Non-insulin Users Research Articles

Cancer occurrence in Danish diabetic patients: duration and insulin effects

Cancer is more frequent among diabetes patients, but it is unknown how this excess varies with duration of diabetes and insulin use. The aim of this study was to analyse disease data to examine this issue further. We linked the Danish National Diabetes Register and Cancer Registry and performed a cohort analysis of the entire Danish population by diabetes status, duration of diabetes and insulin use, comparing cancer incidence rates in diabetic patients with the non-diabetic population for the 15 year period 1995-2009, using Poisson regression with natural splines to describe the variation by duration. We found 20,032 cancer cases among patients not using insulin and 2,794 cancer cases among diabetic patients using insulin. The cancer incidence rate ratio among non-insulin users relative to the non-diabetic population decreased from over 2 at diagnosis to 1.15 after 2 years of diabetes duration. The cancer incidence rate ratio was higher among patients using insulin, decreasing from 5 at the start of insulin treatment to about 1.3 [corrected] after 5 years of insulin use. Among non-insulin users, cancers of the stomach, colorectum, liver, pancreas, lung, corpus uteri, kidney and brain, and lymphomas were elevated. Among insulin users the rate ratio of prostate cancer was decreasing by duration whereas we found higher risk of cancer of the stomach, lung, liver, pancreas and kidney. Breast cancer incidence rates were not affected by either diabetes or insulin use. The observed duration effects suggest that both increased surveillance for cancer in the first years after diagnosis of diabetes, and reverse causation, where undiagnosed cancers increase the likelihood of diabetes diagnosis, play a role. For longer durations, a combination of common causes for diabetes and cancer, as well as the effects of diabetes and insulin exposure per se, may play a role in the association between diabetes and some cancers.

A survey of blood glucose monitoring in patients with type 2 diabetes: are recommendations from health care professionals being followed?

Objective:To survey the self-reported use of self-monitoring of blood glucose (SMBG) among patients with type 2 diabetes (T2DM), both insulin users (IUs) and non-insulin users (NIUs), in the United States and to examine: how often patients test; what SMBG instructions patients report receiving from their health care providers (HCPs); how the frequency of testing conforms with reported HCP recommendations for testing; and what is done with the results of testing. Differences between IUs and NIUs were also investigated.Methods:A convenience sample of 886 T2DM participants at a series of one-day conferences across the United States completed a survey on current and recommended SMBG frequency, how SMBG results were used, and how HCPs reportedly talked about SMBG issues with the patient. IUs (65% of the sample) and NIUs (35%) were examined separately.Results:IUs and NIUs reported testing significantly less frequently than was recommended (in both cases, p < 0.001), with wide variations within both groups. Many IUs (42%) and NIUs (50%) did not bring SMBG data regularly to medical visits, and 54% of IUs and 56% of NIUs did not respond regularly to out-of-range SMBG readings. HCPs were generally supportive and responsive to SMBG data. More frequent SMBG was associated with more regular HCP attention to SMBG records, for IUs (p = 0.02) and NIUs (p = 0.004).Conclusions:Self-reported SMBG use is common in T2DM, though frequency is lower than HCP recommendations. Wide variations in actual and recommended SMBG were observed. HCP support for SMBG is reportedly common, and is associated with greater SMBG frequency. While SMBG data can be valuable, recommendations are often not followed and data often goes unused by both HCPs and patients.

Comment on: Yang et al. (2010) Associations of Hyperglycemia and Insulin Usage With the Risk of Cancer in Type 2 Diabetes: The Hong Kong Diabetes Registry. Diabetes;59:1254–1260

By analyzing data from the Hong Kong Diabetes Registry, Yang et al. (1) conclude that insulin use is associated with a reduced cancer risk in type 2 diabetes. The authors hypothesize that insulin treatment, by causing tighter glycemic control, less oxidative stress, and less inflammation, reduces the risk of cancer. We believe that the study presents serious methodological problems regarding patient matching as well as follow-up and that the conclusions are unrealistic. From the original cohort of 4,623 diabetic patients, including 169 patients who developed cancer among insulin nonusers (4.6 vs. 3.3% among insulin …

