Our data suggest that efforts to reduce mortality in this population should be focused on treatment and prevention of coronary artery disease, congestive heart failure, diabetes mellitus, and anemia.

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OBJECTIVE -The aims of this study were to update previous estimates of the congestive heart failure (CHF) incidence rate in patients with type 2 diabetes, compare it with an age-and sex-matched nondiabetic group, and describe risk factors for developing CHF in diabetic patients over 6 years of follow-up.RESEARCH DESIGN AND METHODS -We performed a retrospective cohort study of 8,231 patients with type 2 diabetes and 8,845 nondiabetic patients of similar age and sex who did not have CHF as of 1 January 1997, following them for up to 72 months to estimate the CHF incidence rate. In the diabetic cohort, we constructed a Cox regression model to identify risk factors for CHF development.RESULTS -Patients with diabetes were much more likely to develop CHF than patients without diabetes (incidence rate 30.9 vs. 12.4 cases per 1,000 person-years, rate ratio 2.5, 95% CI 2.3-2.7). The difference in CHF development rates between persons with and without diabetes was much greater in younger age-groups. In addition to age and ischemic heart disease, poorer glycemic control (hazard ratio 1.32 per percentage point of HbA 1c ) and greater BMI (1.12 per 2.5 units of BMI) were important predictors of CHF development.CONCLUSIONS -The CHF incidence rate in type 2 diabetes may be much greater than previously believed. Our multivariate results emphasize the importance of controlling modifiable risk factors for CHF, namely hyperglycemia, elevated blood pressure, and obesity. Younger patients may benefit most from risk factor modification.

OBJECTIVE -To estimate the prevalence and incidence of congestive heart failure (CHF) in populations with and without type 2 diabetes and to identify risk factors for diabetes-associated CHF.RESEARCH DESIGN AND METHODS -We searched the inpatient and outpatient electronic medical records of 9,591 individuals diagnosed with type 2 diabetes before 1 January 1997 and those of an age-and sex-matched control group without diabetes for a diagnosis of CHF. Among those without a baseline diagnosis of CHF, we searched forward for 30 months for incident cases of CHF. We constructed multiple logistic regression models to identify risk factors for both prevalent and incident CHF.RESULTS -CHF was prevalent in 11.8% (n ϭ 1,131) of diabetic subjects and 4.5% (n ϭ 435) of control subjects at baseline. We observed incident cases of CHF in 7.7% of diabetic subjects free of CHF at baseline (650 of 8,460) and in 3.4% of control subjects (314 of 9,156). In diabetic subjects, age, diabetes duration, insulin use, ischemic heart disease, and elevated serum creatinine were independent risk factors for both prevalent and incident CHF. Better glycemic control at baseline, and improved glycemic and blood pressure control at follow-up predicted the development of CHF.CONCLUSIONS -Despite controlling for age, duration of diabetes, presence of ischemic heart disease, and presence of hypertension, insulin use was associated with both prevalent and incident CHF. Why insulin use and better glycemic control both at baseline and follow-up independently predicted CHF deserves further study.

OBJECTIVE—In type 2 diabetes, therapies to maintain blood glucose control usually fail after several years. We estimated the glycemic burden that accumulates from treatment failure and describe the time course and predictors of failure. RESEARCH DESIGN AND METHODS—A prospective, population-based study using retrospective observational data. We identified all 7,208 complete courses of treatment with nondrug therapy, sulfonylurea monotherapy, metformin monotherapy, and combination oral antihyperglycemic therapy between 1994 and 2002, inclusive, among members of the Kaiser Permanente Northwest Region. We calculated mean cumulative glycemic burden, defined as HbA1c-months >8.0 or 7.0% for each treatment. We then measured the likelihood that the next HbA1c would exceed 8.0 and 7.0% after HbA1c exceeded each of ten hypothetical treatment thresholds. Finally, we estimated multivariate logistic regression models to predict when HbA1c would continue to deteriorate. RESULTS—In this well-controlled population, the average patient accumulated nearly 5 HbA1c-years of excess glycemic burden >8.0% from diagnosis until starting insulin and about 10 HbA1c-years of burden >7.0%. Whenever patients crossed the American Diabetes Association-recommended treatment threshold of 8.0%, their next HbA1c result was as likely to be <8.0 as >8.0%. Multivariate prediction models had highly statistically significant coefficients, but predicted <10% of the variation in future HbA1c results. CONCLUSIONS—Clinicians should change glucose-lowering treatments in type 2 diabetes much sooner or use treatments that are less likely to fail. An action point at 7.0% or lower is more likely to prevent additional deterioration than the traditional action point of 8.0%.

