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In Reply: In response to Drs Leibson and Narayan, we agree that the use of self-reported diabetes status might lead to the detection of milder diabetes in later periods because of heightened awareness and increased screening. However, this same increased awareness of diabetes might also lead to overattribution of diabetes in CVD-related deaths on death certificates. We agree that the overall burden of CVD due to diabetes is increasing, likely because of increases in the overall prevalence of diabetes. This is a different issue from the one we address in our analysis.

Regarding the concern that the inclusion of some Framingham participants in both the earlier and later cohort could have favored a shorter duration of diabetes in the later period, participants in our earlier cohort did have a non–statistically significant longer mean duration of diabetes compared with the later cohort (6.1 years vs 4.6 years). We have previously demonstrated . . . [Full Text of this Article]

Caroline S. Fox, MD, MPH
foxca@nhlbi.nih.gov
National Heart, Lung, and Blood Institute’s Framingham Heart Study
Framingham, Mass

Paul D. Sorlie, PhD; Peter J. Savage, MD
National Heart, Lung, and Blood Institute
Bethesda, Md

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