Physicians' Academy for Cardiovascular Education

Importance of lifetime CV risk approach in diabetes

Literature - Rosner Preis S, Pencina MJ, Mann DM et al. - Diabetes Care. 2013;36:1590-6. doi: 10.2337/dc12-1121.

Early-adulthood cardiovascular disease risk factor profiles among individuals with and without diabetes in the Framingham Heart Study.

 
Rosner Preis S, Pencina MJ, Mann DM et al.
Diabetes Care. 2013;36:1590-6. doi: 10.2337/dc12-1121.
 

Background

Many studies of diabetes have focused on cardiovascular disease (CVD) risk factors at the time of diabetes diagnosis. CVD risk factors that accompany diabetes, including obesity, hypertension, and dyslipidemia, are however increased decades before the clinical onset of diabetes.
Individuals who develop diabetes may have increased CVD risk factor burden up to 15 years before their diabetes diagnosis, compared with those who do not have development of diabetes [1,2]. However, 15 years before diabetes diagnosis may not be a long enough time range to capture the early middle-age period when risk factor intervention might be more feasible.
A better understanding of the lifelong risk factor burden before the time of diabetes diagnosis can help to identify those at greatest risk for ultimate development of CVD.
The objective of this study was to examine CVD risk factor burden during the time period of up to 30 years before diabetes diagnosis among individuals who did and did not develop diabetes.
Among participants free of CVD, incident diabetes cases occurring at examinations 2 through 8 (1979–2008) of the Framingham Heart Study Offspring cohort were age- and sex matched 1:2 to controls [3-5]. CVD risk factors (hypertension, high LDL cholesterol, low HDL cholesterol, high triglycerides, obesity) were measured at the time of diabetes diagnosis and at time points 10, 20, and 30 years prior. Risk factor levels at each time point were compared between diabetes cases and controls. A total of 525 diabetes cases and 1,049 age- and sex-matched controls were derived from examinations 2 through 8.
 

Main results

  • At time points 10, 20, and 30 years before diabetes diagnosis, the cases had higher levels of blood pressure, triglycerides, and BMI, and had lower levels of HDL cholesterol than the controls.
  • Individuals who eventually developed diabetes had higher levels of hypertension (OR, 2.2; P = 0.003), high LDL (OR, 1.5; P = 0.04), low HDL (OR, 2.1; P = 0.0001), high triglycerides (OR, 1.7; P = 0.04), and obesity (OR, 3.3; P,0.0001) at time points 30 years before diabetes diagnosis.
  • After further adjustment for BMI, the ORs for hypertension (OR, 1.9; P = 0.02) and low HDL (OR, 1.7; P = 0.01) remained statistically significant.
 

Conclusion

CVD risk factors are increased at the time of diabetes diagnosis and up to 30 years before the diagnosis of diabetes. Diabetes should therefore be considered a life course disease; treatment and control of risk factors should begin early in life rather than at the time of diabetes diagnosis.
 

References

1. Haffner SM, Stern MP, Hazuda HP, et al. Cardiovascular risk factors in confirmed prediabetic individuals. Does the clock for coronary heart disease start ticking before the onset of clinical diabetes? JAMA 1990;263:2893–2898
2. McPhillips JB, Barrett-Connor E,Wingard DL. Cardiovascular disease risk factors prior to the diagnosis of impaired glucose tolerance and non-insulin-dependent diabetes mellitus in a community of older adults. Am J Epidemiol 1990;131:443–453
3. Dawber TR, Meadors GF, Moore FEJ. Epidemiological approaches to heart disease: the Framingham Study. Am J Public Health 1951;41:279–286
4. Dawber TR, Kannel WB, Lyell LP. An approach to longitudinal studies in a community: the Framingham Study. Ann N Y Acad Sci 1963;107:539–556
5. Kannel WB, Feinleib M, McNamara PM, et al. An investigation of coronary heart disease in families. The Framingham offspring study. Am J Epidemiol 1979;110:281–290
 

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