What
is diabetes?
High
blood sugar levels that result from defects in the body’s ability to produce
and/or resistance to the actions of the hormone insulin characterize diabetes.
There are two major types of diabetes: type 1 and type 2. Type 1 occurs most commonly among juveniles but occasionally
among adults. Type 2 occurs
primarily in adults and only occasionally in juveniles.
More
than 90 percent of the diabetics in the United States are type 2 diabetics.
Many of these patients initially exhibit few or no symptoms, although
increased urination and excessive thirst may be present.
Diabetes is associated with high levels of glucose in the blood.
The presence of obesity or a strongly positive family history for mild
diabetes suggests a high risk for the development of type II diabetes.
Diabetes
is the Nation’s sixth-leading cause of death and the leading cause of
blindness in the United States. It
can also lead to heart disease, stroke, kidney failure, and amputation.
Approximately 15 percent of veterans receiving care in VA medical
facilities have been diagnosed with diabetes.
VA diabetes patients require an estimated $2.5 billion dollars annually
for their treatment and healthcare, including more than 200,000 bed-days per
year.
Nationally,
more than 17 million people are estimated to be diabetic. More than $100 billion are spent for their treatment and care
annually. More than 650,000
additional diabetics are newly diagnosed each year.
Why
are some Vietnam veterans worried about their risk of developing diabetes?
Many
animal studies provide potential biological mechanisms for an association
between herbicide exposure and diabetes risk.
Although earlier reports on humans suggest little association, the
potentially more definitive 1997 report from the Ranch Hand Study (the Air Force
Health Study of the unit responsible for most of the herbicide aerial spraying
in Vietnam) raises the possibility that veterans in the highest herbicide
exposure category may be at increased risk.
What
did the National Academy of Sciences (NAS) conclude about the relationship
between exposure to herbicides and the development of diabetes in its 1993
report, entitled Veterans and Agent Orange – Health Effects of Herbicides
Used in Vietnam?
The
NAS reviewers noted that there was “limited” information suggesting the
possibility of diabetes in chemical production workers and Ranch Hand veterans
exposed to TCDD or dioxin (the contaminant produced during the manufacture of
one of the ingredients of Agent Orange), but that the data were
“inconclusive.” In the
1993 report, the NAS found that there is “inadequate or insufficient”
evidence to determine whether an association exists between exposure to
herbicides and diabetes mellitus.
What
was VA’s reaction to this NAS finding?
After
careful review, Secretary Brown concluded that the credible evidence for an
association does not equal or outweigh the credible evidence against an
association between exposure to herbicides used in Vietnam and the development
of metabolic and digestive disorders, including diabetes mellitus.
In
January 1994, VA published a notice in the Federal Register that
Secretary Brown has determined that a presumption of service connection based on
exposure to herbicides in Vietnam is not warranted for a long list of conditions
identified in the NAS report. A
metabolic and digestive disorder, including diabetes mellitus, was included in
this list. (See 59 Fed. Reg.
341, January 4, 1994).
What
did the 1996 NAS update conclude about diabetes?
The
1996 report again concluded that there is “inadequate or insufficient”
evidence to determine whether an association exists between exposure to
herbicides and diabetes mellitus.
What
was VA’s response to the NAS 1996 finding regarding diabetes?
After
careful review, VA’s Secretary Brown concluded that the credible evidence for
an association does not equal or outweigh the credible evidence against an
association between exposure to herbicides used in Vietnam and the development
of metabolic and digestive disorders, including diabetes mellitus.
In
August 1996, VA published a notice in the Federal Register that Secretary
Brown has determined that a presumption of service connection based on exposure
to herbicides in Vietnam is not warranted for a long list of conditions
identified in the NAS report. Metabolic
and digestive disorders, including diabetes mellitus was included in this list.
(See 61 Fed. Reg. 41442, August 8, 1996).
What
did the 1998 NAS update conclude about diabetes?
Like
the two earlier NAS reports, the 1998 report again concluded that there is
“inadequate or insufficient” evidence to determine whether an association
exists between exposure to herbicides and diabetes mellitus. The 1998 update
“strongly” urged that the National Institute for Safety and Health (NIOSH)
study be documented more completely and published in the peer-review literature
of dioxin-exposed workers, so that its potentially important findings can be
fully evaluated. The NAS report
“strongly” recommended that the Ranch Hand study develop a fully adjusted
multivariate model, fully controlling for baseline age and obesity and, if
possible, for family history of diabetes, central fat distribution, diabetogenic
drug exposure, and a measure of obesity at the time of Vietnam service.
