Prevalence of Lower-Extremity Disease in the U.S. Adult Population >40 Years of Age With and Without Diabetes 1999 –2000 National Health and Nutrition Examination Survey EDWARD W. GREGG, PHD 1 PAUL SORLIE, PHD 2 RYNE PAULOSE-RAM, PHD 3 QIUPING GU, MD 3 MARK S. EBERHARDT, PHD 3 MICHAEL WOLZ, MA 2 VICKI BURT, SCM 3 LESTER CURTIN, PHD 3 MICHAEL ENGELGAU, MD 1 LINDA GEISS, MA 1 OBJECTIVE — Although lower-extremity disease (LED), which includes lower-extremity peripheral arterial disease (PAD) and peripheral neuropathy (PN), is disabling and costly, no nationally representative estimates of its prevalence exist. The aim of this study was to examine the prevalence of lower-extremity PAD, PN, and overall LED in the overall U.S. population and among those with and without diagnosed diabetes. RESEARCH DESIGN AND METHODS — The analysis consisted of data for 2,873 men and women aged 40 years, including 419 with diagnosed diabetes, from the 1999 –2000 National Health and Nutrition Examination Survey. The main outcome measures consisted of the prevalence of lower-extremity PAD (defined as ankle-brachial index 0.9), PN (defined as 1 insensate area based on monofilament testing), and of any LED (defined as either PAD, PN, or history of foot ulcer or lower-extremity amputations). RESULTS — Of the U.S. population aged 40 years, 4.5% (95% CI 3.4 –5.6) have lower- extremity PAD, 14.8% (12.8 –16.8) have PN, and 18.7% (15.9 –21.4) have any LED. Prevalence of PAD, PN, and overall LED increases steeply with age and is higher (P  0.05) in non-Hispanic blacks and Mexican Americans than non-Hispanic whites. The prevalence of LEDs is approxi- mately twice as high for individuals with diagnosed diabetes (PAD 9.5% [5.5–13.4]; PN 28.5% [22.0 –35.1]; any LED 30.2% [22.1–38.3]) as the overall population. CONCLUSIONS — LED is common in the U.S. and twice as high among individuals with diagnosed diabetes. These conditions disproportionately affect the elderly, non-Hispanic blacks, and Mexican Americans. Diabetes Care 27:1591–1597, 2004 L ower-extremity disease (LED), in- cluding lower-extremity peripheral arterial disease (PAD) and peripheral neuropathy (PN), is disabling and costly (1–5). PAD, which can be accompanied by intermittent claudication or rest pain, may necessitate revascularization proce- dures and seriously diminish health- related quality of life. Even when asymptomatic, PAD may decrease mobil- ity and bone mineral density (1,2,4,6) and is a strong predictor of subsequent cardiovascular disease (CVD) and mortal- ity (3,7,8). PN also erodes health-related quality of life, and when it occurs in com- bination with PAD, as is frequently the case with diabetes, it can lead to foot ul- cers and nontraumatic amputations (1,9). Despite the array of complications of LED, its epidemiology in the U.S. has not been well characterized. Previous preva- lence estimates for PAD from the U.S. and Europe, for example, have ranged from 5–20% in general populations aged 50 years (10 –18). The prevalence of PN de- fined by symptoms or impaired vibration sensation in populations with diabetes has ranged from 10 to 42% (19 –24). Part of this variation is probably due to meth- odological differences, including varia- tions in definitions, populations, and measurements. There have been no na- tionally representative estimates of the prevalence of PAD or PN in the overall U.S. population or those with diabetes. In addition, previous studies have not exam- ined the combined burden of PAD and PN or the degree to which these conditions are specific to individuals with diabetes. Because of the lack of population- based data on LEDs in the U.S. and the potential to reduce its burden through pharmacological or behavioral interven- tions (1,4,25–28), new measurements of these conditions were incorporated in the 1999 –2000 National Health and Nutri- tion Examination Survey (NHANES). The objectives of the present study were to determine the prevalence of LED, includ- ing lower-extremity PAD and PN in the U.S. among both the overall population and individuals with diagnosed diabetes. RESEARCH DESIGN AND METHODS — The NHANES is a na- tionally representative survey of the U.S. civilian noninstitutionalized population conducted by the National Center for Health Statistics of the Centers for Disease ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; the 2 Epidemiology and Biometry Program, National Heart, Lung and Blood Institute, the National Institutes of Health, Bethesda, Maryland; and the 3 Division of Health and Nutrition Examination Surveys and Division of Epidemiology, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland. Address correspondence and reprint requests to Edward W. Gregg, PhD, Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Hwy., NE Mailstop K-10, Atlanta, GA 30341. E-mail: edg7@cdc.gov. Received for publication 3 December 2003 and accepted in revised form 24 March 2004. Abbreviations: ABI, ankle-brachial index; CVD, cardiovascular disease; LED, lower-extremity disease; NHANES, National Health and Nutrition Examination Survey; PAD, peripheral arterial disease; PN, periph- eral neuropathy. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2004 by the American Diabetes Association. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E DIABETES CARE, VOLUME 27, NUMBER 7, JULY 2004 1591 Downloaded from http://diabetesjournals.org/care/article-pdf/27/7/1591/664855/zdc00704001591.pdf by guest on 27 August 2022