Showing papers by "Ronald Klein published in 1996"

Relation of Glycemic Control to Diabetic Microvascular Complications in Diabetes Mellitus

Abstract: Objective: To describe the relation between glycated hemoglobin and the incidence or progression, or both, of diabetic microvascular complications in persons with insulin-dependent (IDDM) and non–i...

Prevalence of Self-Reported Erectile Dysfunction in People With Long-Term IDDM

Abstract: OBJECTIVE The purpose of this report is to examine the prevalence of erectile dysfunction and relationships to other characteristics in men with younger-onset diabetes. RESEARCH DESIGN AND METHODS In a population-based cohort study in southern Wisconsin, prevalence of erectile dysfunction was measured based on self reports in men who were 21 years of age or older, were n = 365). RESULTS Of the study group, 20% reported a history of erectile dysfunction. The prevalence of erectile dysfunction increased with increasing age (from 1.1% in those 21–30 years of age to 47.1% in those 43 years of age or older, P for trend P for trend CONCLUSIONS These data suggest that tighter glycemic control and careful selection of antihypertensive medications might prove beneficial.

Association of Zinc and Antioxidant Nutrients With Age-Related Maculopathy

Abstract: Objective: To quantify relationships between dietary intake of zinc and antioxidant nutrients and early and late age-related maculopathy (ARM). Design: A retrospective longitudinal cohort design using data pertaining to diets in the past (1978-1980), which were assessed retrospectively using a food frequency questionnaire. Setting: Beaver Dam, Wis. Patients: A 50% random sample of free-living Beaver Dam Eye Study participants, 43 to 86 years of age (N=1968). Main Outcome Measure: The presence of early and late ARM determined from fundus photography. Results: People in the highest vs lowest quintiles for intake of zinc from foods had lower risk for early ARM (odds ratio=0.6, 95% confidence interval, 0.4-1.0, P for trend Conclusions: The data are weakly supportive of a protective effect of zinc on the development of some forms of early ARM. Prospective studies are needed to further evaluate the potential influence of these and other nutritional factors on different types and stages of age-related macular degeneration.

Parental History of Diabetes in a Population-Based Study

Abstract: OBJECTIVE To evaluate the relative frequency of parental history of diabetes in a population-based study of younger- and older-onset groups of individuals with diabetes and a comparison group of individuals without diabetes. RESEARCH DESIGN AND METHODS Study participants were queried about a family history of diabetes. The frequencies of positive responses for parents and siblings were compared between younger- and older-onset groups. RESULTS At least one parent had diabetes in 18.6% of the families of younger-onset individuals and in 38.6% of the families of older-onset individuals. For those of younger-onset diabetes, 9.1% of fathers, 8.3% of mothers, and 1.3% of both parents had diabetes; the corresponding percentage for those of older-onset diabetes were 11.5, 23.5, and 3.6%, respectively. The difference between frequencies in mothers and fathers was significant ( P CONCLUSIONS These data confirm a familial influence on the frequency of diabetes. The excess of cases in mothers of older-onset diabetic individuals is compatible with both environmental and genetic influences.

Tympanometric Measures in Older Adults

Abstract: Tympanometric measures were obtained in 1240 adults (2147 ears) ranging in age from 48 to 90 years All subjects reported a negative history of otic disease, passed an otoscopic examination, and did not present a significant air-bone gap based on pure-tone audiometry Relative to findings for younger adults, tympanometric measures for older adults in the present study showed greater variability, a slightly lower mean peak compensated static acoustic admittance (peak Ytm), and a significantly higher mean equivalent ear-canal volume (Vea) Across age in the present study, Vea tended to decrease with age and tympanogram width (TW) tended to increase with age Relative to measures for females, males in the present study tended to have higher peak Ytm values, higher Vea values, and slightly lower TW values Overall, our findings indicate a need to adopt criteria that account for age and gender effects in tympanometry protocols for older adults

Sex Hormones and DHEA-SO4 in Relation to Ischemic Heart Disease Mortality in Diabetic subjects: The Wisconsin Epidemiologic Study of Diabetic Retinopathy

