A systematic review of drug therapy to delay or prevent type 2 diabetes

Health care costs and mortality for Canadian urban and rural patients with diabetes: population-based trends from 1993-2001

BACKGROUND

Recent reports suggest that the health status of individuals residing in rural areas (as much as one third of the Canadian population) may be inferior to those who live in urban areas.

OBJECTIVE

This study compared trends in mortality and in provincial health care system costs for individuals with diabetes, according to urban/rural residence in Saskatchewan, Canada.

METHODS

The Canadian National Diabetes Surveillance System criteria were applied to the linked administrative databases of Saskatchewan Health to identify all individuals with diabetes between 1991 and 2001. Annual health care costs across 5 categories of health care services (physician visits, prescription medications, hospitalizations, day surgeries, and dialysis) were identified over a 9-year period (1993-2001). Costs (in 2001 Can $) and mortality rates were directly age adjusted, and comparisons were made across individuals residing in large urban, small urban, and rural areas.

RESULTS

A total of 57,774 individuals with diabetes were identified, approximately half (n = 26,656) of whom resided in rural areas. In 2001, total per capita costs were $3454 for large urban, $3427 for small urban, and $3289 for rural dwellers. Per capita costs of most individual categories were highest in large urban centers over the follow-up period with the exception of hospitalizations, which were highest among rural residents ($1444 vs $1283 for large urban residents). Despite differences in the individual cost categories, overall health care costs according to place of residence were similar. Overall, the age-adjusted mortality rates increased substantially from 12 (1993) to 18 (2001) deaths per 1000 population, although rates were similar across geographic locations.

CONCLUSIONS

From 1993 to 2001, we observed systematic differences in costs of individual resource categories according to urban/rural residence in Saskatchewan, with urban dwellers with diabetes incurring greater costs in most categories. Age-adjusted total costs and mortality rates were similar, however, suggesting that rural populations with diabetes may not be as disadvantaged as commonly believed. Investing in better primary care access for all patients with diabetes may reduce downstream costs in Saskatchewan's provincial health care system.

Is the current therapeutic armamentarium in diabetes enough to control the epidemic and its consequences? What are the current shortcomings?

The prevalence of diabetes is expected to rise together with an increase in morbidity and a reduction in life expectancy. A leading cause of death is cardiovascular disease, and hypertension and diabetes are additive risk factors for this complication. Selected treatment options should neither increase cardiovascular risk in patients with diabetes, nor increase risk of hyperglycaemia in patients with hypertension. The efficacy of present antihyperglycaemic agents is limited and new therapies, such as incretin-targeted agents, are under development. Even though most patients do not achieve glycated haemoglobin targets, trial data show that such interventions reduce the incidence of macrovascular events; however, intensive lowering may be detrimental in patients with existing cardiovascular disease. Currently available oral drugs do not address the key driver of type 2 diabetes--loss of functional beta-cell mass. In the future, new oral treatments must improve this, whilst providing durable blood glucose control and long-term tolerability.

Excess risk of diabetes in persons with hypertension

PROBLEM

Persons with hypertension appear to be at increased risk of diabetes, an important predictor of cardiovascular disease. Whether, and to what extent, this risk may vary across subgroups defined on the basis of important clinical characteristics has not been well characterized.

METHODS

Study population included members of Kaiser Permanente Northwest Region, a large health maintenance organization, aged > or = 35 years and free of diabetes in 1998. Persons in the study population were stratified based on whether or not they had hypertension, and onset of diabetes was ascertained over a 6-year period beginning January 1999. Excess risk of diabetes was characterized in terms of risk differences between persons with and without hypertension, and was estimated on an overall basis and for subgroups defined on the basis of age, sex, and body mass index (BMI).

RESULTS

Study population totaled 104,368; 44% had hypertension. Relative risk (RR) of developing diabetes was 2.7 (95% CI: 2.6-2.8) for those with vs. without hypertension [21.0 (95% CI: 20.7-21.4) vs. 7.8 (95% CI: 7.6-8.0) per 1000 person-years, respectively]. Adjusted for age, sex, and BMI, RR of diabetes was 1.8 (95% CI: 1.7-1.9). With one exception (men, aged > or = 75 years), risk of diabetes was higher across all age and BMI strata for both men and women with vs. without hypertension; differences in risk were greatest among those with high BMI (> or = 35 kg/m(2)). Across BMI strata, RR of developing diabetes was generally higher at younger ages.

CONCLUSION

All persons with hypertension, irrespective of age, sex, and BMI, are at elevated risk of developing diabetes. Men and women with hypertension who are overweight or obese are at substantially elevated risk of diabetes, regardless of age, and should be monitored especially closely for the development of this disease.

NMR-determined lipoprotein subclass profile predicts type 2 diabetes

AIMS

To determine whether nuclear magnetic resonance (NMR)-determined lipoprotein profiles predict type 2 diabetes.

METHODS

Subjects were 813 male and female participants in the Melbourne Collaborative Cohort Study, aged 40-69 years at baseline (1990-1994), and with a baseline fasting plasma glucose <7.0 mmol/L. Incident type 2 diabetes was identified in 1994-1998 by self-report and confirmation from doctors. Eligible cases and a random group of controls were selected, with NMR data available for 59 cases and 754 non-cases.

RESULTS

Concentration of very low density lipoprotein (VLDL) particles (positive) and high density lipoprotein (HDL) particle size (negative) were selected by stepwise regression as predictors of type 2 diabetes. These associations were independent of other non-lipid risk factors, but not plasma triglycerides. Factor analysis identified a factor from NMR variables, explaining 47% of their variation, and characterized by a positive correlation with VLDL, particularly large and medium sized; more low density lipoprotein (LDL) that were smaller; and relatively smaller, but not more HDL particles. This factor was positively associated with diabetes incidence, but not independently of triglycerides.

CONCLUSIONS

We identified an atherogenic NMR lipoprotein profile in people who developed diabetes, but this did not improve diabetes prediction beyond conventional triglyceride levels.

The association between low birth weight and type 2 diabetes: contribution of genetic factors

BACKGROUND

Low birth weight has been associated with an increased risk of type 2 diabetes in adulthood. Poor fetal nutrition has been suggested to explain this association. Our objective was to determine whether genetic factors contribute to the association between low birth weight and subsequent risk of type 2 diabetes.

