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Tracking diabetes: Prevalence, incidence and risk factors
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Wayne J. Millar and T. Kue Young Abstract
Objectives This article examines the prevalence and incidence of diabetes among Canadians aged 18 or older and risk factors associated with developing the condition. Data sources The data are from the 1994/95, 1996/97, 1998/99 and 2000/01 National Population Health Survey and the 2000/01 Canadian Community Health Survey, both conducted by Statistics Canada. Analytical techniques Descriptive statistics on the prevalence and incidence of self-reported diabetes were computed. Multiple logistic regression was used to identify predictors of incident diabetes. Age-adjusted rates were used to compare diabetic and non-diabetic respondents on a variety of health measures. Main results In 2000/01, 4.5% of Canadians aged 18 or older, an estimated 1.1 million, reported having diabetes. The incidence from 1994/95 to 2000/01 was 4.9 new cases per 1,000 person-years at risk. When the possible confounding effects of a number of factors were taken into account, advancing age, family history, sedentary leisure time and excess weight were associated with developing diabetes.
body mass index, physical activity, longitudinal studies, health surveys
Wayne J. Millar (613-951-1631; [email protected]) is with the Health Statistics Division at Statistics Canada, Ottawa, Ontario K1A 0T6; T. Kue Young (416-978-6459; [email protected]) is with the Department of Public Health Sciences at the University of Toronto, Toronto, Ontario M5S 1A8.
iabetes, already one of the most prevalent chronic diseases, is affecting increasing
numbers worldwide.1,2 This increase cannot be
attributed to a single cause, but rather, to a combination of demographic, lifestyle and clinical factors. A decline in diabetes mortality over the past two decades has resulted in a large number of people surviving with the disease. Reductions in physical activity and greater caloric intake have contributed to a substantial rise in the prevalence of overweight, a risk factor for diabetes.3-5 Changes in diagnosis criteria could also influence the number of cases that are identified. In 1998, the cut-point for a diagnosis of diabetes mellitus was lowered from a fasting plasma glucose (FPG) level of 7.8 to 7.0 mmol/L6 (see What is diabetes?). Finally, growing public and physician awareness could increase testing, and result in detection of more cases.7 Studies of diabetes in Canada have generally been based on cross-sectional prevalence data. While useful for public administration purposes, such statistics do not indicate the incidence of new cases over time. With longitudinal data from the National Population Health Survey (NPHS), however, it is possible to estimate the incidence of diabetes since the mid-1990s.
Health Reports, Vol. 14, No. 3, May 2003
Statistics Canada, Catalogue 82-003
Tracking diabetes
Data sources National Population Health Survey This analysis is based on Statistics Canada's National Population Health Survey (NPHS), weighted to represent the population of the 10 provinces. The NPHS, which began in 1994/95, collects information about the health of the Canadian population every two years. It covers household and institutional residents in all provinces and territories, except people on Indian reserves, on Canadian Forces bases, and in some remote areas. The NPHS has a longitudinal and a cross-sectional component. Cross-sectional sample: The 1994/95 and 1996/97 (cycles 1 and 2) cross-sectional samples are made up of longitudinal respondents and other members of their households, as well as individuals selected as part of supplemental samples, or buy-ins, in some provinces. The 1998/99 (cycle 3) cross-sectional sample is made up mostly of longitudinal respondents and their cohabitants. Although no buy-ins were added to the cycle 3 sample, infants born after 1994 and immigrants who entered Canada after 1994 were randomly selected and added to keep the sample representative. To replace sample lost to attrition, individuals in households that were part of the original sampling frame but whose members did not respond in 1994/95 were contacted and asked to participate. NPHS data are stored in two files. The General file contains sociodemographic and some health information for each member of participating households. The Health file contains in-depth health information for one randomly selected household member, as well as the information in the General file pertaining to that individual. In 1994/95, in all selected households, one knowledgeable person provided the socio-demographic and health information about all household members for the General file. As well, one household member, not necessarily the same person, was randomly selected to provide in-depth health information about him- or herself for the Health file. Among individuals in the longitudinal component in 1996/97 and 1998/99, the person providing in-depth health information about himself or herself for the Health file was the randomly selected person for the household in cycle 1 (1994/95), and was usually the person who provided information on all household members for the General file in cycles 2 and 3. In households added to the 1998/99 crosssectional sample, the randomly selected respondent was also the person who provided information for the General file. The 1994/95 provincial, non-institutional sample consisted of 27,263 households, of which 88.7% agreed to participate. After application of a screening rule to keep the sample representative, 20,725 households remained in scope. In 18,342 of these
households, the selected person was aged 12 or older. Their response rate to the in-depth health questions was 96.1%, or 17,626 respondents. The response rate at the household level was 82.6% in 1996/97 and 88.2% in 1998/99. The cross-sectional NPHS data used in this analysis pertain to 16,291, 68,282 and 14,150 respondents aged 18 or older in cycles 1, 2 and 3. Beginning with cycle 4 in 2000/01, the NPHS became strictly longitudinal; the cross-sectional component was taken over by the Canadian Community Health Survey (CCHS). Longitudinal sample: Of the 17,626 randomly selected respondents in 1994/95, 14,786 were eligible members of the longitudinal panel, along with 468 persons for whom only general information was collected. An additional 2,022 of the 2,383 randomly selected respondents under age 12 were also eligible. Thus, the longitudinal sample is composed of the 17,276 respondents who were selected in cycle 1 and had completed at least the General component of the questionnaire. The longitudinal sample size remained the same (17,276) for all cycles. The response rate for the Health component was 83.6% in cycle 1, 92.8% in cycle 2, 88.9% in cycle 3, and 84.8% in cycle 4. The 2000/01 cycle 4 longitudinal square master file was used for this analysis. This file contains records for all longitudinal respondents, regardless of whether they provided information for all four cycles (that is, individuals selected for the longitudinal sample for whom information is available on the General file of cycle 1). The sample used in this analysis pertains to 14,117 respondents aged 18 or older in 1994/95. The diabetes status of 54 respondents could not be determined; they were deleted, leaving 14,063. More detailed descriptions of the NPHS design, sample and interview procedures can be found in published reports.8-10
Canadian Community Health Survey Data about the prevalence of diabetes in 2000/01 and the association with selected health conditions and health care use are from cycle 1.1 of Statistics Canada's Canadian Community Health Survey (CCHS). The CCHS covers the household population aged 12 or older in all provinces and territories, except persons on Indian reserves, on Canadian Forces bases, and in some remote areas. The responding sample size for cycle 1.1 was 131,535, and the response rate was 84.7%. The sample used for this article consists of 116,171 respondents aged 18 or older in the 10 provinces. More detail about the design, sample and interview procedures of the CCHS is available in a previously published report.11
Using the results of successive waves of the NPHS, this analysis tracks changes from 1994/95 to 2000/01 in the prevalence and incidence of diabetes among Canadian adults and identifies potential risk factors (see Data sources, Analytical techniques, Definitions and Limitations). A comparison of the diabetic and non-diabetic populations is based on the 2000/01 Canadian Community Health Survey (CCHS). Prevalence increasing In 2000/01, an estimated 1.1 million Canadians aged 18 or older reported that they were diabetic (see Compromised health). They accounted for 4.5% of the population in that age range, up from 3.4% in 1994/95 (Table 1). In 1994/95, there had been no difference between men and women in the prevalence of diabetes, but by 2000/01, the rate was significantly higher among men. The proportion of men who had been diagnosed rose from 3.4% to 4.8%, while among women, the increase was from 3.3% to 4.2%. The increase among men was significant at ages 18 to 44 and 45 to 64, but among women, only at ages 45 to 64. Table 1 Prevalence of diabetes, by sex and age group, household population aged 18 or older, Canada excluding territories, 1994/95 to 2000/01 1994/95
% Both sexes 18-44 45-64 65-74 75+
4.5* 1.3* 6.0* 12.9 12.5
Men 18-44 45-64 65-74 75+
3.4 0.8E1 4.5 12.5 13.0E1
4.3 1.4E1 5.4 12.3 15.9
Women 3.3 3.2 3.3 4.2* 18-44 1.1E1 1.0 0.7E1 1.3 45-64 3.7 4.1 4.3 5.3* 65-74 9.8 8.8 9.7 11.3 75+ 10.4 9.2 9.7 10.9 Data sources: 1994/95, 1996/97 and 1998/99 National Population Health Survey, cross-sectional sample, Health file; 2000/01 Canadian Community Health Survey E1 Coefficent of variation between 16.6% and 25.0% * Significantly different from 1994/95 (p < 0.05)
What is diabetes? Diabetes is a chronic disease that has no cure, but can be controlled.12 There are two major types. Type 1 diabetes occurs most often in children and young adults and is relatively uncommon, accounting for 10% to 15% of cases.13 It is an autoimmune disease in which the body produces little or no insulin, a hormone needed to convert food into energy. The resulting insulin deficiency is severe, and to survive, a person with type 1 diabetes must regularly inject insulin. Type 2, which results when the pancreas does not produce enough insulin or when the body does not use the insulin that is produced effectively, accounts for 85% to 90% of cases. It may affect children and adolescents, but usually begins after age 30 and becomes more common with advancing age. Another form of the disease—gestational diabetes—is a temporary condition that occurs in up to 4% of pregnancies and increases the risk of eventually developing diabetes. The first symptoms of diabetes are related to high blood sugar levels. As the blood-glucose level rises, glucose passes into the urine. The kidneys excrete additional water to dilute the large amounts of glucose that are being lost. This leads to excessive urination, which in turn, creates abnormal thirst. Because of the severity of insulin deficiency, people with type 1 diabetes almost always lose weight. Most people with type 2 do not lose weight and may not have symptoms for years or decades. Early symptoms of type 2 include recurring skin, gum or bladder infections, slow-to-heal cuts and bruises, itchy skin, vaginal yeast infections, fatigue, blurred vision, frequent urination, and tingling in the hands or feet. Over time, elevated blood sugar levels damage blood vessels, nerves and other internal structures, resulting in serious long-term complications, such as heart attack and stroke. Damage to the blood vessels of the eye can cause vision loss. The kidneys can malfunction, resulting in kidney failure that requires dialysis. Type 2 diabetes can be detected in blood tests before it has fully developed. The fasting plasma glucose (FPG) test measures blood-glucose levels, usually first thing in the morning after an overnight fast. The oral glucose tolerance test (OGTT) measures blood-glucose levels twice: once after fasting, and again two hours after a sugar-rich drink. Diabetes is treated by control of blood sugar levels, combined with control of blood pressure and blood lipids. Insulin replacement therapy or an oral hypoglycemic medication is often needed, although many people with type 2 would not need medication if they lost weight and exercised regularly.
Despite the notable upturn at younger ages, diabetes remains a disease of the elderly. In 2000/01, over 12% of seniors were diabetic, compared with 6% of 45- to 64-year-olds and just over 1% of people aged 18 to 44. A family history is a major risk factor. In 1998/99, 8.5% of people with a diabetic parent and/or sibling reported that they, too, had the disease; the rate