Abstract: OBJECTIVE Sex hormones are associated with atherogenic changes in lipoproteins and changes in glucose and insulin metabolism, yet few data are available on the relationship of sex hormones and dehydroepiandrosterone sulfate (DHEA-SO 4 ) to ischemic heart disease (IHD) in diabetic subjects, a groupwith very high levels of IHD. RESEARCH DESIGN AND METHODS We examined the relation of total and free testosterone, sex hormone binding globulin, estrone, estradiol, and DHEA-SO 4 to the 5-year IHD mortality in the older-onset diabetic subjects in the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) in a matched diabetic subject-control design (two control subjects for every diabetic subject). RESULTS In men ( n = 123), none of the sex hormones or DHEA-SO 4 significantly predicted IHD mortality. In women ( n = 120), lower levels of DHEA-SO 4 ( P P = 0.07) predicted IHD mortality. These results were essentially unchanged after adjustment for duration of diabetes, GHb, diuretic use, and serum creatinine, which are major predictors of IHD mortality in the WESDR. Finding lower testosterone levels in diabetic subjects of IHD in women is contrary to data on risk factors, which suggests that increased androgen activity may beassociated with worse IHD risk factors. CONCLUSIONS This study suggests that alterations in sex hormones and DHEA-SO 4 are unlikely to explain a major proportion of the variation in IHD mortality in diabetic subjects.

The incidence of hypertension in insulin-dependent diabetes

Abstract: Background: There are few epidemiologic data describing the long-term incidence of hypertension in people with diabetes. Methods: In a population-based study performed in southern Wisconsin, 765 individuals diagnosed as having diabetes when they were younger than 30 years and taking insulin participated in baseline, 4-year, and 10-year examinations. Blood pressure was measured by standardized protocols, and hypertension was defined as a mean systolic blood pressure of 160 mm Hg or more (≥140 mm Hg in those younger than 25 years) and/or mean diastolic blood pressure of 95 mm Hg or more (≥90 mm Hg in those younger than 25 years) and/or history of hypertension with the use of antihypertensive medication. Results: The prevalence of hypertension at baseline was 17.3%. The 10-year incidence of hypertension was 25.9%. The incidence of hypertension was greater with older age, longer duration of diabetes, higher glycosylated hemoglobin level, proteinuria, more severe retinopathy, and male gender. After other risk factors were controlled for, the 10-year incidence of hypertension was significantly related to higher glycosylated hemoglobin level (odds ratio, 1.23 per percentage increase; 95% confidence interval, 1.13 to 1.34), presence of gross proteinuria (odds ratio, 3.64; 95% confidence interval, 2.26 to 5.85), longer duration of diabetes (odds ratio, 1.03 per year of diabetes; 95% confidence interval, 1.01 to 1.04), and being male (odds ratio, 1.93; 95% confidence interval, 1.34 to 2.77). Conclusion: These data suggest that control of hyperglycemia and prevention of gross proteinuria may lead to a reduction in the long-term incidence of hypertension. (Arch Intern Med. 1996;156:622-627)

Long-term incidence of lower-extremity amputations in a diabetic population.

Abstract: Objective To describe the 10-year cumulative incidence of and risk factors for lower-extremity amputations in diabetics. Design Cohort study. Setting Primary care. Participants Population-based sample (N = 879) of younger-onset diabetic persons (in whom diabetes was diagnosed before 30 years of age and who were taking insulin) and a stratified random sample (N = 956) of older-onset diabetic persons (diagnosis at or after 30 years of age) participating in baseline, 4-year, and 10-year examinations. Main outcome measure Amputations of the lower extremities as reported by the participants. Results The 10-year cumulative incidence of lower-extremity amputation was 5.4% in younger-onset and 7.3% in older-onset persons. Multivariate analyses were performed by logistic regression. In younger-onset persons, age (odds ratio [OR] for 10 years, 2.0; 95% confidence interval [CI], 1.5-2.8), history of ulcers (OR,4.8; 95% CI, 2.3-9.9), diastolic blood pressure (OR, 2.1 for 10 mm Hg; 95% CI, 1.5-3.0), glycosylated hemoglobin level (OR, 1.4 for 1%; 95% CI, 1.2-1.6), sex (OR, 5.2 for men; 95% CI, 2.2-12.3), and retinopathy (OR, 1.2 for 2 steps; 95% CI, 1.1-1.4) were significantly associated with incidence of lower-extremity amputation. In older-onset persons, history of ulcers (OR, 3.3; 95% CI, 1.6-6.8), glycosylated hemoglobin level (OR, 1.3 for 1%; 95% CI, 1.1-1.5), duration of diabetes (OR, 1.6 for 10 years; 95% CI, 1.1-2.5), sex (OR, 2.6 for men; 95% CI, 1.3-4.9), diastolic blood pressure (OR, 0.7 for 10 mm Hg; 95% CI, 0.5-1.0), and proteinuria (OR, 2.4; 95% CI, 1.0-5.7) were significantly associated with incidence of lower-extremity amputation. Conclusion These data show there are several risk factors for lower-extremity amputation with potential for modification and preventive strategies.

