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OBJECTIVE Because of the increasing incidence and prevalence of diabetes as a leading cause of end-stage renal disease (ESRD) in the aging population, we estimated the expected life-years (LYs) saved from successful prevention of ESRD in elderly patients with diabetes. RESEARCH DESIGN AND METHODS We conducted a population-based cohort study using the National Health Insurance Research Database. We identified all incidences of ESRD in the individuals >65 years of age who were receiving maintenance hemodialysis (N = 24,243) from the registry files of catastrophic illnesses in Taiwan from 1 July 1997 to 31 December 2005. We then retrospectively searched the database to determine whether there had been a diagnosis of diabetes in these cases. After the exclusion of individuals with malignancy (n = 3,423), we extrapolated the survival rates through the end of 2006 using the Monte Carlo method. Using the data of preventable ESRD cases due to diabetes and expected years of life lost (EYLL) in each age stratum, we further estimated the expected LYs saved from successful prevention of ESRD in elderly patients with diabetes. RESULTS The estimated average EYLL was 10.6–5.8 and 12.3–7.3 years for diabetic males and females, respectively, aged 65–79 years. In total, 5,430.1 LYs and 10,177 LYs could be saved by the successful prevention of ESRD in male and female elderly patients with diabetes, respectively, in a single year. CONCLUSIONS The LYs saved by successful prevention of ESRD in elderly patients with diabetes in a single year are substantial and deserve special attention, especially in elderly females.

OBJECTIVE The discrepancy of diabetes incidence and care between socioeconomic statuses has seldom been studied concurrently in nations with universal health coverage. We aimed to delineate whether income disparity is associated with diabetes incidence and inequality of care under a national health insurance (NHI) program in Asia. RESEARCH DESIGN AND METHODS From the Taiwan NHI database in 2000, a representative cohort aged ≥20 years and free of diabetes (n = 600,662) were followed up until 2005. We regarded individuals exempt from paying the NHI premium as being poor. Adjusted hazard ratios (HRs) were used to discover any excess risk of diabetes in the poor population. The indicators used to evaluate quality of diabetes care included the proportion of diabetic patients identified through hospitalization, visits to diabetes clinics, and completion of recommended diabetes tests. RESULTS The incidence of type 2 diabetes in the poor population was 20.4 per 1,000 person-years (HR, 1.5; 95% CI, 1.3–1.7). Compared with their middle-income counterparts, the adjusted odds ratio (OR) for the poor population incidentally identified as having diabetes through hospitalization was 2.2 (P < 0.001). Poor persons with diabetes were less likely to visit any diabetes clinic (OR, 0.4; P < 0.001). The ORs for the poor population with diabetes to receive tests for glycated hemoglobin, low-density lipoprotein cholesterol, triglycerides, and retinopathy were 0.6 (0.4–0.9), 0.4 (0.2–0.7), 0.5 (0.4–0.8), and 0.4 (0.2–0.9), respectively. CONCLUSIONS Poverty is associated not only with higher diabetes incidence but also with inequality of diabetes care in a northeast Asian population, despite universal health coverage.

OBJECTIVE An association between insulin resistance and microalbuminuria in type 2 diabetes has often been found in cross-sectional studies. We aimed to reassess this relationship in a prospective Taiwanese cohort of type 2 diabetic subjects. RESEARCH DESIGN AND METHODS We enrolled 738 normoalbuminuric type 2 diabetic subjects, aged 56.6 ± 9.0 years, between 2003 and 2005 and followed them through the end of 2009. Average follow-up time was 5.2 ± 0.8 years. We used urine albumin-to-creatinine ratio to define microalbuminuria and the homeostasis model assessment of insulin resistance (HOMA-IR) to assess insulin resistance. The incidence rate ratio and Cox proportional hazards model were used to evaluate the association between HOMA-IR and development of microalbuminuria. RESULTS We found incidences of microalbuminuria of 64.8, 83.5, 93.3, and 99.0 per 1,000 person-years for the lowest to highest quartiles of HOMA-IR. Compared with those in the lowest quartile of HOMA-IR, the incidence rate ratios for those in the 2nd, 3rd, and highest quartiles were 1.28 (95% CI 0.88–1.87), 1.44 (0.99–2.08), and 1.52 (1.06–2.20), respectively (trend test: P < 0.001). By comparison with those in the lowest quartile, the adjusted hazard ratios were 1.37 (0.93–2.02), 1.66 (1.12–2.47), and 1.76 (1.20–2.59) for those in the 2nd, 3rd, and highest HOMA-IR quartiles, respectively. CONCLUSIONS According to the dose-response effects of HOMA-IR shown in this prospective study, we conclude that insulin resistance could significantly predict development of microalbuminuria in type 2 diabetic patients.