Comment on: Yang et al. (2010) Associations of Hyperglycemia and Insulin Usage With the Risk of Cancer in Type 2 Diabetes: The Hong Kong Diabetes Registry. Diabetes;59:1254–1260

The article by Yang et al. (1) published in a recent issue of Diabetes claims that diabetic patients on insulin treatment experience an extraordinarily small incidence of cancer compared with those not using insulin (rate ratio [RR] 0.18). The study was discussed in an editorial by Johnson and Gale (2), which was somewhat reserved toward the result for general plausibility reasons. However, there is no reason for reservation just on general grounds; the study is fundamentally flawed and, by its very design, should be expected to give a substantial overestimate of the cancer risk among noninsulin users, hence the reported surprisingly small estimate of the RR for insulin versus noninsulin users. The authors use a so-called new-user design as indicated in the reference (3). This reference merely proposes that the evaluation of drug effects should be carried out after exclusion of prevalent drug users to avoid confounding by duration (because duration is usually not known among prevalent users) and market age of drugs. Yang et al. (1) do exclude prevalent users of insulin from their study, but unfortunately, …

Response to Comment on: Yang et al. (2010) Associations of Hyperglycemia and Insulin Usage With the Risk of Cancer in Type 2 Diabetes: The Hong Kong Diabetes Registry. Diabetes;59:1254–1260

We thank Carstensen (1) for his comments on our article published in the May issue of Diabetes (2). These comments have given us a chance to revisit some of the methodological issues in evaluating cancer risk associated with insulin use in type 2 diabetes. ### Cohort study designs. Carstensen suggests that analysis that considered all follow-up time in both the insulin-user group and the noninsulin-user group might produce more reliable results. In response to this, we estimated the hazard ratio (HR) of cancer with insulin use at or before enrollment or during follow-up in the entire cohort of 4,623 nonprevalent insulin users and 1,480 prevalent insulin users. Without adjusting for covariates, the cumulative incidences of cancer were similar in ever insulin users and nonusers (Fig. 1 A ). However, using the three adjustment schemes in the sensitivity analysis as reported in our article (2), the HRs were 0.68 (95% CI 0.51–0.91; P = 0.0085), 0.66 (0.49–0.88; P = 0.0047), and 0.65 (0.48–0.87; P = 0.0034), respectively. These results are consistent with our sensitivity analysis, which excluded prevalent insulin users, a point agreed on by Carstensen in his comment (1). In both analyses, either including or excluding prevalent insulin users, the follow-up time was calculated as the period of enrollment to the date of cancer, death, or censoring, whichever came first. In our sensitivity analysis, we did not exclude any follow-up time except for prevalent insulin users (Fig. 2). FIG. 1. Kaplan-Meier plots of cumulative incidence of cancer in insulin users and noninsulin users in type 2 diabetes. A : Cumulative incidence of cancer in prevalent insulin users and nonusers ( P from log-rank test = 0.3553). B : Cumulative incidence of cancer in new insulin users and nonusers in the sensitivity analysis ( P from log-rank test = 0.0075). C : Cumulative incidence of cancer in the new …

Diabetes: costs and cost-effectiveness

Diabetes: costs and cost-effectiveness

Exploring patients&amp;rsquo; perceptions for insulin therapy in type 2 diabetes: a Brazilian and Canadian qualitative study

To explore which attributes of insulin therapy drive patients' preferences for management in Canada and Brazil. A qualitative design was implemented in which a total of 32 patients with type 2 diabetes from Canada and Brazil, were interviewed in one of the 4 focus groups, or 16 individual interviews. Eighteen participants (56%) were women and fourteen participants (44%) were men (15 insulin nonusers and 17 insulin users). Two focus groups of 4 participants each and 9 individual interviews were conducted in Brazil. In Canada, 2 focus groups of 4 participants each and 7 individual interviews were conducted. A framework analysis was used to analyse all data. Brazilian participants, when considering two insulin treatments, would prefer the one that had fewer side-effects (specially hypoglycemia events), was noninjectable, had the lowest cost and was most effective. Meanwhile, Canadian participants would prefer a treatment that had fewer side-effects (specially weight gain), was less invasive, was more convenient and was most effective. Finding the insulin-delivery system and the attributes of insulin therapy that best meet patients' preferences may lead to improved control, through improved compliance, which may ultimately reduce the financial burden of the disease and improve quality of life.