METHODS

We retrieved information from original birth records on same-sex Swedish twins with known zygosity, born from 1926 to 1958. We used regression models to investigate whether birth weight was associated with risk of type 2 diabetes in the cohort of twins overall, and in case-control analyses within disease-discordant dizygotic and monozygotic twin pairs.

RESULTS

Of 18,230 twins, 592 (3.2%) had type 2 diabetes. The rate of type 2 diabetes consistently increased with decreasing birth weight, from 2.4% among twins with birth weights of 3500 g or more to 5.3% among those with birth weights less than 2000 g. In the cohort analysis, in which twins are analyzed as independent individuals, the adjusted odds ratio (95% confidence interval) of type 2 diabetes per 500-g decrease in birth weight was 1.44 (1.28-1.63). When we compared the diseased twin with the healthy cotwin, the corresponding odds ratios were 1.38 (1.02-1.85), among dizygotic twins, and 1.02 (0.63-1.64), among monozygotic twins.

CONCLUSIONS

Low birth weight is associated with type 2 diabetes in adulthood. The difference in this association between monozygotic and dizygotic twin pairs suggests that genetic mechanisms play an important role in this association.

Synthesis of hydantoin analogues of (2S,3R,4S)-4-hydroxyisoleucine with insulinotropic properties

The first synthesis of an optically pure (2R,3R,4S)-hydantoin 2, analogue of (2S,3R,4S)-4-hydroxyisoleucine, was achieved in two steps in un-optimized 35% overall yield from previously reported aldehyde synthon 1. (2R,3R,4S)-Hydantoin is stable at acidic pH. This solves the major drawback of (2S,3R,4S)-4-hydroxyisoleucine that easily cyclizes into inactive lactone. Furthermore, (2R,3R,4S)-hydantoin stimulates the insulin secretion by 150% at 25microM compared with 4-hydroxyisoleucine and insulin secretagogue drug repaglinide. In view of its stability and biological activity, (2R,3R,4S)-hydantoin represents a good candidate for type-2 diabetes management and control.

Determinants of new-onset diabetes among 19,257 hypertensive patients randomized in the Anglo-Scandinavian Cardiac Outcomes Trial--Blood Pressure Lowering Arm and the relative influence of antihypertensive medication

OBJECTIVE

The purpose of this study was to determine the baseline predictors of new-onset diabetes (NOD) in hypertensive patients and to develop a risk score to identify those at high risk of NOD.

RESEARCH DESIGN AND METHODS

Among 19,257 hypertensive patients in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) who were randomly assigned to receive one of two antihypertensive regimens (atenolol +/- thiazide or amlodipine +/- perindopril), 14,120 were at risk of developing diabetes at baseline. Of these, 1,366 (9.7%) subsequently developed NOD during median follow-up of 5.5 years. A multivariate Cox model was developed to identify the independent predictors of NOD and individual risk scores.

RESULTS

NOD was significantly associated with an increase in baseline fasting plasma glucose (FPG), BMI, serum triglycerides, and systolic blood pressure. In contrast, amlodipine +/- perindopril in comparison with atenolol +/- thiazide treatment (hazard ratio 0.66 [95% CI 0.59-0.74]), high HDL cholesterol, alcohol use, and age >55 years were found to be significantly protective factors. FPG was the most powerful predictor with risk increasing by 5.8 times (95% CI 5.23-6.43) for each millimole per liter rise >5 mmol/l. The risk of NOD increased steadily with increasing quartile of risk score, with a 19-fold increase (95% CI 14.3-25.4) among those in the highest compared with those in the lowest quartile. The model showed excellent internal validity and discriminative ability.

CONCLUSIONS

Baseline FPG >5 mmol/l, BMI, and use of an atenolol +/- diuretic regimen were among the major determinants of NOD in hypertensive patients. The model developed from these data allows accurate prediction of NOD among hypertensive subjects.

Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group

The increase in heart failure (HF) rates throughout the developed and developing regions of the world poses enormous challenges for caregivers, researchers, and policymakers. Therefore, prevention of this global scourge deserves high priority. Identifying and preventing the well-recognized illnesses that lead to HF, including hypertension and coronary heart disease, should be paramount among the approaches to prevent HF. Aggressive implementation of evidence-based management of risk factors for coronary heart disease should be at the core of HF prevention strategies. Questions currently in need of attention include how to identify and treat patients with asymptomatic left ventricular systolic dysfunction (Stage B HF) and how to prevent its development. The relationship of chronic kidney disease to HF and control of chronic kidney disease in prevention of HF need further investigation. Currently, we have limited understanding of the pathophysiological basis of HF in patients with preserved left ventricular systolic function and management techniques to prevent it. New developments in the field of biomarker identification have opened possibilities for the early detection of individuals at risk for developing HF (Stage A HF). Patient groups meriting special interest include the elderly, women, and ethnic/racial minorities. Future research ought to focus on obtaining a much better knowledge of genetics and HF, especially both genetic risk factors for development of HF and genetic markers as tools to guide prevention. Lastly, a national awareness campaign should be created and implemented to increase public awareness of HF and the importance of its prevention. Heightened public awareness will provide a platform for advocacy to create national research programs and healthcare policies dedicated to the prevention of HF.

Treatment of hypertension in individuals with the cardiometabolic syndrome: role of an angiotensin II receptor blocker, telmisartan

Arterial hypertension is a global public health problem owing to its high prevalence and association with increased risk for cerebral, cardiac and renal events. Hypertension frequently clusters with other cardiometabolic risk factors, such as dysglycemia, low levels of high-density lipoprotein cholesterol and high triglyceride levels. These, along with other factors such as central obesity, increased inflammation, endothelial dysfunction and thrombosis, are components of the metabolic syndrome. All guidelines recommend that the first-line therapy in metabolic syndrome should be based on lifestyle modification, consisting of diet and moderate exercise for at least 30 min/day. Concerning drug treatment of hypertension associated with other cardiometabolic risk factors, many results of head-to-head studies have demonstrated a reduction in new-onset Type 2 diabetes in hypertensive patients treated with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, when compared with conventional antihypertensive therapy. The explanations of the different actions of both these drugs include several mechanisms related to pancreatic insulin release and insulin sensitivity improvement. Another mechanism by which the inhibition of the renin-angiotensin system may improve insulin sensitivity is through the partial peroxisome proliferator-activated receptor-gamma agonism of telmisartan. For that reason, telmisartan has been considered by some experts to be an antihypertensive agent that is particularly useful in the treatment of hypertension associated with cardiometabolic risk factors. The impact of the promising metabolic action exhibited by telmisartan on the outcome of hypertensive patients aggregating other cardiometabolic risk factors waits for adequately randomized and powered clinical trials.