among people who did not report first-degree relatives as having diabetes was 2.0% (Table 2). Diabetes tended to be associated with lifestyle. In 2000/01, rates were high among people who were obese or sedentary. The prevalence was also high among former drinkers and smokers, perhaps reflecting a modification of lifestyle triggered by the diagnosis. There also seems to be some association
Analytical techniques The unadjusted prevalence of diabetes was computed for 1994/95, 1996/97 and 1998/99 based on the National Population Health Survey (NPHS) and for 2000/01 based on the Canadian Community Health Survey (CCHS). The diabetes incidence rate is the number of new cases diagnosed in a given period, divided by the total person-time under observation.14-16 Respondents who were free of "diagnosed diabetes" at the start of each NPHS cycle constitute the population among whom incidence rates were calculated. Since four cycles of longitudinal NPHS data are available, there are three two-year intervals (1994/95 to 1996/97, 1996/97 to 1998/99, and 1998/99 to 2000/01). Three records were created for each individual on the master file, one record for each two-year interval. The number of respondents free of diabetes at the beginning of each interval constituted the population "at risk" of being diagnosed over the next two years. The sum of respondents at risk at the beginning of each of the three intervals was the population at risk during the entire six years: 33,599. A respondent was considered to be an incident case if (s)he did not report diabetes in one cycle, but did report having been diagnosed in the next. Interviews for each cycle were conducted approximately two years apart, so the time-at-risk between two adjacent cycles was assumed to be two years for respondents not reporting a diagnosis at either cycle. For respondents who did not report diabetes when they were interviewed at the beginning of one cycle, but did report it at the next interview, the time-at-risk between the two interviews was taken to be one year, based on the assumption that new diagnoses were evenly distributed throughout the interval. The maximum time-at-risk for respondents not diagnosed throughout the survey cycles was six years. Any interval between the cycles for which the existence or non-existence of diabetes was unknown was not used to calculate time-at-risk. The numerator for the incidence of diabetes was the number of new cases that accumulated over the period; the denominator was the number of person-years contributed by the population at risk (that is, who did not have diabetes) over the follow-up period. Rates
were expressed as cases per 1,000 person-years at risk for each two-year interval and for the entire six years. The selection of independent variables was based on a review of the literature and their availability in the NPHS: sex, age, family history of diabetes, body mass index, physical activity, alcohol use, smoking and education (see Definitions). For all independent variables except family history, data from each survey cycle were used. Information on family history was collected only in 1998/99 (see Limitations). If respondents stated that they had a family history of diabetes in 1998/99, a family history variable was assigned to their responses for 1994/95 and 1996/97. Individuals were considered to have a particular characteristic for the full two years between each cycle, even if the value of the characteristic changed from one interview to the next. For example, respondents' answers to the leisure-time physical activity questions in one interview might place them in the "sedentary" category, but answers in the subsequent interview might qualify as "moderately active." Nonetheless, such respondents would be considered "sedentary" for the entire two years between interviews. For each characteristic, an "unknown" category was created so that respondents for whom diabetes information was available could be included in the analysis even if they had not provided data about other characteristics. Multivariate pooled logistic regression was used to study the association between incident diabetes and the selected risk factors. To ensure an adequate sample size, data for men and women were combined. For the same reason, "missing value" categories were included for some independent variables, but their odds ratios are not shown. To account for survey design effects, standard errors and coefficients of variation were estimated with the bootstrap resampling technique.17-20 Results at the 0.05 level were considered significant. In instances where multiple means or proportions were tested, the significance levels were adjusted via the Exacted Alpha/L Method.
with socio-economic status, as a relatively large proportion of people with less than secondary graduation were diabetic.
Compromised health
Sex Men Women†
4.8* 4.2
Age group 18-44† 45-64 65-74 75+
12,387 7,269 2,154 1,490
1.3 6.0* 12.9* 12.5*
8.5* 2.0 4.2*
According to the results of the 2000/01 Canadian Community Health Survey, people with diabetes tended to have other medical problems, and not surprisingly, made frequent use of health care services, even when the older age profile of the diabetic population was accounted for. Those who reported that they had been diagnosed with diabetes were more likely than non-diabetics to have high blood pressure, heart disease, urinary incontinence and stroke. Vision problems, too, were more common. Given these high percentages, it is not surprising that over a third of diabetics (37%) rated their health as poor or fair, whereas this was true of 11% of non-diabetics. As might be expected, diabetics made relatively frequent use of health care services. For instance, 29% reported 10 or more general practitioner contacts in the previous year, compared with 12% of non-diabetics. Diabetics were also more likely to have had at least three contacts with eye doctors and with other specialists in that time. Fully 18% of diabetics had been hospitalized in the past year, compared with 8% of non-diabetics, and a significantly higher proportion had spent more than two weeks in hospital.
Body mass index (BMI)§ Not overweight (< 25)† Overweight (25.0-29.9) Obese (≥ 30) Missing
55,768 38,393 18,447 3,563
11,895 7,457 3,333 615
2.5 5.2* 10.6* 3.2
Age-adjusted† prevalence of selected health indicators, by diabetes status, household population aged 18 or older, Canada excluding territories, 2000/01
Leisure time Active† Moderately active Sedentary Missing
4,430 5,044 12,022 1,799
3.2 4.0 5.2* 4.8*
Alcohol consumption Current drinker Former drinker Abstainer† Missing
91,252 16,638 7,583 698
3.4* 9.7* 8.0* 3.7
Smoking Daily/Occasional Former smoker Never smoked† Missing
32,886 48,094 34,928 263
6,312 9,136 7,792 58
3.2* 5.9* 4.0 2.4
Table 2 Unadjusted prevalence of diabetes, by selected characteristics, household population aged 18 or older, Canada excluding territories, 2000/01 Sample size
Family history of diabetes‡ Yes No† Missing
Prevalence of diabetes
% 4.5
Education Less than secondary graduation 31,234 5,218 445 8.5* Secondary graduation/Some postsecondary 31,874 6,757 234 3.5 Postsecondary graduation† 51,830 11,111 361 3.3 Missing 1,233 214 14 6.3* Data source: 2000/2001 Canadian Community Health Survey; 1998/99 National Population Health Survey, cross-sectional sample, Health file Note: Because of rounding, detail may not add to totals. † Reference group ‡ 1998/99 National Population Health Survey § Excludes pregnant women. * Significantly different from reference group (p < 0.05) ... Not applicable
Nondiabetic
Diabetic %
Chronic conditions Heart disease High blood pressure Urinary incontinence Stroke
12* 34* 5* 3*
Vision problems None Corrected Uncorrected Glaucoma Cataracts
38* 58* 4* 3* 7*
Fair/Poor self-perceived health
Health care use in past year 10+ physician contacts 3+ eye doctor contacts 3+ other medical specialist contacts Hospitalized Hospitalized more than 14 days
29* 13* 21* 18* 3*
Data source: 2000/01 Canadian Community Health Survey † Adjusted to 2000/01 population, both sexes * Significantly different from non-diabetic (p < 0.05)
However, many of these characteristics are interrelated. For example, advancing age is associated with increased weight, decreased physical activity, and decreased use of alcohol and tobacco. As well, levels of education tend to be relatively low
among elderly people. The potential effects of such confounding relationships should be taken into account to determine associations between diabetes and various risk factors, particularly with regard to new diagnoses.
Definitions Both the National Population Health Survey (NPHS) and the Canadian Community Health Survey (CCHS) contain questions about chronic conditions. NPHS respondents were asked if they had any "long-term health conditions that have been diagnosed by a health professional." CCHS respondents were asked if they had any "long-term health problems." In addition to diabetes from both surveys, this analysis considers heart disease, high blood pressure, stroke, urinary incontinence, glaucoma and cataracts from the CCHS. For descriptive analysis, age was grouped into four categories: 18 to 44, 45 to 64, 65 to 74, and 75 or older. Age was used as a continuous variable in the adjusted analysis. In 1998/99, NPHS respondents were asked about the medical history of their immediate family. A family history of diabetes was considered to exist if a respondent reported that at least one firstdegree relative (biological parent and/or sibling) had the disease. A substantial number (4,005) of respondents did not know their family history. These respondents, who tended to have a higher incidence of diabetes than those without a positive family history (Appendix Table A), were initially excluded. However, additional analysis showed that the independent associations of family history and body mass index with incident diabetes persisted even when these respondents were included and classified as having no family history. Consequently, estimates are shown for this group. In the NPHS and CCHS, respondents were asked their weight and height. Body mass index (BMI) was calculated by dividing weight in kilograms by the square of height in metres. Three categories were defined: not overweight (BMI less than 25), overweight (25 to 29.9) and obese (30 or more). Pregnant women were excluded from the calculations. Leisure-time physical activity was based on total energy expenditure during leisure time. Information about physical activity at work was not available from either survey. Energy expenditure was based on the frequency and duration of respondents' reported leisure-time activities in the previous three months and the metabolic energy demand of each activity. Activities lasting less than 15 minutes were not counted. Three activity levels were defined: active
(3.0 or more kilocalories per kilogram of body weight per day) moderate (1.5 to less than 3.0) and sedentary (less than 1.5). Respondents to both surveys were asked: "During the past 12 months, how often did you drink alcoholic beverages?" For this analysis, three categories of alcohol consumption were established: current (regular and occasional) drinker, former drinker and abstainer. Respondents to both surveys were asked about their past and current cigarette consumption. Three categories of smoking were identified: daily/occasional, former smoker and never smoked. Education was categorized as less than secondary graduation, secondary graduation/some postsecondary and postsecondary graduation. As well as the inclusion of cataracts and glaucoma among chronic conditions, the CCHS asked about vision problems. This analysis uses three categories of vision problems: none, corrected and uncorrected (including no sight). CCHS respondents were asked: "In general would you say your health is: excellent, very good, good, fair, poor?" For this analysis, three categories of self-perceived health were defined: excellent/ very good, good, and fair/poor. In the CCHS, the use of family doctors or general practitioners was determined by asking: "In the past 12 months how many times have you seen or talked on the telephone about your physical, emotional or mental health with a family doctor or general practitioner?" ... an eye specialist (such as an ophthalmologist or optometrist)?" The same general question also related to consultations with other medical specialists (such as surgeon, allergist, orthopedist, gynecologist or psychiatrist). Frequent use of general practitioner services was defined as 10 or more times in the past year. Frequent use of eye or other medical specialists was defined as three or more times in the past year. CCHS respondents were asked if they had been an overnight patient in a hospital, nursing home or convalescent home in the past 12 months and for how many nights. In this analysis, heavy users of hospital services were those who had spent more than 14 days in hospital.