OBJECTIVE This study aimed to investigate the effect of interaction of diabetes and end-stage renal disease (ESRD) on the risks of cardiovascular (CV) events. RESEARCH DESIGN AND METHODS By using two representative national cohorts, we determined the age- and sex-specific incidences and 20-year risks of incident CV events, including acute myocardial infarction (AMI), stroke, and congestive heart failure (CHF), stratified by the presence of diabetes, de novo diabetes after ESRD, or ESRD. Individuals were excluded if age RESULTS A total 648,851 non-ESRD individuals and 71,397 ESRD patients, including 53,342 and 34,754 diabetic patients, respectively, were followed up during 1998–2009. A monotonic risk pattern of CV-related incidences was noted with the presence of diabetes, ESRD, or both, respectively, after stratification by age and sex. De novo diabetes showed similar increased risks for CV incidences, especially AMI and stroke. There is a multiplicatively synergistic effect of diabetes and ESRD for CV-related risks, especially for AMI and stroke, of which the adjusted hazard ratios (aHRs) were 5.24 (95% CI 4.83–5.68) and 2.43 (2.32–2.55), respectively, in comparison with people without diabetes or ESRD; de novo diabetes after ESRD had similar effects with aHRs of 4.12 (3.49–4.87) and 1.75 (1.57–1.95), respectively. CONCLUSIONS Diabetes and ESRD synergistically increase risks of CV events. Proactive screening and control for diabetes in patients with ESRD should be built into our daily practice.

OBJECTIVE An association between insulin resistance and microalbuminuria in type 2 diabetes has often been found in cross-sectional studies. We aimed to reassess this relationship in a prospective Taiwanese cohort of type 2 diabetic subjects. RESEARCH DESIGN AND METHODS We enrolled 738 normoalbuminuric type 2 diabetic subjects, aged 56.6 ± 9.0 years, between 2003 and 2005 and followed them through the end of 2009. Average follow-up time was 5.2 ± 0.8 years. We used urine albumin-to-creatinine ratio to define microalbuminuria and the homeostasis model assessment of insulin resistance (HOMA-IR) to assess insulin resistance. The incidence rate ratio and Cox proportional hazards model were used to evaluate the association between HOMA-IR and development of microalbuminuria. RESULTS We found incidences of microalbuminuria of 64.8, 83.5, 93.3, and 99.0 per 1,000 person-years for the lowest to highest quartiles of HOMA-IR. Compared with those in the lowest quartile of HOMA-IR, the incidence rate ratios for those in the 2nd, 3rd, and highest quartiles were 1.28 (95% CI 0.88–1.87), 1.44 (0.99–2.08), and 1.52 (1.06–2.20), respectively (trend test: P < 0.001). By comparison with those in the lowest quartile, the adjusted hazard ratios were 1.37 (0.93–2.02), 1.66 (1.12–2.47), and 1.76 (1.20–2.59) for those in the 2nd, 3rd, and highest HOMA-IR quartiles, respectively. CONCLUSIONS According to the dose-response effects of HOMA-IR shown in this prospective study, we conclude that insulin resistance could significantly predict development of microalbuminuria in type 2 diabetic patients.

OBJECTIVE In this randomized controlled trial we evaluated the effect of registered dietitian–led management of diabetes on glycemic control and macronutrient intake in type 2 diabetic patients in primary care clinics in Taiwan and studied the association between changes in macronutrient intake and glycemic measures. RESEARCH DESIGN AND METHODS We recruited 154 adult patients with type 2 diabetes and randomly assigned them to a routine care control group (n = 79) or a registered dietitian–led intervention group (n = 75) who received on-site diabetic self-management education every 3 months over 12 months. RESULTS Over the 1-year period, neither the intervention group (n = 75) nor the control group (n = 79) had significant changes in A1C, whereas the intervention patients with poorly controlled baseline A1C (≥7%) (n = 56) had significantly greater improvements in A1C and fasting plasma glucose than the control subjects (n = 60) (−0.7 vs. −0.2%, P = 0.034; −13.4 vs. 16.9 mg/dl, P = 0.007) during the same period. We also found significant net intervention-control group differences in overall energy intake (−229.06 ± 309.16 vs. 56.10 ± 309.41 kcal/day) and carbohydrate intake (−31.24 ± 61.53 vs. 7.15 ± 54.09 g/day) (P < 0.001) in patients with poorly controlled A1C. Multivariable adjusted modeling revealed an independent association between changes in carbohydrate intake and A1C in the intervention group (n = 56; β = 0.10, SEM = 0.033, P = 0.004). CONCLUSIONS On-site registered dietitian–led management of diabetes can improve glycemic control in patients with poorly managed type 2 diabetes in primary care clinics in Taiwan. A reduction in carbohydrate intake may improve glycemic status.