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Managing People at High Risk for Diabetes
- David M. Eddy, MD, PhD;
- Leonard Schlessinger, PhD; and
- Richard Kahn, PhD
- From Kaiser Permanente, Pasadena, CA; Kaiser Permanente, Oakland, CA 94611; and American Diabetes Association, Alexandria, VA 22307.
IN RESPONSE:
We are pleased to address the issues raised by Dr. Herman and his colleagues. Concerning glycemic progression, they are correct that we used UKPDS data to help build our model. We see that as a strength, not a weakness. The resulting model accurately simulates the progression of diabetes across the entire time horizon of our analysis—from impaired fasting glucose and impaired glucose tolerance (it independently predicted the rates in the Diabetes Prevention Program) through to clinical diabetes and for at least 15 years thereafter.
Dr. Herman and associates argue for a faster rate of glycemic progression. They assume that everyone progresses from “diabetes onset” to “clinical diabetes” in exactly 10 years (1), which implies a rate that is greater than than twice that seen in the UKPDS. We see several problems with this assumption, beyond the fact that it contradicts the UKPDS. They based their assumption on 2 papers (2, 3) that estimated that retinopathy first begins to appear in populations about 4 to 7 years before clinical diagnosis. These papers, in turn, cited a study that followed 30 people after onset of diabetes and noted that the first case of retinopathy appeared 5 years after onset (4). The 10-year assumption comes from adding …