Orlistat in the prevention of diabetes in the obese patient

There has been an increase in the concern about preventing type 2 diabetes mellitus (T2DM), a disease with great and increasing prevalence. The prevalence of obesity, physical inactivity, Western processed diet, important risk factors for the development of T2DM, are also rising. Free fatty acids are increased in obesity and reduce insulin clearance and increase hepatic glucose production. Implementation of a healthy lifestyle has been show to slow the progression of impaired glucose tolerance to T2DM. Orlistat is an inhibitor of lipase activity, with proved efficacy in body weight reduction and long-term management of obesity and more favorable effects on carbohydrate metabolism and it was prospectively shown in XENDOS study that orlistat promoted long-term weight loss and prevented T2DM onset in obese individuals with normal and impaired glucose tolerance at baseline over four years. This benefit could be associated to the weight loss itself, to the limited absorption of lipids and reduction of plasma free fatty acids, to increased production of incretins or to modulation of secretion of cytokines by adipocytes, all effects secondary to orlistat treatment. A proposed strategy is to identify subjects at highest risk to receive a drug intervention, using lifestyle interventions alone at the community level.

Long term pharmacotherapy for obesity and overweight: updated meta-analysis

OBJECTIVE

To summarise the long term efficacy of anti-obesity drugs in reducing weight and improving health status.

DESIGN

Updated meta-analysis of randomised trials.

DATA SOURCES

Medline, Embase, the Cochrane controlled trials register, the Current Science meta-register of controlled trials, and reference lists of identified articles. All data sources were searched from December 2002 (end date of last search) to December 2006.

STUDIES REVIEWED

Double blind randomised placebo controlled trials of approved anti-obesity drugs used in adults (age over 18) for one year or longer.

RESULTS

30 trials of one to four years' duration met the inclusion criteria: 16 orlistat (n=10 631 participants), 10 sibutramine (n=2623), and four rimonabant (n=6365). Of these, 14 trials were new and 16 had previously been identified. Attrition rates averaged 30-40%. Compared with placebo, orlistat reduced weight by 2.9 kg (95% confidence interval 2.5 kg to 3.2 kg), sibutramine by 4.2 kg (3.6 kg to 4.7 kg), and rimonabant by 4.7 kg (4.1 kg to 5.3 kg). Patients receiving active drug treatment were significantly more likely to achieve 5% and 10% weight loss thresholds. Orlistat reduced the incidence of diabetes and improved concentrations of total cholesterol and low density lipoprotein cholesterol, blood pressure, and glycaemic control in patients with diabetes but increased rates of gastrointestinal side effects and slightly lowered concentrations of high density lipoprotein. Sibutramine improved [corrected] concentrations of high density lipoprotein cholesterol and triglycerides [corrected] Rimonabant improved concentrations of high density lipoprotein cholesterol and triglycerides, blood pressure, and glycaemic control in patients with diabetes but increased the risk of mood disorders.

CONCLUSIONS

Orlistat, sibutramine, and rimonabant modestly reduce weight, have differing effects on cardiovascular risk profiles, and have specific adverse effects.

Prevention of diabetes development in those with the metabolic syndrome

Metabolic syndrome is characterized by abnormal glucose levels, central obesity, hypertension, elevated triglycerides, and low HDL cholesterol. This article reviews available data regarding the impact of lifestyle modification and drug therapies on the progression to diabetes in high risk individuals, such as those with hypertension, dyslipidemia, obesity, and prediabetes. Lifestyle and pharmacological interventions may alter metabolic parameters and impact progression to diabetes. However, the cost-effectiveness of these interventions are unclear.

Prolonged decrease of adipocyte size after rosiglitazone treatment in high- and low-fat-fed rats

OBJECTIVE

The anti-diabetic thiazolidinediones (TZDs) stimulate adipocyte differentiation and decrease mean adipocyte size. However, whether these smaller, more insulin-sensitive adipocytes maintain their size after TZD therapy is discontinued has not been studied.

RESEARCH METHODS AND PROCEDURES

Adult female Sprague-Dawley rats were fed a low-fat (10% fat) diet or, to elevate body weight (BW), a high-fat (HF) diet (45% fat) for 6 weeks. Rats were initially randomized to groups (n = 12) fed either low-fat or HF diets, with or without the TZD rosiglitazone (ROSI; 5 mg/kg per day), for 6 weeks. ROSI was then discontinued, and all animals were fed HF for another 6 weeks before sacrifice. Retroperitoneal (RP) adipose tissue morphology was determined from tissue collected by serial biopsies before and after 6 weeks of ROSI treatment and at sacrifice.

RESULTS

Measures of BW and adiposity did not differ among groups 6 weeks after stopping ROSI treatment. However, during treatment, ROSI in both diets significantly decreased RP adipocyte size and increased RP DNA content, and these effects continued to be observed after discontinuing treatment. ROSI administration also decreased circulating insulin, leptin, and triglycerides and increased circulating adiponectin levels; however, these effects were reversed on stopping treatment.

DISCUSSION

These results demonstrated that TZD-induced effects on adipocyte size and number were maintained after discontinuing treatment, even with consumption of an obesigenic diet. However, additional studies are needed to determine whether TZD-treated animals eventually achieve an adipocyte size similar to that of untreated animals at the expense of a higher BW.

Benefits and harms of antidiabetic agents in patients with diabetes and heart failure: systematic review

OBJECTIVE

To review the literature on the association between antidiabetic agents and morbidity and mortality in people with heart failure and diabetes.

DESIGN

Systematic review and meta-analysis of controlled studies (randomised trials or cohort studies) evaluating antidiabetic agents and outcomes (death and admission to hospital) in patients with heart failure and diabetes.

DATA SOURCES

Electronic databases, manual reference search, and contact with investigators.