OBJECTIVE -We sought to estimate the rate of progression from newly acquired (incident) impaired fasting glucose (IFG) to diabetes under the old and new IFG criteria and to identify predictors of progression to diabetes.RESEARCH DESIGN AND METHODS -We identified 5,452 members of an HMO with no prior history of diabetes, with at least two elevated fasting glucose tests (100 -125 mg/dl) measured between 1 January 1994 and 31 December 2003, and with a normal fasting glucose test before the two elevated tests. All data were obtained from electronic records of routine clinical care. Subjects were followed until they developed diabetes, died, left the health plan, or until 31 December 2005.RESULTS -Overall, 8.1% of subjects whose initial abnormal fasting glucose was 100 -109 mg/dl (added IFG subjects) and 24.3% of subjects whose initial abnormal fasting glucose was 110 -125 mg/dl (original IFG subjects) developed diabetes (P Ͻ 0.0001). Added IFG subjects who progressed to diabetes did so within a mean of 41.4 months, a rate of 1.34% per year. Original IFG subjects converted at a rate of 5.56% per year after an average of 29.0 months. A steeper rate of increasing fasting glucose; higher BMI, blood pressure, and triglycerides; and lower HDL cholesterol predicted diabetes development.CONCLUSIONS -To our knowledge, these are the first estimates of diabetes incidence from a clinical care setting when the date of IFG onset is approximately known under the new criterion for IFG. The older criterion was more predictive of diabetes development. Many newly identified IFG patients progress to diabetes in Ͻ3 years, which is the currently recommended screening interval. Diabetes Care 30:228 -233, 2007T he American Diabetes Association (ADA) defines impaired fasting glucose (IFG) as an intermediate state of hyperglycemia in which glucose levels do not meet criteria for diabetes but are too high to be considered normal (1). Although the ADA calls IFG "pre-diabetes" (1), reported estimates of diabetes development in IFG patients vary widely (2). The Hoorn Study (3) found that 33% of patients with IFG but not impaired glucose tolerance (IGT) and 64.5% of patients with IFG and IGT developed diabetes over a follow-up of 5.8 -6.5 years. The Paris Prospective Study (4) reported much lower proportions: 2.7% among patients with normal glucose tolerance or isolated IFG and 14.9% among patients with IFG and IGT over 30 months of follow-up. An Italian study (5) spanning 11.5 years found that 9.1% of patients with isolated IFG and 44.4% of subjects with IFG and IGT developed diabetes. Studies of nonwhite populations have reported diabetes development proportions ranging from 21.6% over 5 years among Mauritians with isolated IFG (6) to 41.2% over 5 years among Pima Indians with IFG and IGT (7). The highest proportion of diabetes development, 72.7% over 7 years among subjects with IGT and IFG, was found in a Brazilian-Japanese population (8).Most of this wide variation in reported rates of diabetes development among IFG patients probably arises f...

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. Body mass index and future healthcare costs: a retrospective cohort study. Obes Res. 2001;9:210 -218. Objective: To assess the relationship between body mass index (BMI) and future healthcare costs. Research Methods and Procedures:We undertook a retrospective cohort study of the relationship between obesity and future healthcare costs at Kaiser Permanente Northwest Division, a large health maintenance organization in Portland, Oregon. Study subjects (n ϭ 1286) consisted of persons who responded to a 1990 health survey that was mailed to a random sample of adult Kaiser Permanente Northwest Division members who were 35 to 64 years of age; had a BMI Ն 20 kg/m 2 (based on self-reported height and weight); did not smoke cigarettes; and did not have a history of coronary heart disease, stroke, human immunodeficiency virus, or cancer. Subjects were stratified according to their BMI in 1990 (20 to 24.9, 25 to 29.9, and Ն30 kg/m 2 ; n ϭ 545, 474, and 367, respectively). We then tallied their costs (in 1998 US dollars) for all inpatient care, outpatient services, and prescription drugs over a 9-year period (1990 through 1998). Results: For persons with BMIs of 20 to 24.9 kg/m 2 , mean (ϮSE) annual costs of prescription drugs, outpatient services, inpatient care, and all medical care averaged $261 (Ϯ18), $848 (Ϯ59), $532 (Ϯ85), and $1631 (Ϯ120), respectively, over the study period. Cost ratios (95% confidence intervals) for persons with BMIs of 25 to 29.9 kg/m 2 and Ն30 kg/m 2 , respectively, were 1.37 (1.12 to 1.66) and 2.05 (1.62 to 2.55) for prescription drugs, 0.96 (0.83 to 1.13) and 1.14 (0.97 to 1.37) for outpatient services, 1.20 (0.81 to 1.86) and 1.38 (0.91 to 2.14) for inpatient care, and 1.10 (0.91 to 1.35) and 1.36 (1.11 to 1.68) for all medical care. Discussion: Future healthcare costs are higher for persons who are overweight, especially those with BMIs Ն 30 kg/m 2 .