The
NAS reviewers also recommended that consideration be given to a combined
analysis of Ranch Hand and NIOSH studies to further examine the possibility that
herbicide or dioxin exposure leads to an increased risk of diabetes. The NAS added that using the “new” American Diabetes
Association (ADA) definition of diabetes, outcome data from both studies could
be made comparable.
What
was VA’s response to the NAS 1998 report regarding diabetes?
Shortly
after the NAS report was released, one additional important study was published
(Calvert GM, Sweeney MH, Deddens J, Wall DK. 1999.
An evaluation of Diabetes Mellitus, Serum Glucose, and Thyroid Function
Among U.S. Workers Exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxon.
Occupational and Environmental Medicine 56:270-276). This led
Secretary West to request that the NAS review its previous finding in light of
this recent paper. This special, expedited review was completed in May 2000 but
was delayed, at VA request, to allow for consideration of a Ranch Hand report
which included important findings regarding diabetes. On October 11, 2000, NAS released its report, which noted
that diabetes should be included in category two (limited/suggestive evidence of
an association). On November 9,
2000, Acting Secretary Gober announced that VA would presumptively recognize
diabetes for service connection. Implementing
proposed regulations were published in the federal register in January 2001 (See
66 Fed. Reg. 2376 January 2001.) The final rule was published in May 2001
See 66 Fed. Reg. 2316 May 8, 2001.
What
did the NAS conclude regarding diabetes in subsequent updates?
In
both the 2002 and 2002 updates the NAS concluded that there is
limited/suggestive evidence of an association between exposure to herbicides and
diabetes.
What
about type 1 diabetes?
The NAS conclusions were limited to type 2 diabetes. Consequently, VA presumptive service – connection was restricted to type 2 diabetes.
What
is VA doing with the American Diabetes Association (ADA) on behalf of veterans
with diabetes?
On
March 3, 1998, VA and the ADA signed a Memorandum of Understanding and announced
that they would collaborate in determining the most effective ways to treat
diabetes. This includes assessing
blood monitoring devices and other technology; sharing information to guide
research and further collaboration; and exploring the exchange of benchmarking
information on quality cost, and productivity.
The
ADA is the largest voluntary health organization dedicated to diabetes research.
It operates programs in all 50 States and in more than 800 communities.
Where
can a veteran get additional information about diabetes?
For
additional information please see, our Web site at www.va.gov/diabetes.
Information
regarding diabetes and related matters can be obtained at public libraries.
Information about diabetes an Agent Orange exposure can be obtained from
the Environmental Health Clinicians at every VA medical center, from the
Environmental Agents Service (131), Department of Veterans Affairs, 810 Vermont
Avenue, N.W., Washington, DC 20420.
Private health organizations, such as the JDF the ADA, also may be
helpful.
Where
can a veteran get additional information regarding Agent Orange - related
issues?
The
following Agent Orange fact sheets (including the one you are reading) are
available on the World Wide Web at www.va.gov/AgentOrange:
A1.Agent Orange - General Information; A2.Agent Orange Class Action Lawsuit; B1.Agent Orange Registry Program; B2.Agent Orange – Health Care Eligibility; B3.Agent Orange and VA Disability Compensation; B4.VA
Information Resources on Agent Orange and Related Matters; C1.Agent
Orange – The Problem Encountered in Research; C2.Agent Orange and Vietnam Related Research – VA Projects; C3.Agent
Orange and Vietnam Related Research – Non-VA Projects; D1.Agent
Orange and Birth Defects; D2.Agent
Orange and Chloracne; D3.Agent Orange
and Non-Hodgkin’s Lymphoma; D4.Agent
Orange and Soft Tissue Sarcomas; D5.Agent
Orange and Peripheral Neuropathy; D6.Agent
Orange and Hodgkin’s Disease; D7.Agent
Orange and Porphyria Cutanea Tarda; D8.Agent
Orange and Multiple Myeloma; D9.Agent
Orange and Respiratory Cancers; D10.Agent
Orange and Prostate Cancer; D11.Agent
Orange and Spina Bifida; D12.Agent
Orange and Diabetes; and D13.Agent Orange and Chronic Lymphocytic Leukemia. Hard copies can be obtained from local VA medical centers or
from the VA Central Office at the Environmental Agents Service (131) Department
of Veterans Affairs, 810 Vermont Avenue, N.W., Washington, DC 20420.
At the same Web site you will find copies of past and current issues of the “Agent Orange Review” newsletter and other items of interest.
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This fact sheet was updated in late October 2003 and does not include subsequent developments.