Associations of Hyperglycemia and Insulin Usage With the Risk of Cancer in Type 2 Diabetes: The Hong Kong Diabetes Registry

OBJECTIVEInsulin has mitogenic effects, although hyperglycemia may be a risk factor for cancer in type 2 diabetes. It remains uncertain whether use of insulin increases cancer risk because of its effect on cell growth and proliferation or decreases cancer risk because of its glucose-lowering effect.RESEARCH DESIGN AND METHODSA 1:2-matched new insulin user cohort on age (±3 years), smoking status, and likelihood of initiating insulin therapy (±0.05) was selected from a cohort of 4,623 Chinese patients with type 2 diabetes, free of cancer, and naive to insulin at enrollment. Stratified Cox regression analysis on the matched pairs was used to obtain hazard ratios (HRs) of insulin therapy and A1C for cancer risk. A structured adjustment scheme was used to adjust for covariates.RESULTSOf 973 new insulin users, 971 had matched nonusers (n = 1935). The cancer incidence in insulin nonusers was much higher than that in insulin users (49.2 vs. 10.2, per 1,000 person-years, P < 0.0001). After further adjustment for all other covariates with a P value less than 0.3 and nonlinear associations with cancer, A1C was associated with an increased cancer risk (HR per percentage 1.26, 95% CI 1.03–1.55), whereas use of insulin was associated with a decreased cancer risk (HR of insulin users vs. nonusers: 0.17, 0.09–0.32). Consistent results were found in analyses including all 973 insulin users and 3,650 nonusers.CONCLUSIONSIn Chinese patients with type 2 diabetes, hyperglycemia predicts cancer, whereas insulin usage was associated with a reduced cancer risk.

The use of insulin and the effect on survival of non-small cell lung cancer patients

e22073 Background: Diabetes mellitus (DM) is one of the common morbidities in United States. Insulin therapy has been frequently used in its treatment. Some studies have postulated that activation of Insulin and Insulin-like growth factor (IGF) pathway may contribute to cancer proliferation, growth and resistance to anticancer therapies. The impact of insulin on diabetic patients with non-small cell lung cancer (NSCLC) has not been reported. Methods: 1,233 patients with NSCLC diagnosed between January 1999 and December 2004 were identified from the Tumor Registry at Henry Ford Health System. Based on inclusion criteria, data from 1,206 patients were extracted from the electronic medical records. Statistical analyses were performed between insulin and non insulin users. Results: Out of 1,206 patients, 193 patients had NSCLC and DM. Data was available from 192 patients. Sixty (31.3%) were on insulin at the time of NSCLC diagnosis and defined as insulin users, while 132 were not on insulin and defined as non- users (68.7%). Demographics, co-morbidities, disease stage at diagnosis, therapeutic interventions, and laboratory values were analyzed for overall and cancer-specific survival. More insulin users (81%) than non-users (64%) presented with advanced disease (stage ≥ 3) at diagnosis (P=0.02). Although no significant difference of Hemoglobin A1c was observed, the median survival from all causes of death was 6.5 months for insulin-users versus 9.9 months for non-users (P=0.08). When survival time was calculated from cancer-specific death, the median survival between insulin and non-insulin users was 7.2 months versus 38.7 months, respectively (P=0.002), with a hazard ratio (HR) for insulin use equals 1.91. Results from our univariable and multivariable analyses will be presented at the ASCO annual meeting in detail. Conclusions: This data indicates that the use of insulin may adversely affect the biology and clinical course of NSCLC with a tendency of advanced disease stage at diagnosis and a shorter cancer-specific survival time. Prospective study of DM with NSCLC or other cancer diagnosis will improve our understanding of this potential adverse effect on cancer biology and provide scientific rational to target IGF-pathway especially in diabetic patients. No significant financial relationships to disclose.