Rising incidence The rate at which new cases of diabetes were diagnosed increased in recent years. Between 1994/95 and 1996/97, the two-year incidence rate was 4.0 cases per 1,000 person-years at risk; between 1998/99 and 2000/01, the rate was 6.7 cases (Table 3). The increase among men from 3.5 to 6.8 cases per 1,000 person-years at risk was statistically significant, but the apparent rise in rates among women from 4.5 to 6.5 cases was not. From 1994/95 to 2000/01, 353 new cases of diabetes were reported by NPHS respondents, representing about 497,000 new diagnoses. The overall incidence rate for this six-year period was 4.9 cases per 1,000 person-years at risk. Incidence rose with age from 1.8 new cases per 1,000 person-years at risk for 18- to 44-year-olds to 14.2 cases at age 75 or older (Table 4). Even when adjustments were made for the effects of factors such as family history, weight, physical activity, drinking, smoking and education, the odds of developing diabetes were significantly higher at older ages (Table 5).
Table 3 Two-year incidence of diabetes, by sex, household population aged 18 or older, Canada excluding territories, 1994/95 to 2000/01 New cases per 1,000 person-years at risk
95% confidence interval
Family history A family history of a disease may indicate a genetic predisposition. It might also increase awareness, which could instigate testing and detection. Among people who had a biological parent and/or sibling with diabetes, the six-year incidence rate was 9.7 new cases per 1,000 person-years at risk, compared with 3.0 cases among people without such a background. A family history, however, may also signal a shared Table 4 Unadjusted six-year incidence of diabetes, by selected characteristics, household population aged 18 or older, Canada excluding territories, 1994/95 to 2000/01 New cases per 1,000 person-years at risk
Sex Men† Women
3.8, 5.8 4.1, 6.0
1.1, 2.4 5.7, 8.4 8.4, 14.9 8.8, 19.7
9.7* 3.0* 5.8*
7.5, 11.9 2.3, 3.6 4.1, 7.4
1.9 6.1* 13.5*
1.3, 2.5 4.8, 7.5 10.6, 16.4
2.7 4.5 5.8*
1.6, 3.9 3.1, 5.9 4.8, 6.8
3.7 10.7* 8.7*
3.0, 4.3 7.7, 13.8 5.2, 12.2
7.0, 10.7
Age group 18-44‡ 45-64 65-74 75+ Family history of diabetes Yes No† Missing Body mass index (BMI)§ Not overweight (< 25)‡ Overweight (25.0-29.9) Obese (≥ 30) Leisure time Active‡ Moderately active Sedentary
Both sexes 1994/95 to 1996/97 1996/97 to 1998/99 1998/99 to 2000/01
4.0 4.4 6.7 †
Alcohol consumption Current drinker‡ Former drinker Abstainer
Men 1994/95 to 1996/97 1996/97 to 1998/99 1998/99 to 2000/01
Smoking Daily/Occasional Former smoker Never smoked‡
Women 1994/95 to 1996/97 1996/97 to 1998/99 1998/99 to 2000/01
Data source: 1994/95, 1996/97, 1998/99, 2000/01 National Population Health Survey, longitudinal sample, Health file Note: Critical ratio adjusted for multiple comparisons and non-independent samples † Significantly higher than 1994/95 to 1996/97 (p < 0.05)
Education Less than secondary graduation Secondary graduation/Some postsecondary Postsecondary graduation‡
Data source: 1994/95, 1996/97, 1998/99, 2000/01 National Population Health Survey, longitudinal sample, Health file † Reference group ‡ Reference group at beginning of each two-year interval § Excludes pregnant women. * Significantly different from reference group (p < 0.05)
home environment that increases the risk of developing a disease. In the case of diabetes, shared behaviour in nutrition, physical activity, smoking and alcohol use could contribute to higher incidence rates.21-23 Yet even when these factors along with age, sex and education were taken into account, the odds that a person with a diabetic parent or sibling would be diagnosed with the disease were almost three times those of a person without such a family history.
Table 5 Adjusted odds ratios relating selected characteristics to incidence of diabetes between 1994/95 and 2000/01, household population aged 18 or older, Canada excluding territories Adjusted odds ratio
0.78, 1.56 ...
Age (in years)‡
1.06, 1.21
Family history of diabetes Yes No† Missing
2.75* 1.00 1.56*
1.94, 3.90 ... 1.06, 2.30
Body mass index (BMI)§ Not overweight (< 25)† Overweight (25.0-29.9) Obese (≥ 30)
1.00 1.59* 1.77*
... 1.30, 1.94 1.56, 2.02
Leisure time Active† Moderately active Sedentary
1.00 1.51 1.65*
Alcohol consumption Current drinker† Former drinker Abstainer
Smoking Daily/Occasional Former smoker Never smoked†
0.65, 1.61 0.85, 1.80 ...
Education Less than secondary graduation Secondary graduation/Some postsecondary Postsecondary graduation†
Data source: 1994/95, 1996/97, 1998/99, 2000/01 National Population Health Survey, longitudinal sample, Health file † Reference group ‡ Age-squared was used in model, but data are not shown. § Excludes pregnant women. * Significantly different from reference group (p < 0.05) … Not applicable
Weight and exercise Excess weight is an important risk factor for the development of type 2 diabetes,24-27 and the risk tends to rise as weight increases.28 The six-year incidence rate among people who were obese was 13.5 new cases per 1,000 person-years at risk, and among those who were overweight, 6.1 cases. This compared with 1.9 cases among people who were not overweight. The association remained significant when factors such as age, family history and physical activity were considered. The odds that an obese or overweight person would be diagnosed with diabetes were one and a half times those of someone who was not overweight. Physical activity has been shown to reduce the risk of developing diabetes.29-39 Over the six years covered by the NPHS, the incidence of the disease was 2.7 new cases per 1,000 person-years at risk for people who were physically active in their leisure time, compared with 5.8 new cases for those with sedentary pursuits. Even though active people are less likely to have excess weight,40,41 when BMI and the other factors were taken into account, the odds of incident diabetes were significantly higher among people who were sedentary. Drinking and smoking The six-year incidence rates of diabetes were highest among former drinkers at 10.7 new cases per 1,000 person-years at risk and abstainers at 8.7 new cases. The rate among current drinkers was just 3.7 cases. People with a family history of diabetes may abstain from alcohol, thus accounting for the higher incidence rate in that group. As well, the high incidence rates among former drinkers and abstainers might be attributable to the age structure of the two groups, since drinking tends to decline at older ages.42 Yet even when family history, age, and the other factors were considered, the odds of incident diabetes were significantly higher among former drinkers and abstainers than among current drinkers. Prospective studies have suggested that smoking may be a risk factor for diabetes,27,43-47 but according to the analysis of the NPHS data, the odds of developing diabetes over the six years did not differ
significantly by smoking status. This is in line with a 1996 report that attempted to control for a wide range of variables and suggested that a causal relationship between smoking and insulin resistance is unlikely.48 Education From 1994/95 to 2000/01, the incidence rate of diabetes for people with less than secondary graduation was 8.8 new cases per 1,000 person-years at risk, considerably above the rate for postsecondary graduates (3.6 cases). But when age, sex, family history, and lifestyle factors were taken into account, the odds of developing diabetes over the period did not differ significantly by education.
Nonetheless, the association between education and diabetes is complex. Similar incidence rates may conceal great differences between education groups in factors that contribute to a diagnosis of diabetes, but that could not be accounted for in this analysis. For example, less-educated people are generally more likely to report chronic diseases,59 not just diabetes, which could contribute to higher incidence rates. On the other hand, they may not be aware of the means of preventing diabetes and the symptoms associated with it, which could mean fewer diagnoses. Better-educated people, by contrast, tend to be more aware of risk factors and symptoms, which could increase their demand for screening and result in elevated incidence rates. But at the same
Limitations Diabetes tends to be underdiagnosed,49,50 as the onset of the disease may occur several years before clinical diagnosis.13 It has been estimated that as many as one-third of adults with the condition have not been diagnosed. 51 Consequently, some National Population Health Survey (NPHS) and Canadian Community Health Survey (CCHS) respondents who did not report diabetes may actually have had it, so its incidence and prevalence may be underestimated. On the other hand, no independent source was available to confirm if respondents who reported diabetes (or other chronic conditions) had actually been diagnosed by a health professional. However, a study that compared self-reports of diabetes with hospital and physician claims data suggests that self-reports were fairly accurate.52 Reliance on self-reports entails other problems. For instance, selfreported weight and height (used to calculate BMI) may underestimate the prevalence of overweight, particularly among seniors.53-55 With age, loss of bone mass and height is common, but people tend to report their height as measured in younger years. Similarly, self-reported leisure-time physical activity may bias results toward underestimation of the effect of physical activity on chronic disease incidence and prevalence.56-58 In NPHS and CCHS data, type 1 and type 2 diabetes cannot be differentiated. Since the risk factors are not the same, the strength of the relationship between the independent variables and the incidence of diabetes (that is, type 2) may have been diluted.
Although the prevalence of diabetes is high among Aboriginal people,60-63 the NPHS longitudinal file sample was not large enough to yield precise estimates for this population. Family history was defined as the presence of diabetes in a biological parent and/or sibling. The number of first-degree relatives with the disease would have been useful,64-66 but this information is not available. In addition, the question about family history was not asked until the third NPHS cycle, and the responses were applied to individuals who participated in the first cycle. No family history information was available for respondents who had died or moved into residential care by the time of the cycle 3 interview. The analysis of the association between the independent variables and the incidence of diabetes assumed that the respondent's status in each independent variable category remained stable during each two-year interval. But factors like physical activity or weight might have changed markedly during the interval, so the lack of such information could affect inferences about the importance of some independent variables on the incidence of diabetes. The cycle 4 NPHS Longitudinal Master File contains records for all longitudinal respondents for whom there was some information in 1994/95. If individuals became non-respondents after the first cycle, they could still contribute to the estimates. In cases where the survey lacks full information on these individuals, there is a potential for bias if those without full responses behave differently from those with full responses for the characteristic being studied.
time, they might be more likely to take preventive measures and make lifestyle changes that would lower the incidence of the disease. Concluding remarks In 2000/01, 4.5% of Canadians aged 18 or older— an estimated 1.1 million—had diabetes, and the pace at which new cases were diagnosed seems to have increased. The analysis of data from the Canadian Community Health Survey reinforces other studies that have shown that that diabetes not only takes a personal toll on those with the disease, but also imposes a substantial burden on physician and hospital services.67-74 The analysis of longitudinal data from the National Population Health Survey shows that age, family history, weight and physical activity were the most important predictors of incident diabetes. Age and family history, of course, cannot be modified. However, weight and physical activity can be changed. The results underscore the importance of public health initiatives aimed at reducing diabetes risk by attaining and maintaining a healthy weight.6,75 People who gain weight and accumulate fat around the waist, abdomen and upper body tend to have relatively high odds of developing the disease.76 A recent cohort study found that during a 13-year period, overweight men and women who reported intentional weight loss had about a 25% reduction in the rate of developing diabetes, compared with their counterparts who did not report intentional weight loss.77 Higher levels of physical activity may help to prevent type 2 diabetes by increasing sensitivity to insulin and inhibiting progression of the disease in its early stages. And through its influence on weight control, physical activity is important in preventing diabetes.78,79 Even when weight was accounted for in the NPHS analysis, physical activity was independently associated with a lower risk of developing the disease. Current patterns of overweight and physical activity suggest that the prevalence of diabetes will rise in the next decade. Despite the benefits of