The Medical Management of Hyperglycemia Over a 10-Year Period in People With Diabetes

Abstract: OBJECTIVE The purpose of the study was to examine changes in the medical management of glycemia in diabetes and its relation to changes in hyperglycemia as measured by glycated hemoglobin. RESEARCH DESIGN AND METHODS A total of 765 patients with younger-onset diabetes diagnosed before 30 years of age and 533 older-onset diabetic patients participated in a population-based study in southern Wisconsin, at baseline (1980–1982), at 4 years (1984–1986), and at 10 years (1990–1992). Glycated hemoglobin, the presence of complications, and information regarding medical management of glycemia, hypoglycemic reactions, and socioeconomic factors were determined using standardized protocols at the three examinations. RESULTS In the younger-onset group, there was a significant increase ( P < 0.001) in the use of three or more insulin injections per day or in the use of an insulin infusion pump from 3.6% of the cohort at baseline to 24.4% at the 10-year follow-up. This increase was associated with female sex, the presence of gross proteinuria, more education, and better glycemic control at baseline. In the older-onset group, there was a significant ( P < 0.05) increase in the proportion of patients taking insulin, from 49.2% at baseline to 61.9% at the 10-year follow-up. This was associated with being younger, having a longer duration of diabetes, having higher glycated hemoglobin values, and having more education at baseline, or developing proliferative diabetic retinopathy or macular edema between baseline and the 4-year follow-up. CONCLUSIONS These data suggest a change in the pattern of use of insulin to treat people with diabetes. However, there is still a large number of individuals with poorly controlled diabetes in the population.

Longitudinal Patterns of Glycemic Control and Diabetes Care from Diagnosis in a Population-based Cohort with Type 1 Diabetes

Abstract: Glycosylated hemoglobin is an indicator of long-term glycemic control and a strong predictor of diabetic complications. This paper provides a comprehensive description of glycemic control (total glycosylated hemoglobin (GHb)) up to 4.5 years duration of diabetes by age, duration, and sex in a population-based cohort (n = 507) aged less than 20 years followed from diagnosis of Type 1 diabetes in Wisconsin during 1987-1994 Important aspects of demographics and diabetes care are described to allow comparison with other populations. Since large variations between laboratories are known to exist in the measurement of GHb, levels are also interpreted relative to the frequency of short-term complications. GHb increased after diagnosis, but leveled off after 2-3 years. Peak GHb values occurred in the age group 12-15 years. The within-individual standard deviation in GHb between tests, adjusted for age and duration was 1.6%. The mean GHb at last testing was 11.3%, with a standard deviation across individuals of 2.9%. The majority (74%) of individuals saw a diabetes specialist at least once. The mean number of insulin injections per day increased from 2.2 to 2.5 across the 4.5-year duration, and the insulin dose increased from 0.6 to 0.9 units per day per kg body weight. Despite the quite satisfactory level of care, 38% of subjects had GHb levels associated with significant short-term complications.

Pattern of age-related maculopathy in the macular area. The Beaver Dam Eye Study.