Can blood glucose self-monitoring improve treatment outcomes in type 2 diabetes?

Background Increased cardiovascular risk in diabetes cannot be attributed to the higher prevalence of classic risk factors. Importance of postprandial hyperglycemia Most of the cardiovascular risk factors have shown to be directly related to the degree of postprandial glycemia (PPG). PPG should be recognized as a marker for the increased risk of cardiovascular disease. Assessment of targets for glycemia control Two important methods available—self-monitoring of blood glucose (SMBG) reveals immediate hour-to-hour blood glucose, while long-term glycemia is assessed by HbA1c. Reducing PPG and glycemia excursions is as important as lowering fasting plasma glucose and HbA1c levels. Effectiveness of SMBG SMBG plays a key role in diabetes care, and has proven to be effective for insulin treated type 2 diabetic patients. Debate continues on the effectiveness of SMBG in non-insulin treated type 2 diabetes. Whether non-insulin treated type 2 diabetic patients benefit from SMBG, a large-scale randomized controlled trial with the follow-up period to investigate long-term effects should be carried out. A general recommendation is that insulin treated patients perform SMBG at least three times per day. SMBG frequency for non-insulin users should be individualized to treatment regimen and level of control.

Insulin Use and Weight Maintenance in Well‐controlled Type 2 Diabetes: A Prospective Cohort Study

Intensification of glycemic control is associated with weight gain, however, less is known about weight change during the maintenance phase of glycemic management. On the basis of current models of energy homeostasis, we hypothesize that insulin use will result in less weight gain than oral antidiabetic agents in patients with well-controlled diabetes. This is a prospective cohort nested within a randomized control trial at an academic clinic, with enrollment from June 2002 to January 2005. A total of 163 patients with type 2 diabetes were enrolled after obtaining glycemic control. Insulin use was assessed by self-report at baseline. Participants were weighed at baseline and five follow-up visits over 24 months. The weight change was compared between insulin users and noninsulin users. The average (s.d.) age was 55 (11), 44% are female and 21% are black. The median duration of diabetes was 5 (0.5-10) years. At baseline, 88 participants (54%) reported insulin use with an average of 69 (6) units/day. Baseline BMI in the insulin users was 35 (6) and 33 (6) in noninsulin patients. Over 24 months, noninsulin patients gained 2.3 additional kilograms compared with insulin users (2.8 kg (6.8) vs. 0.5 kg (6.5), P = 0.065). After adjusting for age, race, sex, baseline weight, intervention status, and change in A1C, insulin users had 2.5 kg less weight gain than noninsulin users (P = 0.033). Less weight gain was observed over 24 months in insulin-treated patients. Whether this effect may be due to central catabolic effects of insulin merits additional confirmatory study and mechanistic investigation.

Self-monitoring of blood glucose before and after Medicare expansion among Medicare beneficiaries with diabetes who do not use insulin.

The Balanced Budget Act of 1997 authorized Medicare to expand the coverage of glucose monitors and strips to non-insulin users with diabetes and self-management training to non-hospital-based programs. We examined the impact of this expansion on self-monitoring of blood glucose among Medicare beneficiaries who were not using insulin to treat their diabetes. With data from the 1996-2000 Behavioral Risk Factor Surveillance System and a logistic regression model using a complex survey design, we compared the probability of self-monitoring of blood glucose among Medicare beneficiaries at the frequency recommended by the American Academy of Family Physicians' clinical guidelines before and after the Medicare expansion. We also compared the change in the frequency of self-monitoring of blood glucose during these periods between Medicare beneficiaries and persons with private insurance by using a difference-in-difference model. Medicare expansion was positively associated with the probability of self-monitoring of blood glucose for both Medicare beneficiaries and persons with private insurance; the magnitude was between 7.1 and 16.6 percentage points. The Medicare expansion effectively increased the frequency of the recommended self-monitoring of blood glucose in the Medicare population.

Racial/ethnic differences in multiple self-care behaviors in adults with diabetes.