REVIEW METHODS

Two reviewers independently extracted data. Risk estimates for specific treatments were abstracted and pooled estimates derived by meta-analysis where appropriate.

RESULTS

Eight studies were included. Three of four studies found that insulin use was associated with increased risk for all cause mortality (odds ratio 1.25, 95% confidence interval 1.03 to 1.51; 3.42, 1.40 to 8.37 in studies that did not adjust for diet and antidiabetic drugs; hazard ratio 1.66, 1.20 to 2.31; 0.96, 0.88 to 1.05 in the studies that did). Metformin was associated with significantly reduced all cause mortality in two studies (hazard ratio 0.86, 0.78 to 0.97) compared with other antidiabetic drugs and insulin; 0.70, 0.54 to 0.91 compared with sulfonylureas); a similar trend was seen in a third. Metformin was not associated with increased hospital admission for any cause or for heart failure specifically. In four studies, use of thiazolidinediones was associated with reduced all cause mortality (pooled odds ratio 0.83, 0.71 to 0.97, I2=52%, P=0.02). Thiazolidinediones were associated with increased risk of hospital admission for heart failure (pooled odds ratio 1.13 (1.04 to 1.22), I2=0%, P=0.004). The two studies of sulfonylureas had conflicting results, probably because of differences in comparator treatments. Important limitations were noted in all studies.

CONCLUSION

Metformin was the only antidiabetic agent not associated with harm in patients with heart failure and diabetes. It was associated with reduced all cause mortality in two of the three studies.

Incidence of new-onset diabetes and impaired fasting glucose in patients with recent myocardial infarction and the effect of clinical and lifestyle risk factors

BACKGROUND

Individuals with diabetes are at higher risk of myocardial infarction than non-diabetics. However, much less is known about the incidence of, and risk factors for, development of diabetes and impaired fasting glucose in patients who have had a myocardial infarction. We set out to estimate this incidence and investigate whether lifestyle factors such as dietary habits might alter this risk.

METHODS

We used prospectively obtained data for 8291 Italian patients with a myocardial infarction within the previous 3 months, who were free of diabetes (determined by medication use, a physician-reported diagnosis, or fasting glucose > or =7 mmol/L) at baseline. Incidence of new-onset diabetes (new diabetes medication or fasting glucose > or =7 mmol/L) and impaired fasting glucose (fasting glucose > or =6.1 mmol/L and <7 mmol/L) were assessed at follow-up at 0.5, 1.0, 1.5, 2.5, and 3.5 years. Baseline data for body-mass index (BMI), other risk factors, dietary habits, and medications were updated during follow-up. A Mediterranean diet score was assigned according to consumption of cooked and raw vegetables, fruit, fish, and olive oil. Associations of demographic, clinical, and lifestyle risk-factors with incidence of diabetes and impaired fasting glucose were assessed with multivariable Cox proportional hazards.

FINDINGS

During 26 795 person-years (mean follow-up 3.2 years [SD 0.9]), 998 individuals (12%) developed new-onset diabetes (incidence 37 cases per 1000 person-years). Of the 7533 without impaired fasting glucose at baseline, 2514 (33%) developed new-onset impaired fasting glucose or diabetes (incidence 123 cases per 1000 person-years), rising to 3859 (62%) of 6229 with the lower cutoff for impaired fasting glucose of 5.6 mmol/L (incidence 321 cases per 1000 person-years). Independent risk factors for new-onset diabetes or impaired fasting glucose included older age, hypertension, use of beta-blockers, lipid-lowering medications (protective), and diuretic use. Independent lifestyle risk-factors included higher BMI, greater BMI gain during follow-up, current smoking, a lower Mediterranean dietary score, and wine consumption of more than 1 L/day. Data for physical activity were unavailable, but inability to perform exercise testing was associated with higher incidence of diabetes and impaired fasting glucose.

INTERPRETATION

Compared with population-based cohorts, patients with a recent myocardial infarction had a higher annual incidence rate of impaired fasting glucose (1.8 vs 27.5% in our study) and diabetes (0.8-1.6% compared with 3.7%) in this study. Thus, our results indicate that myocardial infarction could be a prediabetes risk equivalent. Smoking cessation, prevention of weight gain, and consumption of typical Mediterranean foods might lower this risk, which emphasises the need for guidance on diet and other lifestyle factors for patients who have had a myocardial infarction.

The new clinical trials with thiazolidinediones--DREAM, ADOPT, and CHICAGO: promises fulfilled?

PURPOSE OF REVIEW

Despite extensive documentation of their insulin-sensitizing and antihyperglycemic effects, the importance and place of the thiazolidinediones in diabetes management remain unclear. Three new controlled clinical trials of thiazolidinediones offer new information on the clinical utility of these agents.

RECENT FINDINGS

During the past year, three new trials of thiazolidinediones were reported. In Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication, rosiglitazone reduced progression to diabetes in prediabetic patients by 60%. A Diabetes Outcome Progression Trial found rosiglitazone to have greater antihyperglycemic durability than metformin and glyburide in patients with recently diagnosed type 2 diabetes. Finally, in the Carotid Intima-media Thickness in Atherosclerosis using Pioglitazone, treatment with pioglitazone in patients with type 2 diabetes slowed progression of carotid wall thickness compared with the sulfonylurea glimepiride.

SUMMARY

These trials support the contention that thiazolidinediones have superior efficacy in improving and stabilizing glycemic control than older antihyperglycemic agents, especially early in the course of type 2 diabetes. Findings from the Carotid Intima-media Thickness in Atherosclerosis using Pioglitazone add to the evidence that these agents have clinically meaningful vasculoprotective effects. Although generally well tolerated, they promote weight gain, limiting their acceptability to some extent, and occasionally lead to a diagnosis of heart failure, mostly in susceptible individuals.

Elevated fasting glucose levels predicts IGT and diabetes also in middle-age subjects

To add to the discussion whether higher normal range fasting plasma glucose levels or "IFG" may be able to predict the risk to develop type 2 diabetes we tested in 294 healthy middle-age persons during a mean follow up time of 3.8 years which range of fasting glucose levels allowed to predict type 2 diabetes. A significant increase in frequency of IGT/diabetes was significantly observed for the "IFG" category. We therefore conclude that elevated fasting glucose levels in the "IFG" category predict the development of IGT/diabetes in a middle-age population.

