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ContextHigher rates of microvascular complications have been reported for minorities. Disparate access to quality health care is a common explanation for ethnic disparities in diabetic complication rates in the US population. Examining an ethnically diverse population with uniform health care coverage may be useful.Objective To assess ethnic disparities in the incidence of diabetic complications within a nonprofit prepaid health care organization.

OBJECTIVESome preclinical in vivo studies and limited human data suggest a possible increased risk of bladder cancer with pioglitazone therapy. This is an interim report of an ongoing cohort study examining the association between pioglitazone therapy and the risk of bladder cancer in patients with diabetes.RESEARCH DESIGN AND METHODSThis study includes 193,099 patients in the Kaiser Permanente Northern California diabetes registry who were ≥40 years of age between 1997 and 2002. Those with prior bladder cancer were excluded. Ever use of each diabetes medication (defined as two or more prescriptions within 6 months) was treated as a time-dependent variable. Cox regression–generated hazard ratios (HRs) compared pioglitazone use with nonpioglitazone use adjusted for age, sex, race/ethnicity, diabetes medications, A1C, heart failure, household income, renal function, other bladder conditions, and smoking.RESULTSThe group treated with pioglitazone comprised 30,173 patients. There were 90 cases of bladder cancer among pioglitazone users and 791 cases of bladder cancer among nonpioglitazone users. Overall, ever use of pioglitazone was not associated with risk of bladder cancer (HR 1.2 [95% CI 0.9–1.5]), with similar results in men and women (test for interaction P = 0.8). However, in the a priori category of >24 months of therapy, there was an increased risk (1.4 [1.03–2.0]). Ninety-five percent of cancers diagnosed among pioglitazone users were detected at early stage.CONCLUSIONSIn this cohort of patients with diabetes, short-term use of pioglitazone was not associated with an increased incidence of bladder cancer, but use for more than 2 years was weakly associated with increased risk.

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OBJECTIVE To estimate the relationship between the rate of gestational weight gain before the 50-g, 1-hour oral glucose challenge test screening for gestational diabetes mellitus (GDM) and subsequent risk of GDM. METHODS We conducted a nested case–control study (345 women with GDM and 800 women in the control group) within a multiethnic cohort of women delivering between 1996 and 1998 who were screened for GDM at 24–28 weeks of gestation. GDM was diagnosed according to the National Diabetes Data Group plasma glucose cut-offs for the 100-g, 3-hour oral glucose tolerance test. Women’s plasma glucose levels, weights, and covariate data were obtained by medical record chart review. RESULTS After adjusting for age at delivery, race/ethnicity, parity, and prepregnancy body mass index, the risk of GDM increased with increasing rates of gestational weight gain. Compared with the lowest tertile of rate of gestational weight gain (less than 0.27 kg/week [less than 0.60 lb/wk]), a rate of weight gain from 0.27–0.40 kg/wk (0.60–0.88 lb/wk) and 0.41 kg/wk (0.89 lb/wk) or more, were associated with increased risks of GDM (odds ratio 1.43, 95% confidence interval 0.96–2.14; and odds ratio 1.74, 95% confidence interval 1.16–2.60, respectively). The association between the rate of gestational weight gain and GDM was primarily attributed to increased weight gain in the first trimester. The association was stronger in overweight or obese and nonwhite women. CONCLUSION High rates of gestational weight gain, especially early in pregnancy, may increase a woman’s risk of GDM. Gestational weight gain during early pregnancy may represent a modifiable risk factor for GDM and needs more attention from health care providers. LEVEL OF EVIDENCE II

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These results confirm previous evidence that poor glycemic control may be associated with an increased risk of heart failure among adult patients with diabetes.

Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes care , but little is known about barriers to this self-care practice. RESEARCH DESIGN AND METHODS-This cross-sectional study examines SMBG practice patterns and barriers in 44,181 adults with pharmacologically treated diabetes fro m the Kaiser Permanente Nort h e rn California Region who responded to a health survey (83% response rate). The primary outcome is self-re p o rted frequency of SMBG. R E S U LT S-Although most patients re p o rted some level of SMBG monitoring, 60% of those with type 1 diabetes and 67% of those with type 2 diabetes re p o rted practicing SMBG less frequently than recommended by the American Diabetes Association (three to four times daily for type 1 diabetes, and once daily for type 2 diabetes treated pharmacologically). Significant independent predictors of nonadherent practice of SMBG included longer time since diagnosis, less intensive therapy, male sex, age, belonging to an ethnic minority, having a lower education and neighborhood income, difficulty communicating in English, higher out-of-pocket costs for glucometer strips (especially for subjects with lower incomes), smoking, and excessive alcohol consumption. C O N C L U S I O N S-Considerable gaps persist between actual and recommended SMBG practices in this large managed care organization. A somewhat reduced SMBG frequency in subjects with linguistic barriers, some ethnic minorities, and subjects with lower education levels suggests the potential for targeted, culturally sensitive, multilingual health education. The somewhat lower frequency of SMBG among subjects paying higher out-of-pocket expenditure s for strips suggests that removal of financial barriers by providing more comprehensive coverage for these costs may enhance adherence to recommendations for SMBG.