ObjectiveTo assess racial/ethnic differences in multiple diabetes self-care behaviors.DesignCross-sectional study.Participants21,459 participants with diabetes in the 2003 Behavioral Risk Factor Surveillance survey.MeasurementsThe study assessed self-care behaviors including physical activity, fruits/vegetables consumption, glucose testing, and foot examination, as well as a composite of the 4 self-care behaviors across racial/ethnic groups. Multiple logistic regression was used to assess the independent association between race/ethnicity, the composite variable, and each self-care behavior controlling for covariates. STATA was used for statistical analysis.ResultsOverall, 6% engaged in all 4 self-care behaviors, with a range of 5% in non-insulin users to 8% in insulin users. Blacks were less likely to exercise (OR 0.63, 95% CI 0.51, 0.79), while Hispanics and “others” were not significantly different from whites. Hispanics (OR 0.64, 95% CI 0.49, 0.82) and others (OR 0.69, 95% CI 0.49, 0.96) were less likely to do home glucose testing, while blacks were not significantly different from whites. Blacks (OR 1.42, 95% CI 1.12, 1.80) were more likely to do home foot examinations, while Hispanics and others were not significantly different from whites. Blacks (OR 0.56, 95% CI 0.36, 0.87) were less likely to engage in all 4 behaviors, while Hispanics and others were not significantly different from whites. There were no significant racial/ethnic differences in fruit and vegetable consumption.ConclusionsFew patients engage in multiple self-care behaviors at recommended levels, and there are significant racial/ethnic differences in physical activity, dietary, and foot care behaviors among adults with diabetes.

Driving distance as a barrier to glycemic control in diabetes

Despite advances in treatment of diabetes, many barriers to good glycemic control remain. To determine the relationship between glycemic control and the driving distance from home to the site of primary care. Cross-sectional analysis of data from the Vermont Diabetes Information System. Nine-hundred and seventy-three adults with diabetes in primary care. The mean age was 64.9 years, 57% were female, and 18.4% used insulin. Hemoglobin A1c, shortest driving distance from a patient's home to the site of primary care calculated by geographic software, self-reported gender, age, education, income, marital status, race, insurance coverage, diabetic complications, and use of insulin and oral hypoglycemic agents. Controlling for social, demographic, seasonal, and treatment variables, there was a positive, significant relationship between glycemic control and driving distance (beta=+0.07%/10 km, P<.001, 95% confidence interval [CI]=+0.03, +0.11). Driving distance had a stronger association with glycemic control among insulin users (beta=+0.22%/10 km, P=.016, 95% CI=+0.04, +0.40) than among noninsulin users (beta=+0.06%/10 km, P=.006, 95% CI=+0.02, +0.10). Longer driving distances from home to the site of primary care were associated with poorer glycemic control in this population of older, rural subjects. While the mechanism for this effect is not known, providers should be aware of this potential barrier to good glycemic control.

The Association of Body Mass Index and Pancreatic Cancer in Residents of Southeastern Michigan, 1996–1999

Increased body mass index has emerged as a potential risk factor for pancreatic cancer. The authors examined whether the association between body mass index and pancreatic cancer was modified by gender, smoking, and diabetes in residents of southeastern Michigan, 1996-1999. A total of 231 patients with newly diagnosed adenocarcinoma of the exocrine pancreas were compared with 388 general population controls. In-person interviews were conducted to ascertain information on demographic and lifestyle factors. Unconditional logistic regression models estimated the association between body mass index and pancreatic cancer. Males' risk for pancreatic cancer significantly increased with increasing body mass index (p(trend) = 0.048), while no relation was found for women (p(trend) = 0.37). Among nonsmokers, those in the highest category of body mass index were 3.3 times (95% confidence interval: 1.2, 9.2) more likely to have pancreatic cancer compared with those with low body mass index. In contrast, no relation was found for smokers (p(trend) = 0.94). While body mass index was not associated with pancreatic cancer risk among insulin users (p(trend) = 0.11), a significant increase in risk was seen in non-insulin users (p(trend) = 0.039). This well-designed, population-based study offered further evidence that increased body mass index is related to pancreatic cancer risk, especially for men and nonsmokers. In addition, body mass index may play a role in the etiology of pancreatic cancer even in the absence of diabetes.