Drug treatment of the overweight patient

Three medications with approval for long-term use in the treatment of obesity are currently available in the United States. Sibutramine (U.S. Food and Drug Administration [FDA] approved in 1997), orlistat (FDA approved in 1999), and rimonabant (available in Europe and given FDA approvable status in 2006 and expected to be marketed in 2007) represent modern approaches to medications used adjunctively for weight management. As demonstrated in large clinical trials of 2 to 4 years' duration, these medications significantly increase weight loss compared with placebo; weight loss with these drugs reaches a nadir between 20 and 28 weeks; weight loss, averaged 8%-10%, with the placebo contributing 4%-6% of that. Weight maintenance is demonstrated as long as adherence to medication continues. All medications have side effects that need to be considered. For sibutramine, there is a rise in blood pressure and heart rate that may require discontinuation of the drug in a small percent of patients. For orlistat, steatorrhea produces the principal gastrointestinal side effects. Rimonabant appears to have a favorable safety and tolerability profile. Nausea and gastrointestinal symptoms are the chief tolerability issue, but they are usually self-limited. In addition there are several drugs and drug combinations in phase 2 or phase 2 trials that will be reported on in the coming years.

Beta-cell preservation with thiazolidinediones

Progressive beta-cell dysfunction and beta-cell failure are fundamental pathogenic features of type 2 diabetes. Ultimately, the development and continued progression of diabetes is a consequence of the failure of the beta-cell to overcome insulin resistance. Strategies that aim to prevent diabetes must, therefore, ultimately aim to stabilize the progressive decline of the beta-cell. Clinical study evidence from several sources now suggests that thiazolidinediones (TZDs) have profound effects on the beta-cell, such as improving insulin secretory capacity, preserving beta-cell mass and islet structure and protecting beta-cells from oxidative stress, as well as improving measures of beta-cell function, such as insulinogenic index and homeostasis model assessment of beta-cell function (HOMA-%B). Furthermore, intervention studies suggest that TZDs have the potential to delay, stabilize and possibly even prevent the onset on diabetes in high-risk individuals, and these effects appear to accompany improvements in beta-cell function. Here, we review the evidence, from in vitro studies to large intervention trials, for the effects of TZDs on beta-cell function and the consequences for glucose-lowering therapy.

Waking up from the DREAM of preventing diabetes with drugs

The current epidemic of diabetes makes a drug to prevent it attractive. But despite promotion of recent research evidence, Victor Montori, William Isley, and Gordon Guyatt argue that we are not there yet

Pharmacological interventions in the prevention of type 2 diabetes

(1) Diabetes is a chronic disease whose incidence is increasing worldwide. The long-term complications of diabetes place a large health and economic burden onto individuals, their families and communities as a whole.(2) Guidelines on the prevention of diabetes recommend lifestyle changes such as smoking cessation and weight loss to decrease type 2 diabetes incidence in patients with impaired glucose tolerance or impaired fasting glucose.(3) The role of lifestyle changes and weight loss in preventing diabetes has been proven in large, randomized, controlled clinical trials. To date, the evidence in favor of pharmacological methods is less robust; however, encouraging results obtained so far suggest a promising future role for these agents.(4) Several oral hypoglycemic agents and the antiobesity drug orlistat have been shown to significantly decrease progression to diabetes. The role of other agents such as statins, oestrogen and antihypertensive agents remains to be clarified in additional well-designed studies of diabetes prevention.

Risk of diabetes in a real-world setting among patients initiating antihypertensive therapy with valsartan or amlodipine

In the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial, the risk of new-onset diabetes was reported to be 23% lower among patients initiating therapy with valsartan versus amlodipine. The objective of our study was to examine whether this finding is generalizable to 'real-world' clinical practice. A retrospective cohort design and a large US health insurance database were employed for analyses. Study subjects included all hypertensive patients, aged >or=35 years, who were free from diabetes and who initiated treatment with valsartan (n=9999) or amlodipine (n=18 698) between January 1999 and March 2005. Unadjusted absolute risks of diabetes were 21.4 (95% confidence interval (CI) 18.9-24.3) and 26.3 (95% CI 24.3-28.3) per 1000 patient-years for valsartan and amlodipine, respectively; the corresponding relative risk (RR) for valsartan was 0.82 (95% CI 0.70-0.94). Multivariate analyses - controlling for age, sex, presence of hypercholesterolemia, cardiovascular disease and kidney disease, and pretreatment medical care expenditures - yielded similar results (RR=0.79, 95% CI 0.68-0.92). Our study thus corroborates the finding from VALUE that diabetes risk is lower for patients who receive valsartan versus amlodipine, and extends this finding to a 'real-world' setting.

Antidiabetic agents in subjects with mild dysglycaemia: prevention or early treatment of type 2 diabetes?

Besides lifestyle, various pharmacological treatments have proven their efficacy to reduce the incidence of type 2 diabetes in high-risk individuals, especially in those with impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG). Major placebo-controlled clinical trials demonstrated favourable effects of various glucose-lowering drugs generally used for the treatment of type 2 diabetes, i.e. metformin, acarbose and thiazolidinediones (glitazones). These trials showed a lower rate of progression to overt diabetes and a higher regression rate to a normal glucose status with active treatment as compared to placebo after a follow up of several years. Ongoing trials should confirm such a favourable effect with those drugs and may demonstrate a similar protective effect with other pharmacological approaches such as glinides or even basal insulin regimen. However, the reported favourable effects were generally observed while the subjects were still on treatment, and partially vanished after a rather short period of wash-out of several weeks. Therefore, the distinction between a true preventing effect and simply a masking effect is difficult with glucose-lowering drugs. In addition, as type 2 diabetes is a progressive disease, it is still questionable whether the effect corresponds to a prevention effect or only to a postponing of the development of the disease. Owing to the pathophysiology of the disease, the only way to block the progression of type 2 diabetes is probably to avoid the progressive loss of beta-cell function and/or mass. Whatsoever, these data obtained in large clinical trials bring further argument to support early treatment of diabetes, even at a prediabetic state, in order to stop the vicious circle leading to an inevitable deterioration of glycaemia in predisposed subjects.

