July 21, 1999 issue of JAMA has an article titled, Alcohol Intake and the Risk of Coronary Heart Disease Mortality in Persons with Older-Onset Diabetes Mellitus, by Valmadrid, CT, MD, MPH et al. Despite nutrition information and guidelines that advise against depriving diabetic patients of the potential benefit of moderate alcohol intake against cardiovascular events, the association between alcohol consumption and risk of cardiovascular outcomes in diabetic individuals has not been determined. The researchers examined the relationship between alcohol intake and coronary heart disease (CHD) mortality in persons with older-onset diabetes. The study took place from 1984 through 1996, with a follow-up of up to 12.3 years and was a population-based prospective cohort study. A total of 983 older-onset diabetics (mean age 68.6 years of age), 45.2% male, 98.5 % white, were interviewed about their past-year intake of alcoholic beverages during a 1984-1986 follow-up examination of a population based study of diabetic persons in southern Wisconsin. The main outcome measure was the time to mortality from coronary heart disease by category alcohol intake.
Results indicate that alcohol use was inversely associated with the risk of CHD mortality in older-onset diabetics. The CHD mortality rates for never and former drinkers were 43.9 and 38.5 per 1000 person-years, respectively, while the rates for those with alcohol intakes of less than 1, 2 to 13, and 14 or more g/d were 25.3, 20.8 and 10.0 per 1000 person-years, respectively. Compared with never drinkers and controlling for age, sex, cigarette smoking, glycosylated hemoglobin level, insulin use, plasma C-peptide level, history of angina or myocardial infarction, digoxin use, and the presence and severity of diabetic retinopathy, former drinkers had a relative risk (RR) of .69 for those who drank less than 2g/d ( less frequent than 1 drink a week), the RR was 0.54, for 2 to 13 g/d , it was 0.44 and for 14 or more g/d (about 1 drink or more a day), it was 0.21. Further adjustments for blood pressure, body mass index, education, physical activity, diabetes duration, hypertension history, overt nephropathy, peripheral neuropathy, lipid measures, or intake of medications such as aspirin and antihypertensive agents did not change the associations observed.
The researchers concluded an overall beneficial effect of alcohol consumption in decreasing the risk of death due to CHD in people with older-onset diabetes.
Improved glycemic control reduces the impact of weight gain on cardiovascular risk factors in type 1 diabetes, by Williams, KV, MD, MPH, et al in Diabetes Care 22:1077-1083, 1999, assesses the prevalence and incidence of being overweight in type 1 diabetes, identifies factors associated with weight gain and improved glycemic control, and examines relationships among weight gain, glycemic control, and cardiovascular risk factors. The prevalence and incidence of being overweight in the Pittsburgh Epidemiology of Diabetes Complications (EDC) cohort were compared with the general population (National Health and Nutrition Examination Survey, NHANES). Factors associated with weight gain and improved glycemic control were identified and relationship among weight gain, glycemic control, and cardiovascular risk factors were examined over a 6.9 ± 2.2 year period.
At baseline, the prevalence of being overweight (BMI>27.8 kg/m2 for men and > 27.3 kg/m2 for women) was 10.4% and 11.4%, respectively, and was lower than age- and sex-specific estimates for the general population. The incidence of being overweight was comparable in men and women and did not differ from the general population. Weight gain correlated with improvements in HbA1c. Patients with the highest baseline HbA1c levels gained the most weight and had the greatest improvement in glycemic control. A lower baseline BMI was also associated with greater improvement in glycemic control. Weight gain favorably influenced the lipid profile in the setting of improved glycemic control, but adversely influenced the lipid profile in the absence of improved glycemic control. Weight change was directly associated with blood pressure change, but the incidence of hypertension was more strongly influenced by the development of neuropathy.
The researchers concluded that the prevalence of being overweight in type 1 diabetes remains lower than that in the general population. Moderate weight gain did not adversely affect the cardiovascular risk profile in the setting of improved glycemic control.
Bone mineral density in patients with type 1 and type 2 diabetes, by Tuaminen, JT, et al, in Diabetes Care 22:119601200, 1999, assesses the effect of type 1 and type 2 diabetes and insulin treatment on bone mineral density (BMD) in middle-aged and elderly men and women. The study measured BMD and evaluated known determinants of osteoporosis in 56 type 1 and 68 type 2 diabetic patients and 498 non-diabetic community control subjects. All patients, aged 52-72 years, developed diabetes after the age of 30 years ( that is after achievement of peak bone mass) and were treated with insulin. BMD was measured at the proximal femur with dual-energy X-ray absorptiometry.