Preference for insulin delivery systems among current insulin users and nonusers

Background: It is not known whether preferences for the vial and syringe (VS) or the insulin injection pen device (IIPD) differ between current insulin users and nonusers. Additional benefits in treatment might be realized if preference were considered when discussing insulin use with patients initiating or changing insulin treatment. Objective: The objective of this study was to examine respondent preferences for the VS and the IIPD between current insulin users and nonusers. Methods: US residents with type 1 or 2 diabetes mellitus who responded to a year-2001 mail survey completed a 19-item self-administered questionnaire designed to assess respondents' expectations of attributes related to the VS and IIPD. Items were analyzed on a 5-point Likert-type scale with higher scores indicating greater agreement that attributes met expectations. Composite scores for ease of use, activity interference, and social acceptability were used to further examine differences between insulin users and nonusers regarding their preferences for the VS or IIPD. Observed differences in preferences were evaluated statistically using the chisquare test, paired Student t test, and regression analysis. Results: Questionnaires were received from 302 respondents, producing an adjusted response rate of 20.8%. Respondents ranged in age from 18 to 83 years (mean [SD], 52.4 [13.2] years), with 62% reporting annual income above US $25,000. Of the 242 usable responses, 99 respondents were insulin users and 143 were not. Statistical evaluation using analysis of variance revealed significant regression coefficients ( P ≤ 0.001) for both insulin users and nonusers for each of the 3 dimensions (ease of use, activity interference, and social acceptability with respect to preference). Conclusions: Based on this survey analysis, overall preference for the IIPD appeared to be higher compared with the VS among both insulin users and nonusers. Social acceptability was the strongest predictor of preference for the IIPD. For current insulin users, social acceptability and ease of use were significant predictors of preference for the VS. For insulin nonusers, these results suggested that patient discussions about VS should emphasize activity interference and ease of use.

PDB8: FACTORS ASSOCIATED WITH PRESCRIPTION CLAIMS FOR BLOOD GLUCOSE TEST STRIPS AMONG FEE-FOR-SERVICE NEW MEXICO MEDICAID PATIENTS

OBJECTIVE: Continuous blood glucose monitoring which requires the use of blood glucose test strips (BGTS) is essential for diabetes management. The objective of this study was to identify predictors of claims for BGTS submitted to the New Mexico Medicaid fee-for-service (NMMFFS) program. METHODS: Patients with prescription claims for insulin or oral diabetic medications between December 1, 1999 and November 30, 2000 were identified from the NMMFFS claims database. It was determined if these patients had claims for BGTS. Information on demographic predictors including age, gender, race/ethnicity, insulin use, and area of residence (rural, urban, intermediate) were extracted. A forward stepwise logistic regression analysis using the likelihood-ratio (LR) test, was performed to identify significant predictors of claims for BGTS. RESULTS: A total of 5636 diabetic patients, mean age 65.93 (SD = 17.25), were identified. Of these, 38.6% (n = 2178) had claims for BGTS. About 70% (n = 3974) were female, 45.1% (n = 2543) had claims for insulin, and 38.8% (n = 2185) resided in an urban area. Additionally, there were 42.7% (n = 2408) non-Hispanic whites, 30.8% (n = 1738) Hispanics, and 9.2% (n = 519) American Indians. The logistic regression results indicated that younger patients (OR = 0.97, 95% CI = 0.97–0.98) and patients with claims for insulin (OR = 1.88, 95%CI = 1.68–2.11) were more likely to have claims for BGTS. However, males (OR = 0.64, 95% CI = 0.56–0.73), patients who lived in intermediate areas (OR = 0.74, 95% CI = 0.65–0.83), non-Hispanic whites (OR = 0.78, 95% CI = 0.67–0.91), Hispanics (OR = 0.63, 95% CI = 0.53–0.75) and American Indians (OR = 0.40, 95% CI = 0.32–0.51) were all less likely to have claims for BGTS. CONCLUSIONS: Elderly patients who are female, non-insulin users, non-Hispanic white, Hispanic or American Indian and live in intermediate areas are less likely to have claims for strips. Therefore, educational interventions are needed to increase claims for BGTS in these patients, thus improving blood glucose monitoring.