Abstract: Purpose. To describe the distribution of lesions associated with age-related maculopathy by location in the macula in a population of adult Americans. Methods. Four thousand nine hundred twenty-six persons ranging in age from 43 to 84 years and living in Beaver Dam, Wisconsin, at the time of a census (1987-1988) were examined from 1988 to 1990. Lesions typical of age-related maculopathy were determined by masked grading of stereoscopic color fundus photographs using the Wisconsin Age-Related Maculopathy Grading System. The extent and prevalence of different types of lesions were determined for each of nine macular subfield regions : central, inner superior, inner nasal, inner inferior, inner temporal, outer superior, outer nasal, outer inferior, and outer temporal. Results. Lesions associated with early age-related maculopathy were distributed in specific patterns. Soft indistinct drusen were more prevalent in the temporal and superior quadrants than in the nasal and inferior quadrants, whereas pigmentary abnormalities associated with age-related maculopathy were more prevalent in the superior or nasal quadrants than in the inferior or temporal quadrants. After weighting for subfield area, all types of lesions were most prevalent in the central macular region. Conclusion. Various lesions associated with early age-related maculopathy were located in specific patterns in the macula. It is not known whether these patterns resulted from environmental, anatomic, or physiologic factors.

Interexaminer reliability of otoscopic signs and tympanometric measures for older adults.

Abstract: To accurately classify hearing loss and otic disorders among older adults, examiners must be able to consistently assess otoscopic signs and perform middle-ear screening tympanograms. As part of a population-based study of hearing loss in Beaver Dam, Wisconsin, the interexaminer reliability of otoscopic examinations and screening tympanograms was evaluated using 45 replicate examinations. Data from 1941 participants 48 to 91 years of age were used to compare otoscopic and tympanometric results. Overall agreement for nine otoscopic signs ranged from 73 percent (vascularity) to 100 percent (drainage). There were small examiner differences in tympanometric measures of equivalent ear-canal volume (Vea) and tympanogram width. No significant differences were observed for peak compensated static acoustic admittance and tympanogram peak pressure. Our findings suggest that examiners can be trained to consistently and accurately assess otoscopic signs and obtain reliable tympanometric results.

Visual sensitivity and age-related eye diseases. The Beaver Dam Eye Study

Abstract: Objective: To evaluate the relationships between visual sensitivity and age-related ocular disorders.Design: Prevalence survey of age-related eye diseases. Setting: Beaver Dam, Wisconsin.Participants: A total community sample of persons 43–84 at the time of the census (1987–1988) was invited to participate (n = 5,926).Main Outcome Measure: Visual sensitivity was measured by a perimeter. Sensitivities were evaluated with regard to age, sex and age-related eye diseases.Results: Sensitivity was inversely associated with age and was lower in women in each age stratum. Central cataract, cataract surgery, and late age-related maculopathy were significantly related to decreased sensitivity in multivariate analyses.Conclusions: Visual sensitivity, an indication of the ability of the eye to detect a light stimulus, was diminished in those with central cataract, cataract surgery, and late age-related maculopathy. This may be related to diminished vision in environmental conditions of low illumination. Since visual ...

Smoke Gets in Your Eyes Too

Abstract: AGE-RELATED macular degeneration is an important cause of loss of vision in older Americans. 1-3 The late stages of this disease have been estimated to be the cause of severe loss of vision (defined as 20/200 or worse in the better eye) in more than 230 000 people. 4 The early stages of the disease have been estimated to affect about 30% of individuals 75 years of age or older, and the late stages of the disease have been estimated to affect about 7%. 5 See also pp 1141 and 1147. The disease is characterized in its early form by the presence of large, soft, confluent drusen and pigmentary abnormalities. 6-8 At this stage, the visual acuity is usually normal. 3 Later in its course, it is characterized by the development of either a wet or dry form. The wet form (exudative macular degeneration) is manifest by the development of

Dietary Fat and Age-Related Maculopathy-Reply

Abstract: In reply We thank Dr Friedman for his interest in our article 1 and for his comments regarding a model of the pathogenesis of age-related macular degeneration. 2 We agree that there is little evidence to suggest that fatty plaques, characteristic of atherosclerosis in large vessels, accumulate in choroidal vessels. However, some studies have shown that risk factors for atherosclerosis are related to the presence of age-related macular degeneration. In a study of Dutch elderly, the risk for age-related macular degeneration was higher among people with plaques in the carotid artery and at the carotid bifurcation and in those with lower-extremity arterial disease. 3 The presence of shared risk factors for arterial disease in several locations is consistent with the possibility that some processes in the pathogenesis of small-vessel arteriosclerosis, atherosclerosis, and age-related maculopathy may be shared. Experimental investigations are required to predict the pathogenic interrelationships of these conditions.