDC is collaborating with representatives of professional and
voluntary organizations to develop guidelines for consumers and
health-care providers for the management and referral of persons
with epilepsy in primary-care settings.
     November is National Epilepsy Month. Additional information
about epilepsy and its treatment is available from the Epilepsy
Foundation of America, telephone (800) 332-1000 or (301) 459-3700.
References
1. Hauser WA, Hesdorffer DC. Epilepsy: frequency, causes, and
consequences. New York: Epilepsy Foundation of America, 1990.
2. Annegers JF, Hauser WA, Elveback LR. Remission of seizures and
relapse in patients with epilepsy. Epilepsia 1979;20:729-37.
3. Dodrill CB. Correlates of generalized tonic-clonic seizures with
intellectual, neuropsychological, emotional, and social function in
patients with epilepsy. Epilepsia 1986;27:399-411.
4. NCHS. National Hospital Discharge Survey: annual summary, 1992.
Hyattsville, Maryland: US Department of Health and Human Services,
Public Health Service, CDC, October 1994. (Vital and health
statistics; series 13, no. 119).
5. Jerath BK, Kimbell BA. Hospitalization rates for epilepsy in the
United States, 1973-1976. Epilepsia 1981;22:55-64.
6. Hauser WA, Kurland LT. The epidemiology of epilepsy in
Rochester, Minnesota, 1935 through 1967. Epilepsia 1975;16:1-66.
7. CDC. Prevalence of self-reported epilepsy--United States,
1986-1990. MMWR 1994;43;810-1,817-8.
8. Haerer AF, Anderson DW, Schoenberg BS. Prevalence and clinical
features of epilepsy in a biracial United States population.
Epilepsia 1986;27:66-75.
9. Lesser RP. The role of epilepsy centers in delivering care to
patients with intractable epilepsy. Neurology 1994;44:1347-52.

* Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Rhode Island, and Vermont; North
Central=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota,
Missouri, Nebraska, North Dakota, Ohio, South Dakota, and
Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia,
Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North
Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and
West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii,
Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and
Wyoming.


Notice to Readers
Availability of Information on Diabetes Awareness
     Three resources to promote diabetes awareness have recently
been published and are available to the public. The 1995 National
Diabetes Fact Sheet provides statistical information about the
impact of diabetes in the United States. The fact sheet was a
collaborative effort involving a consortium of federal agencies
(CDC; the Health and Human Resource Services Administration; the
Indian Health Service; the National Institute of Diabetes and
Digestive and Kidney Diseases, National Institutes of Health; and
the Department of Veterans Affairs) and volunteer diabetes
organizations (the American Association of Diabetes Educators, the
American Diabetes Association, and the Juvenile Diabetes
Foundation). The document is available free of charge through any
of the agencies or national headquarters of the organizations
participating in the consortium or on CDC's Diabetes Home Page on
Internet (http://www.cdc.gov/nccdphp/ddt/ddthome.htm). To order the
document from CDC, write to TISB, Mailstop K-13, Attention: DK,
CDC, 4770 Buford Highway, N.E., Atlanta, GA 30341-3724.
     This consortium, as well as the Pedorthic Footwear Association
(PFA) and the California College of Podiatric Medicine (CCPM), is
collaborating on a foot-care awareness campaign to detect loss of
protective foot sensation, which can lead to foot ulcers and
eventually to amputations. Additional information about the
campaign is available from any of the agencies or national
headquarters of the organizations participating in the consortium,
PFA, or CCPM.
     The National Diabetes Data Group, National Institutes of
Health, has published Diabetes in America, 2nd Edition, a
compilation and assessment of the scope and impact of diabetes in
the United States (1). The book addresses the descriptive
epidemiology of diabetes, complications of the disease,
characteristics of therapy and medical care for diabetes, economic
aspects, and diabetes in specific racial/ethnic populations. A
substantial portion of the data is derived from CDC's National
Center for Health Statistics surveys, including the National Health
Interview Survey, National Health and Nutrition Examination Survey,
National Hospital Discharge Survey, National Ambulatory Medical
Care Survey, and the vital statistics system. The document is
available for $20 (postage and handling charge) from the National
Diabetes Information Clearinghouse, National Institute of Diabetes
and Digestive and Kidney Diseases, One Information Way, Bethesda,
MD, 20892-3560; telephone (301) 654-3327.
References
1. National Diabetes Data Group, National Institutes of Health.
Diabetes in America. 2nd ed. Bethesda, Maryland: US Department of
Health and Human Services, Public Health Service, National
Institutes of Health, 1995; DHHS publication no. (NIH)95-1468.