Further insight into data interpretation and conclusions

To the Editor:

I read with great interest the paper by Roche and Wang entitled “Factors associated with a diabetes diagnosis and late diabetes diagnosis for males and females” in the Journal of Clinical and Translational Endocrinology, 2014, Vol. 1(3):77–84. Authors identified some of the factors related to diabetes and early/late diabetes diagnosis from extremely complex process of clinical, demographic, socioeconomic, lifestyle and psychosocial factors. I am very pleased to see that authors conducted their study on Newfoundland population where diabetes prevalence is the highest in Canada; however, a limited number of studies have been conducted on this population. As it is my research interest, I perhaps might be able to add little more to this study.

One of the two outcome variables of this study is the ‘early’ and ‘late’ diabetes diagnosis, which was identified using diabetes related comorbidities and complications based on ICD codes. In addition to potential errors involved in assigning ICD codes as mentioned in previous studies [1], the comorbidities/complications listed in Table 1 of Roche and Wang [2] could be resulted from other diseases instead of diabetes. The data might be better filtered, at least, if the conditions of higher frequencies were identified and then other potential causes of such conditions were examined. For example, although diabetes is one of the risk factors, cardiovascular disease could be caused by various other factors such as high blood pressure, cholesterol and overweight/obesity. Controlling such confounding variables, a better assessment of independent effect might be obtained.

The second point I want to comment on this study is the stress. Consistent with previous studies, authors reported that stress increases the risk of diabetes. In fact, their data provides more insight into diabetes relates stress effects. Stress could be a cause of onset of diabetes; on the other hand, diabetes itself could cause stress [3]. Although authors did not discuss, their data also supports the second point (i.e. diabetes related stress). Table 3 of Roche and Wang [2] shows that early diabetes diagnosed male and females are more stressful (59.4% male and 68.3% female) than the late diagnosed counterpart (49.9% male and 62.9% female). Diabetes related stress might be developed from patients' concerns about its management, emotional burden and access to health care, and also how they react and cope with the disease 3, 4. Therefore, early diagnosed patients might report stressful life as found in this study.