Current Diabetes Reports

, Volume 10, Issue 1, pp 16–23

Multifactorial Intervention to Reduce Cardiovascular Events in Type 2 Diabetes

  • Swapnil N. Rajpathak
  • Vikas Aggarwal
  • Frank B. Hu
Article

Abstract

Type 2 diabetes is associated with a significantly increased risk of cardiovascular disease (CVD) morbidity and mortality. Although several clinical trials have evaluated the effects of interventions to reduce CVD risk in people with diabetes, such studies are primarily conducted to target individual risk factors such as hypertension, hyperglycemia, and dyslipidemia rather than using a multifactorial interventional approach. Existing clinical trial data suggest that intensive multifactorial interventions that target several important risk factors simultaneously result in a significantly greater risk reduction in CVD risk compared with single risk factor interventions. However, few studies have evaluated the efficacy and effectiveness of such interventions on CVD hard end points. A multidisciplinary team management of diabetes should focus on weight control, diet, physical activity, diabetes education, and adherence to pharmacotherapy. An individually tailored aggressive management program to reduce multiple CVD risk factors simultaneously has great potential to prevent CVD morbidity and mortality among patients with type 2 diabetes.

Keywords

Diabetes Cardiovascular disease Multifactorial intervention Lifestyle intervention Nutrition Lipids Obesity Hypertension Hypoglycemia 

References

Papers of particular interest, published recently, have been highlighted as follows: • Of importance •• Of major importance