exercise, the majority of Canadians, with and without diabetes, are not active in their leisure time and the proportion of the population who are overweight is rising. Moreover, the number of seniors will increase, so even if incidence rates remain stable, demographic changes may lead to a considerable upturn in the overall prevalence of the disease.
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1 Boyle JP, Honeycutt AA, Narayan KM, et al. Projection of diabetes burden through 2050: Impact of changing demography and disease prevalence in the U.S. Diabetes Care 2001; 24(11): 1936-40. 2 King H, Remers M. Global estimates for the prevalence of diabetes mellitus and impaired glucose tolerance in adults. Diabetes Care 1993; 16: 157-77. 3 van Dam RM, Rimm EB, Willett WC, et al. Dietary patterns and risk for type 2 diabetes mellitus in U.S. men. Annals of Internal Medicine 5-2-2002; 136(3): 201-9. 4 Amos AF, McCarty DJ, Zimmet PZ. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetic Medicine 1997; 14 Suppl 5: S1-85. 5 Zimmet PZ, McCarty DJ, de Courten MP. The global epidemiology of non-insulin-dependent diabetes mellitus and the metabolic syndrome. Journal of Diabetes and Its Complications 1997; 11(2): 60-8. 6 Meltzer S, Leiter L, Daneman D, et al. 1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Medical Association Journal 1998; 159(8)(suppl): s1-29 7 Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non-insulin-dependent diabetes. In: Harris MI, Cowie CC, Stern MP, et al, eds. Diabetes in America. 2nd ed., Bethesda, Maryland: National Diabetes Data Group of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 1995: 47-67. 8 Tambay JL, Catlin G. Sample design of the National Population Health Survey. Health Reports (Statistics Canada, Catalogue 82-003) 1995; 7(1): 28-38. 9 Swain L, Catlin G, Beaudet M. The National Population Health Survey—its longitudinal nature. Health Reports (Statistics Canada, Catalogue 82-003) 1999; 10(4): 69-82. 10 Statistics Canada. Population Health Surveys Program. National Population Health Survey, Cycle 4 (2000-2001), Household Component, Longitudinal Documentation. Ottawa: Statistics Canada, 2002. 11 Béland Y. Canadian Community Health Sur vey— methodological overview. Health Reports (Statistics Canada, Catalogue 82-003) 2002; 13(3): 9-14. 12 Berkow R, Beers MH, Fletcher AJ, eds. The Merck Manual of Medical Information. Whitehouse Station, New Jersey: Merck and Co. Inc., 1997.
Tracking diabetes 13 Harris MI, Robbins DC. Prevalence of adult-onset IDDM in the U.S. population. Diabetes Care 1994; 17(11): 1337-40. 14 Last JM (ed). A Dictionary of Epidemiology. 3rd ed. Edited for the International Epidemiological Association. Toronto: Oxford University Press, 1995. 15 Rothman KJ, Greenland S. Measures of disease frequency. In: Rothman KJ, Greenland S, eds. Modern Epidemiology, 2nd ed. Philadelphia: Lippincott-Raven, 1998: 29-64. 16 Cupples LA, D'Agostino RB, Anderson K, et al. Comparison of baseline and repeated measure covariate techniques in the Framingham Heart Study. Statistics in Medicine 1988; 7: 205-8. 17 Korn EL, Graubard MA. Epidemiological studies utilizing surveys: Accounting for the sampling design. American Journal of Public Health 2002; 81(9): 1166-73. 18 Rao JNK, Wu CFJ, Yue K. Some recent work on resampling methods for complex surveys. Survey Methodology (Statistics Canada, Catalogue 12-001) 1992; 18(2): 209-17. 19 Rust KF, Rao JNK. Variance estimation for complex surveys using replication techniques. Statistical Methods in Medical Research 1996; 5: 283-310. 20 Yeo D, Mantel H, Liu TP. Bootstrap variance estimation for the National Population Health Survey. American Statistical Association: Proceedings of the Survey Research Methods Section. Baltimore: August 1999. 21 Morris RD, Rimm DL, Hartz AJ, et al. Obesity and heredity in the etiology of non-insulin-dependent diabetes mellitus in 32,662 adult white women. American Journal of Epidemiology 1989; 130(1): 112-21. 22 Mykkanen L, Laasko M, Uusitupa M, et al. Prevalence of diabetes and impaired glucose tolerance in elderly subjects and their association with obesity and family history of diabetes. Diabetes Care 2002; 13(11): 1099-105. 23 Sargeant LA, Wareham NJ, Khaw KT. Family history of diabetes mellitus identifies a group at increased risk for the metabolic consequences of obesity and physical inactivity in EPIC-Norfolk: a population based study. The European Prospective Investigation into Cancer. International Journal of Obesity and Related Metabolic Disorders 2002; 24(10): 1333-9. 24 Looker HC, Knowler WC, Hanson RL. Changes in BMI and weight before and after the development of type 2 diabetes. Diabetes Care 2001; 24(11): 1917-22. 25 Paris RM, Bedno SA, Krauss MR, et al. Weighing in on type 2 diabetes in the military: characteristics of U.S. military personnel at entry who develop type 2 diabetes. Diabetes Care 2001; 24(11): 1894-8. 26 Field AE, Coakley EH, Must A, et al. Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Archives of Internal Medicine 2001; 161(13): 1581-6. 27 Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. The New England Journal of Medicine 2001; 345(11): 790-7. 28 Hillier TA, Pedula KL. Characteristics of an adult population with newly diagnosed type 2 diabetes: the relation of obesity and age of onset. Diabetes Care 2001; 24(9): 1522-7.
29 U.S. Department of Health and Human Services. Physical activity and health. A report of the Surgeon General. S/ 017-02300196-5. Pittsburg, Pennsylvania: Superindent of Documents, 1996. 30 Holbrook TL, Barrett-Connor E, Wingard DL. The association between lifetime weight and weight control patterns with diabetes among men and women in an adult community. International Journal of Obesity 1989; 13(5): 723-9. 31 Manson JE, Rimm EB, Stampfer MJ, et al. Physical activity and incidence of non-insulin-dependent diabetes mellitus in women. Lancet 1991; 338(8770): 774-8. 32 Manson JE, Nathan DM, Krolewski AS, et al. A prospective study of exercise and incidence of diabetes among US male physicians. The Journal of the American Medical Association 1992; 268(1): 63-7. 33 Perry IJ, Wannamethee SG, Walker MK, et al. Prospective study of risk factors for development of non-insulin dependent diabetes in middle aged British men. British Journal of Medicine 1995; 310(6979): 560-4. 34 Lynch J, Helmrich SP, Lakka TA, et al. Moderately intense physical activities and high levels of cardiorespiratory fitness reduce the risk of non-insulin-dependent diabetes mellitus in middle-aged men. Archives of Internal Medicine 1996; 156(12): 1307-14. 35 Kriska AM, Hanley AJ, Harris SB, et al. Physical activity, physical fitness, and insulin and glucose concentrations in an isolated Native Canadian population experiencing rapid lifestyle change. Diabetes Care 2001; 24(10): 1787-92. 36 Hu FB, Leitzmann MF, Stampfer MJ, et al. Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Archives of Internal Medicine 2001; 161(12): 1542-8. 37 Helmrich SP, Ragland DR, Leung RW, et al. Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus. The New England Journal of Medicine 1991; 325(3): 147-52. 38 Wareham NJ, Wong DY, Day NE. Glucose intolerance and physical inactivity: the relative importance of low habitual energy expenditure and cardiorespiratory fitness. American Journal of Epidemiology 2000; 152(2): 132-9. 39 Chipkin SR, Klugh SA, Chasan-Taber L. Exercise and diabetes. Cardiology Clinics 2001; 19(3): 489-505. 40 Ross R, Janssen I. Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise 2001; 33(6) (Suppl): S521-7. 41 Ball K, Owen N, Salmon J, et al. Associations of physical activity with body weight and fat in men and women. International Journal of Obesity and Related Metabolic Disorders 2001; 25(6): 914-9. 42 Statistics Canada. Taking risks/Taking care in Health Reports: The Health Divide—How the Sexes Differ (Catalogue 82-003) 2001; 12(3): 11-20. 43 Rimm EB, Chan J, Stampfer MJ, et al. Prospective study of cigarette smoking, alcohol use, and the risk of diabetes in men. British Journal of Medicine 1995; 310: 555-9.
44 Kawakami N, Takatsuka N, Shimizu H, et al. Effects of smoking on the incidence of non-insulin-dependent diabetes mellitus. Replication and extension in a Japanese cohort of male employees. American Journal of Epidemiology 1997; 145(2): 103-9. 45 Manson JE, Ajani UA, Liu S, et al. A prospective study of cigarette smoking and the incidence of diabetes mellitus among US male physicians. American Journal of Medicine 2000; 109(7): 538-42. 46 Will JC, Galuska DA, Ford ES, et al. Cigarette smoking and diabetes mellitus: evidence of a positive association from a large prospective cohort study. International Journal of Epidemiology 2001; 30(3): 540-6. 47 Wannamethee SG, Shaper AG, Perry IJ. Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men. Diabetes Care 2001; 24(9): 1590-5. 48 Wareham NJ, Ness EM, Byrne CD, et al. Cigarette smoking is not associated with hyperinsulinemia: evidence against a causal relationship between smoking and insulin resistance. Metabolism 1996; 45(12): 1551-6. 49 Leiter LA, Barr A, Belanger A, et al. Diabetes Screening in Canada (DIASCAN) Study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices. Diabetes Care 2001; 24(6): 1038-43. 50 Worrall G, Moulton N. The ratio of diagnosed to undiagnosed diabetes in patients 40 years and older. Canadian Journal of Public Health 1992; 83(5): 379-81. 51 Young TK, Mustard CA. Undiagnosed diabetes: does it matter? Canadian Medical Association Journal 2001; 164(1): 24-8. 52 Robinson JR, Young TK, Roos LL, et al. Estimating the burden of disease. Comparing administrative data and selfreports. Medical Care 1997; 35(9): 932-47. 53 Kuskowska-Wolk A, Karlsson P, Stolt M, et al. The predictive validity of body mass index based on self-reported weight and height. International Journal of Obesity 1988; 13(4): 441-53. 54 Millar WJ. Distribution of body weight and height: comparison of estimates based on self-reported and observed measures. Epidemiology and Community Health 1986; 40(4): 319-23. 55 Rowland ML. Self-reported weight and height. American Journal of Clinical Nutrition 1990; 52(6): 1125-33. 56 Sesso HD, Paffenbarger RSJr, Lee I-M. Physical activity and coronary heart disease in men. The Harvard Alumni Heart Study. Circulation 2000; 102: 975-80. 57 Mensink GB, Ziese T, Kok FJ. Benefits of leisure-time physical activity on the cardiovascular risk profile at older age. International Journal of Epidemiology 1999; 28(4): 659-66. 58 Manson JE, Hu FB, Rich-Edwards JW, et al. A prospective study of walking as compared to vigorous activity in the prevention of coronary heart disease in women. The New England Journal of Medicine 1999; 341(9): 650-8. 59 Pincus T, Callahan LF, Burkhauser RV. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the 18-64 United States population. Journal of Chronic Diseases 1987; 40(9): 865-74.