Results indicated that among both sexes, BMD values were significantly lower in type 1 diabetic patients than in type 2 diabetic patients or the control subjects. When adjusted for age and BMI, the differences between type 1 diabetic patients and control subjects remained essentially unchanged in both sexes, whereas the differences between type 1 and type 2 diabetics were significant only in men. After further adjustment for confounding factors, the average BMD values were still lower in type 1 diabetic subjects than in type 2 diabetic subjects although with lesser significance. Past low-energy fractures were more common in type 2 diabetic women than in type 2.
The researchers suggested that the lower BMD in type 1 verses type 2 diabetic patients and control subjects probably results from more rapid bone loss after the onset of type 1 diabetes. This cannot be explained by insulin treatment, which was prescribed for both types of patients. Because the causes of low BMD in type 1 diabetes are unknown, researchers suggested that these patients should be evaluated for the risk of osteoporosis and related fractures and offered appropriate preventive measures.
Type 2 diabetes mellitus greater cardiovascular risks and greater benefits of therapy, by Fagan, TC et al, in the Archives of Internal Medicine, May 24, 1999, is an editorial that discusses the benefits of therapy for complications of microvascular disease in this AMA position statement based on research from England, Europe and the US. The paper begins with the statistics that type 2 diabetes is associated with a 2-3 fold increased risk factor for cardiovascular morbidity and mortality. The risk is approximately 2-fold in men and 4-fold in women. The risk of coronary disease is increased 4-fold in diabetic persons compared with nondiabetic persons, and the risk for myocardial infarction (MI) and death from coronary disease are the same in diabetic people without previous MI as in nondiabetic persons with previous MI. The relative risk for stroke in diabetic persons is 2-to 3-fold the risk for nondiabetic people, and there is a greater relative risk in women compared to men. The authors reviewed the 8 year United Kingdom Prospective Diabetes Study, the Systolic Hypertension in Europe Trial, the Hypertension Optimal Treatment Trial, the Systolic Hypertension in the elderly Program, and the Helsinki Heart Study.
Conclusions indicate that people with type 2 diabetes are at markedly increased risk of microvascular disease ( retinopathy, nephropathy, and neuropathy). Treatment of hyperglycemia improves the risk of microvascular disease, but has little, if any, effect on macrovascular disease. Treatment of hypertension and dyslipidemias benefits diabetic people as much or more than nondiabetic people. Actually reducing BP is more important than which particular medication is chosen, since benefit has been shown whether therapy is based on diuretics, Beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or calcium antagonists. Reduction of LDL cholesterol levels in diabetic persons with coronary disease or low HDL cholesterol levels and no evidence of coronary disease decreases morbidity from coronary disease.
Recommendations are that type 2 diabetics should receive aggressive therapy to achieve normoglycemia in order to prevent microvascular disease. Those with elevated BP should be aggressively treated toward a goal of less than 130 mm Hg systolic and less than 85 mm Hg diastolic in order to reduce the risk of stroke, coronary events, and other manifestations of macrovascular disease. Results of the Hypertension Optimal Treatment Trail suggest that further reduction of diastolic BP, below 80 mm Hg, is probably beneficial. Diabetic persons with elevated LDL cholesterol levels, normal LDL levels with known coronary disease, or low HDL cholesterol levels should probably have their LDL cholesterol level lowered to less then 2.59 mm ol/L With the array of effective and well-tolerated antihypertensive, hypolipidemic, and diabetic therapeutic agents available, and with the proven long-term benefits in the treatment of hypertension, dyslipidemia, and hyperglycemia (at least for microvascular events in diabetic persons, it is imperative to identify and treat these risk factors aggressively to reduce the excess cardiovascular morbidity and mortality and microvascular morbidity associated with type 2 diabetes. As suggested by the results of the United Kingdom Prospective Diabetes Study and by the American Diabetes Association, diabetic persons with any evidence of cardiovascular disease should receive prophylactic aspirin, unless absolutely contraindicated.
