Risk Factors for Adverse Outcomes in Patients with Type 2 Diabetes: New Data

This week’s New England Journal of Medicine or the “NEJM” (Volume 379, No. 7) contained two very interesting articles about type two diabetes (T2DM).  The first was entitled: “Smoking Cessation, Weight Change, Type 2 Diabetes, and Mortality.” and written by Hu Y et. al.  The investigators gathered information  from 3 large data bases bases in the U.S.  They identified patients who had reported quitting smoking.  They then prospectively assessed changes in in the patients’ smoking status and body weight, and their risks of developing type 2 diabetes.  They found that recent quitters (2-6 years after smoking cessation) showed an increased risk of developing type 2 diabetes compared to those patients who had longer duration of smoking cessation.  The temporary increase in the risk was directly related to the amount of weight gain; quitters who did not gain weight showed no increase in risk for developing diabetes.The most interesting thing was that even among the quitters who gained weight, there was no increased risk of mortality related to cardiovascular disease or other causes.  The bottom line was that smoking cessation is a very good thing, even if it is accompanied with some weight gain.

The second article was particularly interesting.  It was entitied: ‘Risk Factors, Mortality, and Cardiovascular Outcomes in Patients with Type 2 Diabetes.” and was written by Rawshani A et. al.  This was another cohort study using data from the Swedish National Diabetes Register (271,174 patients) and matched them with 1.3 million controls.  They assessed patients with diabetes according to age categories and according to five risk factors (elevated HbA1c, elevated LDL-cholesterol, albuminuria, smoking, and elevated blood pressure.  The median follow-up among all the study participants was almost 6 years, during which time there were 175,345 deaths.  In the patients with type 2 diabetes, the excess risk of death decreased stepwise for each of the five variables that were within the target range (for HbA1c the target range was 7% or less).  In patients with type 2 diabetes, a HbA1c outside of the target range was the strongest predictor for stroke and myocardial infarction.  Overall, smoking was the strongest predictor of death.  The investigators concluded that patients with type 2 diabetes who had all five risk-factor variables within the target range showed little or no excess risk of death, myocardial infarction, or stroke as compared with the general population.

In my opinion, the study by Rawshani et. al. was extraordinary, not only for the study cohort size, but also for the conclusions.  We physicians and other health care professionals who care for patients with diabetes MUST let patients know over and over, how important glycemic control is, and how important it is not to be a smoker.  Show them the data.

Note: unless you are a subscriber (or have a friend or colleague who is a subscriber) to the NEJM you will not be able to access these articles from the NEJM website (NEJM.org).  You can get them at any U.S. medical school library.  Let me know if you want either or both of the articles and can’t figure out how to get them..

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