What attracts patients with diabetes to an internet support group? A 21-month longitudinal website study.

To establish and evaluate a web-based educational and emotional resource for patients with diabetes and their family members. A total of 47 365 user visits over a 21-month period to three internet discussion groups about diabetes were tracked for user activity, characteristics and level of satisfaction. The primary domains of users were the US (70%) and Canada (4%). Of all users, 7.55% posted messages, while 92.45% read messages posted by others. The average length of use was 15 min 5 s. Forty-four per cent posted messages to the nutrition discussion, 38% posted messages to the motivational discussion, and 18% posted messages to the family discussion. The most common postings addressed nutrition (42%), the emotional impact of diabetes (18%), managing high or low blood glucose levels (10%), and complications (8%). Respondents to the satisfaction survey were 64% female, 43% were insulin and 37% non-insulin users. Eighty-four per cent were older than 30 years, 34% had recently diagnosed diabetes and 32% had diabetes > 10 years. Forty-three per cent visited more than three times. Seventy-nine per cent of all respondents rated participation in the chat as having a positive effect on coping with diabetes. A professionally moderated internet discussion group is actively visited by a broad base of patients and families, and appears to be a useful strategy for engaging patients with chronic disease for emotional support and information exchange.

Impact of diabetes on crash risks of truck-permit holders and commercial drivers.

The U.S. and some Canadian government agencies have waived commercial license restrictions for some insulin-using diabetic drivers. However, the U.S. Federal Highway Administration is no longer giving waivers. Scientific evidence to support such regulations has been sparse. This article presents detailed analyses of crash risks for users and nonusers of insulin among diabetic truck-permit holders in Québec, Canada. Diabetic truck-permit holders were group-matched by age to a random sample of healthy permit holders. Data on permits, medical conditions, and crashes involving 13,453 permit holder-years in 1987-1990 were extracted from the files of the public insurer for automobile injuries in Québec. Additional health status data were obtained from the provincial public health insurer. A telephone survey was conducted to collect data on driving patterns and exposure. Risk ratios were estimated using negative binomial regression models. Risk ratios for crashes vary by category of diabetes. Permit holders for single-unit trucks (STs) who are diabetic without complications and not using insulin have an increased crash risk of 1.68 when compared with healthy permit holders of the same permit class. When controlling for risk exposure, commercial drivers with an ST permit and the same diabetic condition have an increased risk of 1.76. Insulin use is not associated with higher crash risk. The increased crash risk for the group with uncomplicated diabetes not using insulin is a new finding. The lack of consistent increases in crash risks among diabetic commercial drivers with complications or who use insulin may be a "healthy worker effect" masking the real risk, because these licensees have a lower participation rate as professional drivers.

Prevalence of self-rated visual impairment among adults with diabetes.

This study estimated the prevalence of self-rated visual impairment among US adults with diabetes and identified correlates of such impairment. Self-reported data from the 1995 Behavioral Risk Factor Surveillance System survey of adults 18 years and older with diabetes were analyzed. Correlates of visual impairment were examined by multiple logistic regression analysis. The prevalence of self-rated visual impairment was 24.8% (95% confidence interval [CI] = 22.3%, 27.3%). Among insulin users, multivariable-adjusted odds ratios were 4.9 (95% CI = 2.6, 9.2) for those who had not completed high school and 1.8 (95% CI = 1.0, 2.8) for those who had completed high school compared with those with higher levels of education. Comparable estimates of odds ratios for nonusers of insulin were 2.2 (95% CI = 1.4, 3.4) and 1.3 (95% CI = 0.9, 2.0), respectively. Among nonusers, the adjusted odds for minority adults were 2.4 (95% CI = 1.0, 3.7) times the odds for non-Hispanic Whites. By these data, 1.6 million US adults with diabetes reported having some degree of visual impairment. Future research on the specific causes of visual impairment may help in estimating the avoidable public health burden.