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Letters
January 25, 2006

Leading Causes of Death in the United States—Reply

JAMA. 2006;295(4):383-384. doi:10.1001/jama.295.4.384-a

In Reply: We agree with Drs Tierney, Gregg, and Narayan that mortality from diabetes coded as an underlying cause of death underestimates the impact of diabetes on mortality. However, the increase in the death rate from diabetes during the 1990s cannot be explained by coding changes or by an increased awareness causing diabetes to be selected as the underlying cause. The ratio of deaths for which diabetes is the underlying cause to those in which diabetes is mentioned anywhere on the death certificate has changed very little between 1990 (29.3%) and 2002 (32.7%).1,2 We do not believe that tracking the mortality experience of persons with diabetes would provide a better measure than death certificate information. While survival reflects progress in treatment, it does not take into account the large increase in incidence. The decline in cardiovascular disease mortality may contribute slightly to the rising mortality rates from diabetes, as Tierney et al suggest. However, a more important factor is the doubling in the prevalence of obesity since 1970, and the continuing increase in the prevalence of diabetes among US adults from 4.9% in 1990 to 7.3% in 2000.3

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