60 Young TK, McIntyre LL, Dooley J, et al. Epidemiological features of diabetes mellitus among Indians in northwestern Ontario and northeastern Manitoba. Canadian Medical Association Journal 1985; 132: 793-7. 61 Young TK, Szathmary EJ, Evers S, et al. Geographical distribution of diabetes among the native population of Canada. Social Science and Medicine 1990; 31(2): 129-39. 62 Young TK, Schraer CD, Shubnikoff EV, et al. Prevalence of diagnosed diabetes in circumpolar indigenous populations. International Journal of Epidemiology 1992; 21(4): 730-6. 63 Young TK, Reading J, Elias B, et al. Type 2 diabetes in Canada's first nations: status of an epidemic in progress. Canadian Medical Association Journal 2000; 163(5): 561-6. 64 Hunt SC, Williams RR, Barlow GK. A comparison of positive family history definitions for defining risk of future disease. Journal of Chronic Diseases 1986; 39(10): 809-21. 65 Khoury MJ, Flanders WD. Bias in using family history as a risk factor in case-control studies of disease. Epidemiology 1995; 6(5): 511-9. 66 Wagener DK, Sacks JM, Laporte RE. The Pittsburgh study of insulin-dependent diabetes mellitus: risk for diabetes among relatives of IDDM. Diabetes 1982; 31(2): 182-203. 67 Ray NF, Thamer M, Taylor T, et al. Hospitalization and expenditures for the treatment of general medical conditions among the U.S. diabetic population in 1991. Journal of Clinical Endocrinology and Metabolism 1996; 81(10): 3671-9. 68 Knuiman MW, Welborn TA, Bartholomew HC. Self-reported health and use of health services: a comparison of diabetic and nondiabetic persons from a national sample. Australian and New Zealand Journal of Public Health 1996; 20(3): 241-7. 69 Brown GC, Brown MM, Sharma S, et al. Quality of life associated with diabetes mellitus in an adult population. Journal of Diabetes Complications 2000; 14(1): 18-24. 70 Lloyd CE, Dyer PH, Barnett AH. Prevalence of symptoms of depression and anxiety in a diabetes clinic population. Diabetic Medicine 2000; 17(3): 198-202. 71 Gregg EW, Beckles GL, Williamson DF, et al. Diabetes and physical disability among older U.S. adults. Diabetes Care 2000; 23(9): 1272-7. 72 Gavard JA, Lustman APJ. Prevalence of depression in adults with diabetes mellitus. Diabetes Care 1993; 16: 1167-78. 73 Wingard DL, Barrett-Connor EL, Scheidt-Nave C, et al. Prevalence of cardiovascular and renal complications in older adults with normal or impaired glucose tolerance or NIDDM. A population-based study. Diabetes Care 1993; 16(7): 1022-5. 74 Jonsson PM, Nystrom L, Rosenqvist U, et al. Diabetes mellitus and health service utilization: a case-control study of outpatient visits 8 years after diagnosis. Diabetic Medicine 1996; 13(12): 1056-63. 75 Reeder BA, Angel A, Ledoux M, et al. Obesity and its relation to cardiovascular disease risk factors in Canadian adults. Canadian Medical Association Journal 1992; 146(11): 2009-19. 76 Björntorp P. Classification of obese patients with complications related to the distribution of body fat. American Journal of Clinical Nutrition 1987; 45: 1120-5.
77 Will JC, Williamson DF, Ford ES, et al. Intentional weight loss and 13-year diabetes incidence in overweight adults. American Journal of Public Health 2002; 92(8): 1245-8. 78 Spelsberg A, Manson JE. Physical activity in the treatment and prevention of diabetes. Comprehensive Therapy 1995; 21(10): 559-62. 79 Poirier P, Despres JP. Exercise in weight management of obesity. Cardiology Clinics 2001; 19(3): 459-70.
Appendix Table A Characteristics of household population aged 18 or older with no diagnosis of diabetes, Canada excluding territories, 1994/95 Sample size
Estimated population '000
Sex Men Women
Age group 18-44 45-64 65-74 75+
58.2 27.8 8.8 5.2
Family history of diabetes Yes No Missing
Body mass index (BMI)† Not overweight (< 25) Overweight (25.0-29.9) Obese (≥ 30) Missing
6,835 4,319 2,260 151
Leisure time Active Moderately active Sedentary Missing
5,521 4,127 29
Alcohol consumption Current drinker Former drinker Abstainer Missing Smoking Daily/Occasional Former smoker Never smoked Missing Education Less than secondary graduation Secondary graduation/Some postsecondary Postsecondary graduation Missing
Data source: 1994/95, 1996/97, 1998/99, 2000/01 National Population Health Survey, longitudinal sample, Health file Note: Because of rounding, detail may not add to totals. † Excludes pregnant women. F Coefficient of variation greater than 33.3%
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text:
Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9
All Themes The Possibility of Transformation The Importance of the Right People Focus and Consistency Duality and Contradiction
All Characters Jim Collins Jim Stockdale Darwin E. Smith Colman Mockler Alan Wurtzel Ken Iverson David Maxwell Lee Iacocca
All Terms Good-to-great Direct Comparison Unsustained Comparison Level 5 Leader Stockdale Paradox
All Symbols Hedgehog Concept The Flywheel
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The Possibility of Transformation
The Importance of the Right People
Focus and Consistency
Duality and Contradiction
Jim Stockdale
Darwin E. Smith
Colman Mockler
Alan Wurtzel
Ken Iverson
David Maxwell
Good-to-great
Direct Comparison
Unsustained Comparison
Level 5 Leader
Stockdale Paradox
Hedgehog Concept
Good to Great Summary
Jim Collins states that while his previous book, Built to Last, explained how great companies stay great, it did not delve in the ways that good companies become great ones. That process of transformation is the subject of Good to Great.
Collins and his research team selected eleven corporations that went from showing average or below average performance on the stock market to showing extraordinarily good returns and sustaining those returns for at least fifteen years. Additionally, the team selected eleven direct comparison companies to study from the same industries as the good-to-great companies, as well as six unsustained comparison companies. The direct comparison companies did not show a change from good to great, while the unsustained comparisons did show that change but could not continue their gains over time.
Collins and his team set a goal of figuring out what went into these companies' remarkable transformations, in order to outline a set of universal good-to-great principles that any organization or even individual might use. They eventually uncovered the seven principles that make up the book's core concepts.
The first of the seven principles is the concept of the Level 5 Leader. Over the course of their research, Collins and his team found that every good-to-great company was led at the time of its transformation by a very particular kind of CEO, which they term Level 5 Leaders. In contrast to the stereotype of a brilliant, charismatic leader, Level 5 Leaders are universally humble and devoted to serving the company's success over their own. However, these leaders are not meek or unassertive; on the contrary, they fight forcefully for their companies' well-being while maintaining their personal modesty. The balance between these two characteristics, which may seem initially contradictory, forms the essential trait of Level 5 Leaders. Collins gives several examples of the kinds of behavior, both humble and assertive, that led the research team to characterize the good-to-great CEOs as Level 5 Leaders.
Next, Collins turns his attention to the hiring and employment strategies of good-to-great companies. Contrary to popular wisdom that emphasizes strategic planning above all else, the good-to-great companies almost always focused their attention on hiring the right people before deciding what direction the company should take. Collins uses the metaphor of a bus for this process and gives examples of the ways that good-to-great companies prioritized getting the right people on the bus, even when dire circumstances prompted them to take action. With the right people in place, the companies' CEOs did not need to lead through tyranny; rather, they were able to delegate and share responsibility.
Having the right people on the bus also helped these companies make savvy strategic decisions, since they had a variety of intelligent perspectives to draw from in setting a direction. Throughout this chapter, Collins emphasizes that a person is "the right person" when their motivations align with the company's, and that "right" does not refer to any objective definition of what talents or background employees should have.
Collins next explores the idea that good-to-great companies must confront the brutal facts of their situations without losing hope that they will eventually prevail. Collins calls this form of duality the Stockdale Paradox, after a U.S. Admiral in the Vietnam War who told Collins that his key to surviving a prisoner of war camp was maintaining a balance of hope for the future with realism about the present. While the comparison companies were often in denial about their challenges, the good-to-great companies confronted challenges head-on and made plans based on real facts rather than wishful thinking. At the same time, they remained steadfast in their belief that they could succeed.
The other concept based on good-to-great companies' strategic planning is one of the book's motivating symbols: the Hedgehog Concept. Collins demonstrates how each of the good-to-great companies used one simple, precise concept to drive all of its planning and action. These concepts are termed Hedgehog Concepts after a story about a simple hedgehog who defeats a clever fox by using one focused strategy consistently, while the fox exhausts itself with intricate maneuvers that ultimately fail. Collins lists each of the good-to-great companies' Hedgehog Concepts and shows how the comparison companies did not have similarly focused strategies. Additionally, Collins notes that the research suggests that good-to-great companies engaged in careful, long-term consideration of three specific areas: identifying what the company can do better than anyone else in the world; finding out what exactly drives the company's economic engine; and clarifying what the company and its leadership are deeply passionate about. For those looking to develop their own Hedgehog Concepts, Collins recommends robust debate around those three areas of understanding, which he terms "the three circles."
The next section of the book focuses on disciplined action and how it builds on the resources of disciplined people and disciplined thought discussed in previous chapters. The first key concept based on disciplined action is the idea of an overall culture of discipline, which Collins notes existed in some way at every good-to-great company. These cultures were not ruthless—that is, they did not rely on tyrannical leadership or baseless punishment of employees. Rather, they were formed through the duality of combining rigorous structures with freedom for individuals. Within such cultures, expectations are clear and standards are high, but employees decide how they personally can best meet those standards. Additionally, cultures of discipline as defined here are focused on fanatical adherence to the company's Hedgehog Concept, which must drive everything the company does.
Finally, Collins identifies the savvy use of technology as a particularly important case of disciplined action. Though new technology can be exciting and tempting, Collins's research shows that good-to-great companies pursued technological advances only when doing so made sense as a way to advance their Hedgehog Concepts. Many of them became technological leaders, but they did not do so for the sake of technology in and of itself. In contrast, the comparison companies often pursued technological progress without applying it wisely to the unique circumstances of their companies. Collins notes that while technology can be a powerful accelerator of a company's existing momentum, it cannot create greatness on its own. Many of the executives of good-to-great companies deemphasized technology in describing their own success, demonstrating that technology is truly a tool rather than a strategy.
Collins moves on to the seventh and final good-to-great concept, which unifies the previous six and shows how they can work together to create remarkable transformation. Collins use the symbol of an enormous, heavy flywheel as a symbol for this idea. The flywheel turns slowly and only gains momentum by moving steadily in the same direction for a long time. Moving it requires simple motions repeated over and over again, but once it starts to gain momentum, its own weight becomes an asset, powering it forward until the entire thing reaches a point of breakthrough and starts spinning on its own. Collins uses the image of the flywheel to show how all of the components of the good-to-great companies worked together to build energy toward transformative breakthrough. Crucially, none of the components can work on their own; they only function as part of the flywheel process. In contrast, Collins notes that comparison companies often seemed to be caught in a "doom loop," in which irrational decisions compound over time to prevent success.
In the final chapter, Collins connects the good-to-great concepts to those discussed in his previous book, Built to Last. In that earlier work, Collins conducted different research to show how great companies sustain their greatness over time, and he states that he now views Good to Great as a kind of prequel to Built to Last. The earlier book shows some of the same good-to-great patterns, and the new book also clarifies some of the first one's mysteries. Collins states that in order for a company to transition to greatness and maintain it over time, it must apply all of the concepts from both books, consistently and without exception.
Collins ends by noting how the good-to-great concepts show up even in organizations with little in common with corporations, using the example of a champion track team. Collins tells his readers that working toward greatness in any arena can be a key to leading a meaningful life and encourages them to find at least one area in which they might try our the good-to-great concepts themselves.