Komplexe diätetische und Pharmakotherapie beim metabolischen Syndrom

Metabolic syndrome is characterized by a group of risk factors (obesity, glucose metabolism disorders, dyslipidemia and hypertension) which appear to be caused by obesity related mechanisms of cellular metabolism and the systemic energy balance. A fibre poor diet rich in fat combined with lack of physical activity are important causative factors. A suitable change in diet combined with regular physical exercise and a moderate weight loss of about 5% leads to a massive reduction in the consequential disease diabetes type 2 by 60% in pre-diabetics and reduces the risk factors for metabolic syndrome. Pharmacological therapies using metformin or acarbose were about half as effective in reducing new cases of diabetes, while thiazolidinedione also led to a 60% reduction in new diabetes cases in pre-diabetics in spite of a weight increase. A sensible and realizable change in lifestyle provides a highly efficient therapy of metabolic syndrome, in addition to effective pharmacological options.

Is prevention of Type-2 diabetes feasible and efficient in primary care? A systematic PubMed review

AIM

To answer: (1) Do we have effective treatments to improve prognosis for those identified at risk of Type-2 diabetes? (2) Will prevention be cost-effective?

METHODS

A systematic search was done in PubMed using the following search strategy: "diabetes AND prevention AND (IFG OR IGT)". Restrictions were: "English, Meta-Analysis, Randomized Controlled Trial, Review, Humans".

RESULTS

Few randomised controlled preventive trials were found. Almost all were done in research settings in people with high risk of developing Type-2 diabetes. It seems possible to either delay or prevent Type-2 diabetes through lifestyle interventions and medication. Cost-utility analyses are few in number and come to very different conclusions as to whether health policy should promote prevention of Type-2 diabetes.

CONCLUSION

Intervention studies using lifestyle counselling and drug therapy in research settings illustrate promising results with lowering of the incidence of Type-2 diabetes, meaning that Type-2 diabetes can be delayed or prevented. It is, however, questionable whether these interventions are cost-effective. We need studies in routine clinical settings evaluating morbidity, mortality and cost-effectiveness as primary outcomes. While waiting for these studies to prove cost-effective, patients with pre-diabetes should be treated according to their 10-year risk of cardiovascular disease following present guidelines.

Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis

BACKGROUND

The effect of different classes of antihypertensive drugs on incident diabetes mellitus is controversial because traditional meta-analyses are hindered by heterogeneity across trials and the absence of trials comparing angiotensin-converting-enzyme (ACE) inhibitors with angiotensin-receptor blockers (ARB). We therefore undertook a network meta-analysis, which accounts for both direct and indirect comparisons to assess the effects of antihypertensive agents on incident diabetes.

METHODS

We undertook a systematic review up to Sept 15, 2006, and identified 48 randomised groups of 22 clinical trials with 143,153 participants who did not have diabetes at randomisation and so were eligible for inclusion in our analysis. 17 trials enrolled patients with hypertension, three enrolled high-risk patients, and one enrolled those with heart failure. The main outcome was the proportion of patients who developed diabetes.

FINDINGS

Initial drug therapy used in the trials (and the number of patients with diabetes of the total number at risk) included: an ARB (1189 of 14,185, or 8.38%), ACE inhibitor (1618 of 22,941, or 7.05%), calcium-channel blocker (CCB, 2791 of 38,607, or 7.23%), placebo (1686 of 24,767, or 6.81%), beta blocker (2705 of 35,745, or 7.57%), or diuretic (998 of 18,699, or 5.34%). With an initial diuretic as the standard of comparison (eight groups), the degree of incoherence (a measure of how closely the entire network fits together) was small (omega=0.000017, eight degrees of freedom). The odds ratios were: ARB (five groups) 0.57 (95% CI 0.46-0.72, p<0.0001); ACE inhibitor (eight groups) 0.67 (0.56-0.80, p<0.0001); CCB (nine groups): 0.75 (0.62-0.90, p=0.002); placebo (nine groups) 0.77 (0.63-0.94, p = 0.009); beta blocker (nine groups) 0.90 (0.75-1.09, p=0.30). These estimates changed little in many sensitivity analyses.

INTERPRETATION

The association of antihypertensive drugs with incident diabetes is therefore lowest for ARB and ACE inhibitors followed by CCB and placebo, beta blockers and diuretics in rank order.

Effect of orlistat on weight regain and cardiovascular risk factors following a very-low-energy diet in abdominally obese patients: a 3-year randomized, placebo-controlled study

OBJECTIVE

To investigate the efficacy of orlistat on the maintenance of weight loss over 3 years following a major weight loss induced by very-low-energy diet (VLED) in obese patients with metabolic risk factors such as dyslipidemia, impaired fasting glucose, and diet-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS

Initially, weight loss was induced by an 8-week VLED (600-800 kcal/day) in 383 patients with a mean BMI of 37.5 kg/m(2) (range 30.0-45.2). Those who lost > or = 5% of their body weight (309 of 383 patients) were then randomized to receive lifestyle counseling for 3 years together with either orlistat 120 mg t.i.d. or matching placebo capsules. Primary end points were the maintenance of > or = 5% weight loss after 3 years. Additionally, differences in the development of type 2 diabetes between orlistat and placebo were analyzed.

RESULTS

The VLED induced a mean weight loss of 14.4 +/- 2.0 kg among the subsequently randomized patients. The mean weight gain after 3 years was lower with orlistat than with placebo (4.6 +/- 8.6 vs. 7.0 +/- 7.1 kg; P < 0.02). The number of participants who achieved > or =5% weight loss also favored orlistat (67 vs. 56%; P = 0.037). Waist circumference was significantly more reduced in the orlistat group (P < 0.05), but no other differences in the risk factors were observed between the two groups. The incidences of new cases of type 2 diabetes were significantly reduced in the orlistat group (8 cases out of 153 subjects) versus placebo (17 cases out of 156 subjects) (P = 0.041).

CONCLUSIONS

The addition of orlistat to lifestyle intervention was associated with maintenance of an extra 2.4 kg weight loss after VLED for up to 3 years in obese subjects. The combination of orlistat and lifestyle intervention was associated with a reduced occurrence of type 2 diabetes.

Diagnosing abnormal glucose tolerance in hypertensive women: are we making the best choice?