redpajama_set_name: RedPajamaCommonCrawl


Julius MERTEN was born the 20th of March, 1860 in Trenton, Clinton County, Illinois, the son of Edward and Josephine (Hanke) Merten. He died the 22nd of January, 1947, the age of 86 years, 10 months and 2 days, at his home, Merten Cottage, 334 South Castle Avenue, Salem, Illinois.
Julius' feneral was held Friday, 24 Jan 1947, 2:00 p.m., Hancock Funeral Home and burial was in East Lawn Cemetery in Salem, Illinois.
Julius married Anna "Annie" MAIER the 1st of February, 1899, Evansville, Vanderburgh County, Indiana. She was born the 24th of July 1871, German Ridge, Perry County, Indiana, the daughter of Johann Peter "John" and Margaretha Magdalena "Margaret" (LEISTNER)(MANN) MAIER. Annie died the 22nd of September, 1925, during surgery for a goiter, Engalls Memorial Hospital, Harvey, Cook County, Illinois. She is buried next to Julius in East Lawn Cemetery.
Julius was born in turbulent time, the beginning of the American Civil War, a war that spared few families. Folrtunately the war did not take any of our Merten Family, even though Julius' Uncle Herman Merten, of Sandoval, Illinois, was a sergeant in the war.
Julius was raised on his father's farm in Meridian Township, Clinton County, Illinois, which was near Shattuc. His father moved there when Julius was one year old.
Julius' forst job away from his father's farm was that of a bookkeeper and weighmaster in his uncle's mill, Uncle Joseph Hanke, in Trenton. In 1887 he moved to Shattuc and became a clerk in Henry BOYER's store, which was the first store in Shattuc. Julius later built a two-story building west of the creek and opened his own store. J. MERTEN, Dry Goods & Groceries. He also had the first lumber yard in Shattuc. The post office was located i his store. He served as postmaster from 1893 to 1897. The second floor of the store was used as the community center of Shattuc. Julius held the offices of Town Clerk, School Treasurer, and Treasurer of the Odd Fellows and Modern Woodman Lodges. Julius lived in the Boyer Hotel from 1892 until his marriage in 1899.
Julius met Annie when she was in Shattuc visiting her cousin, John MANN, and family. John MANN, her mother's nephew, had moved to Shattuc in 1885 from Santa Claus, Indian. He purchased the blacksmith shop from Mr. HOPFINGER and was the town's blacksmith unti his death in 1930. His son, Asa MANN, built a new blacksmith shop and garage in 1926, bringing Shattuc into the modern age of mechanics. Asa was also a Studebaker agent until his retirement in 1950.
Julius and Annie married in Indian, near her family. They then returned to Shattuc, whre Julius had built a new house next to his store. Annie spent so much of her time in the store helping Julius, that she hired a maid to do her housework.
Julius Merten Store and Home in Shattuc.
On 19 Jun 1900, the census shows Julius and Annie MERTEN living in Meridian Township, Clinton County, Illinois. Living with them was their daughter, Beatrice MERTEN age 6 months. Also living with them was Julius' brother, Frank MERTEN age 25. The census shows that Julius owned his home and it was free of morgage. He is listed as a merchant. Uncle Frank was lilsted as a clerk in a dry goods store.
In 1909, Julius and Annie sold their store to O. C. KEISTER and Fred WOLLENWEBER. The name of the store was chnged to WOLLENWEBER & KEISTER. Julius moved his family to Salem, the next county east, Marion County, Illinois, about 30 miles east of Shattuc. He went into business with Mr. HANES. They had a Confectionery on the south side of the 100 block of West Main Street in Salem. He later had a grocery store on the 100 block of South Rotan in Salem.
In Mar 1914, Julius and Annie bought the Lemen House at 321 South Franklin Street in Salem, where they had been living since 1909, when the moved to Salem. The Lemen House had been built in 1842 (Photo taken in 1958.) for Rev. Benjamin F. LEMEN and his wife, Mary Putnam (RAND) LEMEN. The Lemen's were a very distinguished family in Illinois. They were friends of President Abraham LINCOLN, who visited them on several occasions in their home before he went to Washington D.C. as our 16th president. Mrs. LEMEN founded the Southern Illinois Female Adacemy in Salem. The LEMEN family founded the first Protestant Church in Illinois (Baptist). Mrs. LEMEN was the niece of General Israel PUTNAM and the great-granddaughter of General GOFF of the French-Indian War. The LEMEN's daughter, Lydia Gertrude LEMEN, married in this house to Count John SOBIESKI, Prince Royal of Poland, and heir to the throne of Poland. The house consisted of four bedrooms and a bath on the second floor and on the first floor was a kitchen, dining room and parlor. There was, by this time, a large front proch across the entire front of the house. As you went into the front door, there was the stairway and a long hallway that led to ta back door, to the back porch. There was full first and second floor back porch which had an outdoor stiarway from the first floor to the second. The property also included a sumer kitchen and a guest house. He sold the house in 1915 to his sister, Rosa Francois, and family. His daughter, Bea and husband later bought this house in 1941 and it remains in the Frakes Family to this day (2002).
This photo of the Lemen-Frakes House was taken in the spring of 1994. It was taken from the 2nd floor window of the house across the street, then owned by cousin Jackie Lee (CLOUD) WILLIAMS. I love the spring when all the redbud trees are budding.
Julius moved south of Salem and bought a farm house, south of the missouri and Illinois Railroad. He remained in the confectionery business, but also had some chickens and stock. He only lived there a short while and wanted to move back into town.
He moved back into Salem and bought the guest house back from his sister, along with the summer kitchen. (In the photo at left you can see the house during WWI, with flag on front porch. Also, the summer kitchen had not been added to the house yet, as you can see it to the right of the house.) He added the summer kitchen to the back of the house sometime later. This house is at 334 South Castle, directly behind (west) of the Lemen-Frakes House.
On 6 Jan 1920, the census shows Jay (59) and Anna (48) MERTER living at 334 South Castle Avenue, Salem, Marion County, Illinois. Living with them were their children Beatrice MERTEN age 20; Morris MERTEN age 17; Eunice MERTEN age 10; Floyd MERTEN age 14; and Clyde MERTEN age 12. They owned their home, but it was morgaged. Julius was listed as a laborer at a seed barn. Beatrice was a clerk at a restaurant. Morris was a call boy at a despatcher's office.
Annie always kept a garden and here she is getting help from children, "Bud" and "Bea." Of course, Bea was more into posing for photos than tending a garden. Julius planted a grape arbor behind Merten Cottage. He would make homemade wine from the concord grapes. They also made wonderful grape jelly. This grape arbor is still there today (2003) and still produces wonderful grapes.
Grandmother Bea recieved her schooling in Salem. She did quit high school during WWI because they dropped German from the cirriculum. She thought it was stupid to not teach the language of the country you were fighting. Also, she was German-Jew and was proud that her family came from Germany. Here is a photo of her in school.
On 3 Jul 1924, because the economy was not good in Salem during the 20's, Julius and Annie moved to Harvey, Cook County, Illinois, a suburb of Chicago. He kept his house in Salem and rented one in Harvey. Their children, Eunice, Floyd and Clyde moved with them. They all hated Harvey and missed Salem greatly, but Julius was able to find a job so they remained. The landlady was very unfriendly.
Wensday morning. I am sitting up this morning. Will write you how everything is here I am alright but as thin as a rail so weak cant walk alone to see Bud he is in the 3rd ward from me The nurse take me to him in the weelchair. Was to see him 3 time havent been to see him yet this morning They are so bussy several operations ar going on this morning a lady from our ward is going to take a ride soon This is a life Hospital life I say. I don't want to come back If I ever get out her.
Bee I am her almost 3 weeks and will be here another week if I take the operation I don't know what to do yet today. i think about the expens taks us the rest of our lives to pay if I improved.
what is to be wil be. That is the old saying anaway.
Annie died six days later while being operated on.
On 3 Apr 1930, the census shows Julus MERTEN age 70 living on Center 153rd Street in Harvey Cook County, Illinois. With him were his children Clyde MERTEN age 22; Eunice HICK age 26; Floyd MERTEN age 24; and Lois HICK age 3. Julius was renting and the rent was $36.00 a month. He owned a radio. Julius was employed as a watchman. Floyd was a Hammerman at a Steel place.
The photo at right was taken in Harvey. Left to Right: Julius MERTEN, Eunice (MERTEN) HICKS holding Lois HICKS, William Randolph FRAKES, William Philip FRAKES, and Maurice MERTEN.
Julius retired in 1935 and returned to his home in Salem. And there he lived out the remaining years of his life.
1. Beatrice Margaret Julietta "Bea" MERTEN, born 1899.
2. Maurice Russell MERTEN, born 1901.
3. Eunice Elva MERTEN, born 1903.
4. Floyd Howard "Bud" MERTEN, born 1905.
5. Clyde Erwin MERTEN, born 1907.
Beatrice Margaret Julietta "Bea" MERTEN, born 13 November 1899, Shattuc, Clinton, County, Illinois. She died 23 October 1985, Salem, Marion County, Illinois. Bea and Bill are both buried in East Lawn Cemetery, Salem, Marion County, Illinois.
Bea married William Philip "Bill" FRAKES 31 January 1924, Vandalia, Fayette County, Illinois. He was born 10 May 1890, Prairie Creek, Vigo County, Indian, son of Francis Marion and Hannah Margaret C. (ARTHUR) FRAKES. He died 14 February 1965, Veteran's Hospital, Marion, Williamson County, Illinois.
On 5 Apr 1930, the census shows William P. (35) and Beatrice M. J. (30) FRAKES living at 334 South Castle Avenue, Salem, Marion County, Illinois. With them were their sons William R. age 4 years and 5 months; and Philip H. age 1 year and 2 months. They were renting, paying $20.00 a month. William was a conductor on a steam railroad.
The photo above and right, is the William P. and Beatrice M. J. (MERTEN) FRAKES family. Left to right: Beatrice, Philip, Judy, Bill and Bill, Sr. The children in front, left to right: Cyndy Thurman, Mark Frakes and seated is Tanya Frakes.
1. William Randolph "Bill" Frakes, born 2 Nov 1925, Salem, Marion County, Illinois. Bill died 17 Jan 2011, St.Louis, Missouri.
2. Philip Howard "Phil" Frakes, born 25 Feb 1929, Salem, Illinois. He died Friday, 16 Sep 2005, Salem, Marion County, Illinois.
Judy married Howard Galloway Thurman, Jr., born 21 May 1934, Salem, Illinois, son of Howard Galloway and Ethel E. (Berg) Thurman. Howard died 6 Jan 2011, Bakersfield, Kern County, California.
1. Marsha Lynn Frakes, born 27 Mar 1949, Salem, Illinois of Bill & Betty.
2. Mark Alan Frakes, born 10 Feb 1954, Cario, Illinois of Bill & Betty.
3. Tanya Rae Frakes, born 7 July 1955, Highland, Illinois of Phil & Monna. Tanya died 23 January 2010, Salem, Marion County, Illinois.
5. Stephen Philip Howard Frakes, born 2 October 1957, Highland, Illinois of Phil & Monna.
8. Terri June Frakes, born 22 April 1962, Highland, Illinois of Phil & Monna.
5. Trent Maurice Adams, 5 Dec 1982, Centralia, Illinois.
7. Brock Richard Adams, 26 Sep 1985, Centralia, Illinois.
8. David Philip Anthony Belfiore, 18 Oct 1985, Orlando, Florida.
David Philip married 1st Samantha Jean Daniels 14 March 2009, Salem, Marion County, Illinois.
David Philip married 2nd Andrea Morlan 19 Oct 2013, Las Vegas, Clark County, Nevada.
9. Brooke Nicole Thurman, 19 Mar 1986, Fresno, California, daughter of Van and Terri.
Brooke married Kevin Trent Bratcher 28 Apr 2012, Hawaii.
10. Nicole Elise Thurman, 9 Jan 1989, Bakersfield, California, daughter of Van and Terri.
Nicole married Jack Joseph Campbell Jan 2011, Bakersfield, Kern County, California.
11. Daniel William Eli Belfiore, 3 Feb 1992, Belleville, Illinois.
Daniel married 1st Erica Amber-lynn Casner. Daughter of Nikki Casner and Terry L. Garren.
12. Jourdan Darlene "Jourdy" Thurman 15 Aug 1996, Bakersfield, California, daughter of Trey.
**. Jillian Rebecca Riley, born 21 Sep 1992, Beaufort, South Carolina, Stepdaughter of Nathan Courtright.
4. Jacob "Jake" Cannon, born 2006, Bakersfield, Kern County, California, son of Tyler. Son of Tyler.
5. Brooklyn Cannon, born Sep 2007, Bakersfield, Kern County, California. Daugher of Riley.
6. Reece Daniel Cannon, born 21 Dec 2007, Bakersfield, Kern County, California. Son of Tyler.
12. Cameron Bennett Cannon, born 24 Jun 2010, Bakersfield, Kern County, California, son of Tyler.
20. Grayson Leo Adams, born 17 Aug 2015, Effingham, Effingham County, Illinois. Son of Brock & Lauren.
Maurice Russell MERTEN, born 4 June 1901, Shattuc, Clinton County, Illinois. Maurice died 13 December 1978, Sterling Heights, Michigan. Maurice and Laverne are buried in Royal Oak Cemetery.
Maurice married Laverne INGLEY 3 September 1929, Detroit, Michigan. She was born 28 April 1907, Port Huron, Michigan, daughter of Lewis and Emma (PUTNAM) INGLEY. Laverne died Jan 1984. Last place of residence was Romeo, Macomb County, Michigan.
On 14 Apr 1930, the census shows Maurice (28) and Laverne (23) MERTEN living Van Dyke Avenue, Detroit, Michigan. They were renting at a cost of $60.00 a month. They owned a radio. He was employed as an auto trimm at an auto factory. Laverne did clerical work for the railroad.
Maurice worked for Stroh's Beer for 33 Years.
They were Presbyterian, both of their children being baptized at the Presbyterian Church on Grand River in Detroit, Michigan.
The two photos at right are Maurice.
1. Karen Anna MERTEN, born 15 January 1933,Detroit, Michigan. She married 1st Sonny PHIPPS. She married 2nd Richard WILLIAMS. Married 3rd Charles OTTENBACHER.
2. Keith Maurice MERTEN, born 6 Dec 1935, Detroit, Michigan. He married Mary Margaret DUHART 22 Oct 1960. She was born 27 Aug 1935.
3. Lisa Ann MERTEN, born 8 February 1962, Dearborn, Michigan. She married Donald Frank SHERMAN 9 Oct 1987. He was born 28 Apr 1963.
4. Barbara Kay MERTEN, born 20 February 1963, Dearborn. She married David Andrew DUBENSKY 19 Jun 1987. He was born 8 Sep 1963.
5. Thomas Christopher MERTEN, born 17 February 1965, Detroit, Michigan. He married Rosemarie HANLON. She was born 8 May 1961, Riverview, Michigan.
6. John Anthony MERTEN, born 16 February 1968, Warren, Michigan.
1. Alexander Douglas SHERMAN, born 4 Feb 1994.
2. Julia Rose SHERMAN, born 24 Sep 1996.
3. Amanda Clair SHERMAN, born 20 Aug 2000.
4. Jack Thomas MERTEN, born 31 Jan 2002, Royal Oak, Michigan. Son of Thomas and Rosemarie.
5. Peter Joseph MERTEN, born 7 Apr 2004, Royal Oak, Michigan. Son of Thomas and Rosemarie.
6. Molly Margaret SHERMAN, born 16 Apr 2004.
The Keith and Mary Merten Family. Photo taken Dec 2007.
Back Row Standing, left to right: Lisa (Merten) Sherman, Don Sherman, Julia Sherman, Barbara (Merten) Dubensky, David Dubensky, John Merten and Thomas Merten.
Middle Row Seated, left to right: Alex Sherman, Keith Merten, Mary Merten and Rosemarie (Hanlon) Merten.
Front Row Kneeling left to right: Amanda Sherman, Molly Sherman, Peter Merten and Jack Merten.
Eunice Elva MERTEN, born 12 June 1903, Shattuc, Clinton County, Illinois. She died 17 July 1983, Salem, Marion County, Illinois.
Aunt Eunice married Earl Travis HICKS 22 Sep 1924, Harvey, Cook County, Illinois. They divorced.
Eunice lived the first six years of her life in Shattuc, where her father was the local merchant.
In 1917, they moved to 334 South Castle Avenue.
In 1924, her parents and two younger brothers moved to Harvey, Illinois. They kept their house on Castle in Salem. After Julius retired, they moved back to Salem and Eunice lived the rest of her life at 334 South Castle.
On 1 Dec 1925, Eunice wrote the following letter to her sister, addressed: Mrs. William FRAKES 421 N Broadway Salem Ill., "Harvey Ill Dec 1, 1925 Dear Sis How is everyone feeling after the Thanksgiving holiday? Did you have Turkey! We received a letter from Maurice yesterday and he, Shorty, Reeden and Jack Huses had a Turkey dinner given by their landlady. Travis and I went to Chicago Saturday afternoon and I bought a new coat. It is black Bolivia with fox fur cuffs and collar and it has a flease bottom. I like to buy in the city as there is such a large variety to choose from. How is Junior? Does he cray as much as you did when a baby. Bee, did you know that Jesse's father in law was working here in Harvey? He is working at the Austin in the same department that Dad is working. He said he knew you when you worked at Garby's. Dad has another job now, in the motor sweeper department. It is lighter work. We received the money order for twenty-two dollars and next time just send eighteen. I have been busy all week straightening the house. We moved last Monday and it is some job. I think this will be the last move, and if we have to move again we are going to sell out. Are you coming up Christmas? It seemed like Christmas the last few days as the ground was covered with snow. Well Bee, I must close as I want to scrub the kitchen and wash my hair. There is always something to do. Write soon. Love Eunice 15238 Lexington Ave."
On 3 Apr 1930, the census shows Eunice HICKS age 26 and her daughter Lois HICKS age 3 living with Eunice's father Julius MERTEN age 70 living in Harvey, Cook County, Illinois. Also there were Eunice's brothers Floyd MERTEN age 24; and Clyde MERTEN age 22. Their rent was $36.00 a month. Julius� was listed as a watchman. Floyd worked at the steel works.
1. Lois Maxine HICKS, born 26 Aug 1926, Harvey, Cook County, Illinois. She died 29 Mar 2004, Salem. She married Val Jean HUDGENS.
1. Brenda Jane HUDGENS, born 29 September 1950, Salem, Illinois. Brenda married Steve LOEW.
2. Norman Eugene HUDGENS, born 22 June 1954, Salem, Illinois. Norman married Karen Jean RICHISON.
3. Patricia Kay "Trish" HUDGENS, born 15 July 1955, Salem, Illinois. Trish married Bret JEZEK.
1. David Val HUDGENS, born 22 Nov 1975, Mt. Vernon, Illinois. David married Stephanie McWHORTER 2007.
2. Gary Michael GARICH, born 13 Sep 1977, Centralia, Illinois. Gary married Amanda Kay DANIELS 2007.
3. Joel Arthur HUDGENS, born 15 May 1979, Mt. Vernon, Illinois. Joel married Marie KARRICK.
4. Cole Edward JEZEK, born 28 Jul 1985, Centralia, Illinois.
5. Rebecca Jane JEZEK, born 10 Feb 1987, Mt. Vernon, Illinois.
1. Joel Blade HUDGENS, born 7 Sep 1997, son of Joel.
2. Ashley Marie HUDGENS, born 30 Jun 2005, daughter of Joel.
Clyde Merten and Eunice (MERTEN) HICKS.
Floyd Howard "Bud" MERTEN, born 12 May 1905, Shattuc, Clinton County, Illinois. He died 20 January 1972, age 66 at his home in Harvey, Cook county, Illinois. He is buried next to his parents, brother Clyde and sister Eunice in East Lawn Cemetery, Salem, Marion County, Illinois.
Bud served in the United States Army during World War II, in the European Theatre, where he was wounded.
He was greatly loved by his brother and sisters, nephews and nieces and friends. A man with great personality. He really enjoyed life.
In the photo, Bud is the one on the left.
Clyde Erwin MERTEN, born 5 October 1907, Shattuc, Clinton County, Illinois. He died 13 August 1990 at his home, Merten Cottage, where he had lived most of his life in Salem. He is buried next to his parents and brother Bud and sister Eunice in East Lawn Cemetery in Salem.
He was employed at Bachmann's Furniture Store until his retirement. He was a very gentle and quiet man. He always kept a vegetable garden. He also made wine from his backyar vineyard.
Front Row, left to right: Uncle William Randolph "Bill" Frakes, Aunt Betty Jean (Hammer) Frakes, Madison Jaye "Madie" Courtright, Monna Marilyn (Conant) Frakes, Stephen Philip Howard Frakes, Marsha Lynn (Frakes) Bagley, Myleigh Rose Clutts, Jennifer Leigh (Bagley) Clutts, William Kelby "Billie" Clutts.
Middle Row, left to right: Brock Richard Adams, Terri June (Frakes) Adams, David Philip Anthony Belfiore, Samantha (Daniels) Belfiore, Norman Eugene Hudgens, Patricia Kay "Trish" (Hudgens) Jezek, Karen Jean (Richeson) Hudgens, Brenda Jane (Hudgens)(Garich) Loew, Timothy Paul "Tim" Bagley.
Back Row, left to right: Nathan Roddy Courtright, Riley Cecil Cannon and Cynthia Tenae "Cyndy" (Thurman) Cannon.
Not pictured: Angie Courtright (who was taking the photo); and Steve Loew and Gary Garich, both of whom had left before the photo was taken.
There were more conventional photos taken, but I like this one where we are laughing, as it shows us more like we really are.
The Salem, Marion County, Illinois Yahoo Group has genealogies and many old photos of Salem, Illinois and many old pictures of some of the families of Salem. There is a file section for histories and genealogies of Salem. There are photo albums for you to place your own photos of your family. You can also place your own family genealogies in the file section.
The Meridian and East Fork Townships Yahoo Group has genealogies and many old photos of Shattuc, Illinois and many old pictures of some of the families of Meridian and East Fork Townships. There is a file section for histories and genealogies of East Fork and Meridian Townships. There are photo albums for you to place your own photos of your family. You can also place your own family genealogies in the file section.
Copyright © 2004-2017 stephenfrakes All rights reserved.