Essential hypertension is a condition of peripheral insulin resistance; thus, fasting plasma glucose level (FPG) alone may not identify glucose tolerance abnormalities. To evaluate the value of an FPG of 100 mg/dL in the detection of these abnormalities in hypertensive women and to identify clinical markers of a high risk of glucose intolerance indicative of further investigation, the authors studied 313 hypertensive women, without known diabetes, in whom an oral glucose tolerance test (OGTT) was performed. The authors demonstrated that FPG alone was not sufficient to identify 27.6% of hypertensive women with glucose intolerance. In this subgroup, the association of waist circumference >or=97 cm and FPG >or=100 mg/dL increased the risk of glucose intolerance with an odds ratio of 6.97. The authors suggest that OGTT should be performed in hypertensive women with normal FPG but with FPG >or=90 mg/dL or waist circumference >or=97 cm.

Sustainability of 8% weight loss, reduction of insulin resistance, and amelioration of atherogenic-metabolic risk factors over 4 years by metformin-diet in women with polycystic ovary syndrome

In 74 women with polycystic ovary syndrome, treated for 4 years with metformin (MET) and diet, we prospectively assessed whether, and to what degree, weight loss, reduction of insulin resistance, and amelioration of coronary heart disease risk factors could be sustained. We hypothesized that response to MET-diet would not differ by pretreatment body mass index (BMI) classes <25 (normal), > or =25 to <30 (overweight), > or =30 to <40 (obese), and > or =40 (extremely obese). [table: see text] Metformin-diet was successful in producing stable approximately 8% weight reduction for all 4 years (trend P < .0001). Percentage of reductions in weight on MET-diet was significant (P < .05) and did not differ among the 3 highest BMI categories (> or =40, > or =30 to <40, > or =25 to <30), but were not significant in the normal-weight category (BMI, <25). On MET-diet, median homeostasis model assessment of insulin resistance (HOMA-IR) was 33% lower than entry at 1 year, 50% at 2 years, 51% at 3 years, and 50% at 4 years (trend, P < .0001). On MET-diet, median low-density lipoprotein cholesterol (LDL-C) was 6% lower than entry at year 1, 6% at year 2, 7% at year 3, and 11% at year 4 (trend P < .0001). On MET-diet, median high-density lipoprotein cholesterol (HDL-C) was 3% higher than entry at year 2, 8% higher at year 3, and 11% higher at year 4 (trend P < .0001). Percentage of reductions in HOMA-IR, LDL-C, triglyceride, and systolic blood pressure, and increments in HDL-C did not differ (P > .1) in the 4 BMI categories. By stepwise regression, weight loss was a significant (P < or = .01) positive explanatory variable for reduction in HOMA-IR for all 4 follow-up years. Metformin-diet in women with polycystic ovary syndrome effectively and safely reduces weight and LDL-C while raising HDL-C, and maintains these outcomes stable over 4 years.

Statins and outcomes in patients admitted to hospital with community acquired pneumonia: population based prospective cohort study

OBJECTIVES

To determine whether statins reduce mortality or need for admission to intensive care in patients admitted to hospital with community acquired pneumonia; and to assess whether previously reported improvements in sepsis related outcomes were a result of the healthy user effect.

DESIGN

Population based prospective cohort study.

SETTING

Six hospitals in Capital Health, Edmonton, Alberta, Canada.

PARTICIPANTS

Adults admitted to hospital with pneumonia and categorised according to use of statins for at least one week before admission and during hospital stay.

MAIN OUTCOME MEASURES

Composite of in-hospital mortality or admission to an intensive care unit.

RESULTS

Of 3415 patients with pneumonia admitted to hospital, 624 (18%) died or were admitted to an intensive care unit. Statin users were less likely to die or be admitted to an intensive care unit than non-users (50/325 (15%) v 574/3090 (19%), odds ratio 0.80, P=0.15). After more complete adjustment for confounding, however, the odds ratios changed from potential benefit (0.78, adjusted for age and sex) to potential harm (1.10, fully adjusted including propensity scores, 95% confidence interval 0.76 to 1.60).

CONCLUSIONS

Statins are not associated with reduced mortality or need for admission to an intensive care unit in patients with pneumonia; reports of benefit in the setting of sepsis may be a result of confounding.

Orlistat: Current issues for patients with type 2 diabetes

Orlistat, a pancreatic lipase inhibitor, was approved by the US Food and Drug Administration (FDA) in the spring of 1999 as an adjunct to lifestyle intervention for weight loss. This paper seeks to examine current issues regarding orlistat use in patients with type 2 diabetes. There are a number of trials that demonstrate the benefits of orlistat over placebo for reducing body weight and improving other health parameters. Of some interest are the preliminary explorations of interaction on cytokine levels, where a possible cardiovascular benefit is plausible. Implications of the FDA approval of over-the-counter use and the pharmaceutical development of another lipase inhibitor are also examined.

Alpha-glucosidase inhibitors for people with impaired glucose tolerance or impaired fasting blood glucose

BACKGROUND

Alpha-glucosidase inhibitors (AGIs) reduce blood glucose levels and may thus prevent type 2 diabetes and cardiovascular disease in patients with impaired glucose tolerance. These possible effects, and the effects on quality of life, plasma lipids and body weight, have never been investigated in a systematic literature review and meta-analysis.

OBJECTIVES

To assess the effects of alpha-glucosidase inhibitors in patients with impaired glucose tolerance (IGT) or impaired fasting blood glucose (IFBG), or both.

SEARCH STRATEGY

We searched The Cochrane Library (Clinical Trials database, formerly known as CENTRAL), PUBMED, EMBASE, Web of Science, LILACS, databases of ongoing trials, reference lists of relevant reviews, and we contacted experts and manufacturers. Date of last search was February 2006.

SELECTION CRITERIA

Randomised controlled trials of at least one-year duration in patients with IGT or IFBG, or both, comparing AGI monotherapy with any other intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer.