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text:
A Flört a fellegekben, (View from the Top), 2003-ban bemutatott romantikus filmvígjáték, Gwyneth Paltrow főszereplésével, amelyben egy kisvárosi fiatal nő elhatározza, hogy beteljesíti álmát és légi utaskísérő lesz.

Történet

Donna kisvárosi lány, aki világot szeretne látni. Miután elolvasta Sally Weston könyvét a 'My Life in the Sky'-t, úgy határoz, hogy követi Sally-t és ő is légi utaskísérő lesz. Először egy kis légitársasághoz kerül, majd megpályázza a Royalty Airlines-t. Két barátnőjével, Sherry-vel és Christine-nel jelentkezik a válogatásra. Donna és Christine bejut, de Sherry nem. Donna szívét-lelkét beleadja, és Sally Weston nyomdokain járva tör a csúcsra, amit ebben az esetben a 'Párizs, First Class International' jelent. A teszt megírása után Donna döbbenten tapasztalja, hogy őt a fapados clevelandi járatra osztották, míg Christine, akinek nagy nehézséget jelentettek az elméleti tudnivalók, megkapja a kiemelt New York-i járatot.

Donna tudja, hogy Christine fiatalabb korában is lopott el ezt-azt, de megdöbben, amikor megtalálja Christine táskájában a Royalty Airline tesztsorát. Donna, Sally Weston-hoz fordul segítségért és kiderül, hogy Christine átírta Donna tesztlapjának sorszámát a sajátjára, tehát kicserélte a tesztlapokat. Ezáltal Donna új esélyt kap a vizsgára, majd maximális pontszámot teljesítve áthelyezik a New York-i, első osztályú, a nemzetközi útvonalra. Azonban magánéletében is fordulópont következik: Döntenie kell barátja és karrierje között; végül a karriert választja.

Bár Donna megkapja a hőn áhított 'Párizs, First Class International'-t, de mégsem boldog. Visszatér Clevelandbe, hogy találkozzon barátjával. A film végén kiderül, hogy Donna a Royalty Airlines pilótája lett.

Szereplők

Díjak, jelölések

Filmzene
 John Koha from The Band Escape – Don't Stop Believin'
 Jo Dee Messina – Downtime
 Tabitha Fair – ABC
 Kaci Lyn Battaglia – I'm Not Anybody's Girl
 Jo Dee Messina – Was That My Life
 LeAnn Rimes – Suddenly
 Tiffany Arbuckle – Boys Don't Cry
 Sofia Loell – Utopia
 Bon Jovi – Livin' on a Prayer
 G.G. – Sincerely
 Tamara Walker – Circle of Love
 Katie Cook – Time after Time
 Danielle Spencer – Tickle Me
 Fifth Dimension – Up Up and Away
 Tom Bowes – Celebration
 Early Edison – New Distraction
 Tom Bowes – For Once in My Life
 The Righteous Brothers – Unchained Melody
 Anna Wilson – Bus Ride
 Natalie Grant – No Sign of It
 Petula Clark – La Vie en Rose
 Sixpence None The Richer – I've Been Waiting
 "View from the Top" Cast – We Are Royalty/We Are Family
 Tamara Walker – Everywhere I Look, There's You

Jegyzetek

További információk

2003 filmjei
Amerikai romantikus filmek
Amerikai filmvígjátékok
Miramax-filmek

redpajama_set_name: RedPajamaWikipedia


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It's now known what causes the itchy skin condition known as eczema.
Herbert B. Allen is a professor and chair of the Department of Dermatology at the College of Medicine.
An estimated 30 million Americans suffer from eczema, a group of medical conditions that cause the skin to become inflamed or irritated. Now, researchers at the College of Medicine have shown for the first time what actually causes the itchy skin condition.
A research team led by Herbert B. Allen, a professor and chair of the College of Medicine's Department of Dermatology, found that the culprit is biofilm, a slime-like substance produced by staphylococcal bacteria, which are normally found on the skin surface. The biofilm blocks sweat ducts, which activates molecules in the immune system known to create itching and inflammation.
Eczema is a skin inflammation characterized by an itchy pink rash and crust on the skin. Fluid accumulates between the cells of the epidermis causing spongiosis (separation of the cells). Clumps of epidermal cells disintegrate to form large yellow vesicles containing inflammatory cells. These vesicles can rupture onto the surface of the skin, forming crusts.
The team recently published their findings in the online edition of JAMA Dermatology.
Allen and his colleagues studied routine swabs from lesional and nonlesional skin from 40 patients with atopic dermatitis, the most common type of eczema.
"We know that eczema is worse when it involves sweating," says Allen.
Allen says that patients can help prevent flare-ups by treating the skin kindly — using less soap, less hot water, less bathing and scrubbing and more moisturizing. Bleach baths can also be effective.
Allen is now looking at diseases that have eczema as part of their presentation, including seborrheic dermatitis, granular parakeratosis, prickly heat and tinea pedis (athlete's foot) to see if blocked ducts also play a role.


The Żnin Sport Amateurs Association will be hosting the 2018 UIM GT15 European Championship this weekend.
10 boats from 7 countries will race over 4 heats on the Żnin Small Lake in Poland with Alex Céwe from Sweden and Britain's Harvey Smith looking to be pre-race favourites.
Smith won the 2017 Powerboat GP GT15 Championship and has been seen campaigning his new F4 Moore hull in British club events this year under the F1 Atlantic team banner.
Smith switches back to GT15 hoping to improve on his fith place overall in the European Championship held in Aluksne, Latvia last year.