MAIN RESULTS

We included five trials (2360 participants), all investigating acarbose, that included patients with IGT or patients 'at increased risk for diabetes' (n = 1). Study duration was one, three (n = 2), five and six years. One study was at low risk of bias and four studies at high risk of bias. Except for the outcome incidence of type 2 diabetes in acarbose versus no treatment (two studies), meta-analyses were not possible. Data from the study at low risk of bias suggests that acarbose decreases the occurrence of type 2 diabetes (NNT = 10), cardiovascular events (NNT = 50, based on 47 events, study not initially powered for this outcome), post-load blood glucose (-0.6 mmol/L, 95% CI -1.0 to -0.3) and body mass index (0.3 kg/m(2), 95% CI -0.1 to -0.5). No statistically significant effects were observed on mortality, other morbidity, glycated haemoglobin, fasting blood glucose, lipids and blood pressure. The effects on the incidence of type 2 diabetes were confirmed in two studies at high risk of bias (OR 0.2, 95% CI 0.1 to 0.6). Adverse effects were mostly of gastro-intestinal origin (OR 3.5, 95% CI 2.7 to 4.4).

AUTHORS' CONCLUSIONS

There is evidence that acarbose reduces the incidence of type 2 diabetes in patients with IGT. However, it is unclear whether this should be seen as prevention, delay or masking of diabetes. Acarbose may prevent the occurrence of cardiovascular events, but this finding needs to be confirmed in more studies.

Effect of ramipril on the incidence of diabetes

BACKGROUND

Previous studies have suggested that blockade of the renin-angiotensin system may prevent diabetes in people with cardiovascular disease or hypertension.

METHODS

In a double-blind, randomized clinical trial with a 2-by-2 factorial design, we randomly assigned 5269 participants without cardiovascular disease but with impaired fasting glucose levels (after an 8-hour fast) or impaired glucose tolerance to receive ramipril (up to 15 mg per day) or placebo (and rosiglitazone or placebo) and followed them for a median of 3 years. We studied the effects of ramipril on the development of diabetes or death, whichever came first (the primary outcome), and on secondary outcomes, including regression to normoglycemia.

RESULTS

The incidence of the primary outcome did not differ significantly between the ramipril group (18.1%) and the placebo group (19.5%; hazard ratio for the ramipril group, 0.91; 95% confidence interval [CI], 0.81 to 1.03; P=0.15). Participants receiving ramipril were more likely to have regression to normoglycemia than those receiving placebo (hazard ratio, 1.16; 95% CI, 1.07 to 1.27; P=0.001). At the end of the study, the median fasting plasma glucose level was not significantly lower in the ramipril group (102.7 mg per deciliter [5.70 mmol per liter]) than in the placebo group (103.4 mg per deciliter [5.74 mmol per liter], P=0.07), though plasma glucose levels 2 hours after an oral glucose load were significantly lower in the ramipril group (135.1 mg per deciliter [7.50 mmol per liter] vs. 140.5 mg per deciliter [7.80 mmol per liter], P=0.01).

CONCLUSIONS

Among persons with impaired fasting glucose levels or impaired glucose tolerance, the use of ramipril for 3 years does not significantly reduce the incidence of diabetes or death but does significantly increase regression to normoglycemia. (ClinicalTrials.gov number, NCT00095654 [ClinicalTrials.gov].).

Predictors of metabolic control at one year in a population of pediatric patients with type 2 diabetes mellitus: a retrospective study

BACKGROUND/OBJECTIVES

The rising prevalence of pediatric type 2 diabetes mellitus (DM2) and non-adherence to diabetes regimens pose challenges to obtaining optimal control. This study evaluated factors that may impact glycemic control (HbA1c): age, Tanner stage, body mass index (BMI), total daily insulin (TDD), metformin dose (MET), activity level, frequency of clinic visits and adherence.

METHODS

One-year data from 72 patients (ages 8.6-17.8 years) were collected retrospectively. From that sample, 57 patients who continued to attend clinic for the entire year were assessed and divided into optimal and suboptimal HbA1c control groups.

RESULTS

All factors measured were similar in the two groups, except for lower initial and 1.0-year HbA1c, TDD, and rates of missing MET and insulin in the optimal HbA1c control group.

CONCLUSIONS

Initial glycemic status and adherence rate predicted metabolic control at one year. Early identification of DM2 may improve metabolic outcome, which may improve medical regimen adherence.

The answer to diabetes prevention: science, surgery, service delivery, or social policy?

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.

Closing the gap between clinical research and clinical practice: can outcome studies with thiazolidinediones improve our understanding of type 2 diabetes?

Recent clinical research has provided a wealth of information to support optimal management strategies in type 2 diabetes mellitus (T2DM). In particular, outcome studies appropriately have had an increasingly important impact on clinical decision-making. Additional, new data are required, however, to close the current gaps in clinical knowledge and improve patient outcomes in T2DM. These outcome studies are particularly important in assessing the long-term benefit of newer agents for which data are available for short-term glycaemic control, effects on lipids and some data on non-traditional cardiovascular risk markers, but outcome data for harder end points relevant to the natural history of T2DM, particularly beta-cell function, are lacking. Outcome studies such as ADOPT and DREAM are investigating the impact of thiazolidinediones (TZDs) on beta-cell function and disease progression in T2DM and impaired glucose tolerance, respectively, the results of which are eagerly anticipated. The primary focus of this article is on TZD outcome studies evaluating beta-cell function and disease progression.

Prevalencia de síndrome metabólico y asociación con la cardiopatía isquémica en pacientes cardiológicos ambulatorios

INTRODUCTION

The metabolic syndrome (MS) is a cluster of cardiovascular risk factors with a common pathological link: insulin resistance. We analyzed its prevalence and its impact for the presence of ischemic heart disease (IHD).

METHODS

We recorded data from 1,000 consecutive patients that attended the outpatient clinic of the Department of Cardiology from a tertiary hospital for the first time. The assessment of the metabolic syndrome was made according to the ATP-III.

RESULTS

The global prevalence of the MS was 27.3% (95% CI: 25.6-28.9), and increased parallel to age. The highest prevalence of MS was found in patients with diabetes or impaired fasting glucose (70.1%) followed by patients with obesity (58.6%) or hypertension (4.3%). MS conferred higher risk for IHD (OR: 5.5) as compared to diabetes (OR: 3.8). Half of the patients with IHD had MS as well as 90% of the diabetics with ischemic heart disease. MS conferred the highest risk for IHD in patients with obesity (OR: 8.6), hypertriglyceridemia (OR: 6.5), family history of IHD (OR: 5.6), overweight (OR: 5.5) or hypertension (OR: 4.6).

CONCLUSIONS

MS is highly prevalent in the patients from a Cardiological outpatient clinic and is an important risk factor for IHD, especially in subjects with obesity.