  1. 1.
    Gregg EW, Cheng YJ, Narayan KM, et al.: The relative contributions of different levels of overweight and obesity to the increased prevalence of diabetes in the United States: 1976–2004. Prev Med 2007, 45:348–52.CrossRefPubMedGoogle Scholar
  2. 2.
    Pickup J, Williams G, eds: Textbook of Diabetes, edn 3. Malden, MA: Blackwell Science; 2003.Google Scholar
  3. 3.
    National Institutes of Health: Diabetes in America, edn 2. Washington, DC: National Institutes of Health; 1995. NIH Publication No. 95–1468.Google Scholar
  4. 4.
    Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001, 285:2486–2497.CrossRefGoogle Scholar
  5. 5.
    Cho E, Rimm EB, Stampfer MJ, et al.: The impact of diabetes mellitus and prior myocardial infarction on mortality from all causes and from coronary heart disease in men. J Am Coll Cardiol 2002, 40:954–960.CrossRefPubMedGoogle Scholar
  6. 6.
    Haffner SM, Lehto S, Ronnemaa T, et al.: Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998, 339:229–234.CrossRefPubMedGoogle Scholar
  7. 7.
    Rubin RJ, Altman WM, Mendelson DN: Health care expenditures for people with diabetes mellitus, 1992. J Clin Endocrinol Metab 1994, 78:809A–809F.CrossRefPubMedGoogle Scholar
  8. 8.
    Turner RC, Millns H, Neil HA, et al.: Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS: 23). BMJ 1998, 316:823–828.PubMedGoogle Scholar
  9. 9.
    •• American Diabetes Association: Standards of medical care in diabetes–2009. Diabetes Care 2009, 32(Suppl 1):S13–S61. This paper provides the current recommendations of the American Diabetes Association for the management of CVD in diabetes.CrossRefGoogle Scholar
  10. 10.
    Wild SH, Dunn CJ, McKeigue PM, Comte S: Glycemic control and cardiovascular disease in type 2 diabetes: a review. Diabetes Metab Res Rev 1999, 15:197–204.CrossRefPubMedGoogle Scholar
  11. 11.
    Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998, 352:837–853.Google Scholar
  12. 12.
    • Gerstein HC, Miller ME, Byington RP, et al.: Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008, 358:2545–2559. This paper provides results from the ACCORD trial that evaluated the effects of intensive glycemic control on cardiovascular risk in diabetes.CrossRefPubMedGoogle Scholar
  13. 13.
    • Patel A, MacMahon S, Chalmers J, et al.: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008, 358:2560–2572. This paper provides results from the ADVANCE trial that evaluated the effects of intensive glycemic control on cardiovascular risk in diabetes.CrossRefPubMedGoogle Scholar
  14. 14.
    • Duckworth W, Abraira C, Moritz T, et al.: Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009, 360:129–139. This paper provides results from the VADT trial that evaluated the effects of intensive glycemic control on cardiovascular risk in diabetes.CrossRefPubMedGoogle Scholar
  15. 15.
    • Kelly TN, Bazzano LA, Fonseca VA, et al.: Systematic review: glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med 2009, 151:394–403. This meta-analysis summarized results from five clinical trials that evaluated the effects of tight glucose control on CVD morbidity and mortality in diabetes.PubMedGoogle Scholar
  16. 16.
    Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group [no authors listed]. BMJ 1998, 317:703–713.Google Scholar
  17. 17.
    Hansson L, Lindholm LH, Niskanen L, et al.: Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet 1999, 353:611–616.CrossRefPubMedGoogle Scholar
  18. 18.
    Curb JD, Pressel SL, Cutler JA, et al.: Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996, 276:1886–1892.Google Scholar
  19. 19.
    Dean JD, Matthews SB, Dolben J, et al.: Cholesterol rich apo B containing lipoproteins and smoking are independently associated with macrovascular disease in normotensive NIDDM patients. Diabet Med 1994, 11:740–747.CrossRefPubMedGoogle Scholar
  20. 20.
    Jonas MA, Oates JA, Ockene JK, Hennekens CH: Statement on smoking and cardiovascular disease for health care professionals. American Heart Association. Circulation 1992, 86:1664–1669.PubMedGoogle Scholar
  21. 21.
    Haire-Joshu D, Glasgow RE, Tibbs TL: Smoking and diabetes. Diabetes Care 2004, 27(Suppl 1):S74–S75.PubMedGoogle Scholar
  22. 22.
    Al-Delaimy WK, Manson JE, Solomon CG, et al.: Smoking and risk of coronary heart disease among women with type 2 diabetes mellitus. Arch Intern Med 2002, 162:273–279.CrossRefPubMedGoogle Scholar
  23. 23.
    Torjesen PA, Birkeland KI, Anderssen SA, et al.: Lifestyle changes may reverse development of the insulin resistance syndrome. The Oslo Diet and Exercise Study: a randomized trial. Diabetes Care 1997, 20:26–31.Google Scholar
  24. 24.
    Goldstein DJ: Beneficial health effects of modest weight loss. Int J Obes Relat Metab Disord 1992, 16:397–415.PubMedGoogle Scholar
  25. 25.
    Chaturvedi N, Fuller JH: Mortality risk by body weight and weight change in people with NIDDM. The WHO Multinational Study of Vascular Disease in Diabetes. Diabetes Care 1995, 18:766–774.CrossRefPubMedGoogle Scholar
  26. 26.
    Lean ME, Powrie JK, Anderson AS, Garthwaite PH: Obesity, weight loss and prognosis in type 2 diabetes. Diabet Med 1990, 7:228–233.CrossRefPubMedGoogle Scholar
  27. 27.
    Cho EY, Manson JE, Stampfer MJ, et al.: A prospective study of obesity and risk of coronary heart disease among diabetic women. Diabetes Care 2002, 25:1142–1148.CrossRefPubMedGoogle Scholar
  28. 28.
    Hu FB, Stampfer MJ, Manson JE, et al.: Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med 1997, 337:1491–1499.CrossRefPubMedGoogle Scholar
  29. 29.
    Hu FB, Manson JE, Willett WC: Types of dietary fat and risk of coronary heart disease: a critical review. J Am Coll Nutr 2001, 20:5–19.PubMedGoogle Scholar
  30. 30.
    Mozaffarian D, Rimm EB: Fish intake, contaminants, and human health: evaluating the risks and the benefits. JAMA 2006, 296:1885–1899.CrossRefPubMedGoogle Scholar
  31. 31.
    Hu FB, Cho E, Rexrode KM, et al.: Fish and long-chain omega-3 fatty acid intake and risk of coronary heart disease and total mortality in diabetic women. Circulation 2003, 107:1852–1857.CrossRefPubMedGoogle Scholar
  32. 32.
    Wolever TMS, Nuttall FQ, Lee R, et al.: Prediction of the relative blood-glucose response of mixed meals using the white bread glycemic index. Diabetes Care 1985, 8:418–428.CrossRefPubMedGoogle Scholar
  33. 33.
    Salmeron J, Manson JE, Stampfer MJ, et al.: Dietary fiber, glycemic load, and risk of non-insulin-dependent diabetes mellitus in women. JAMA 1997, 277:472–477.CrossRefPubMedGoogle Scholar
  34. 34.
    Salmeron J, Ascherio A, Rimm EB, et al.: Dietary fiber, glycemic load, and risk of NIDDM in men. Diabetes Care 1997, 20:545–550.CrossRefPubMedGoogle Scholar
  35. 35.
    Liu S, Willett WC, Stampfer MJ, et al.: A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women. Am J Clin Nutr 2000, 71:1455–1461.PubMedGoogle Scholar
  36. 36.
    Liu S, Manson JE, Stampfer MJ, et al.: A prospective study of whole-grain intake and risk of type 2 diabetes mellitus in US women. Am J Public Health 2000, 90:1409–1415.CrossRefPubMedGoogle Scholar
  37. 37.
    Meyer KA, Kushi LH, Jacobs DR Jr, et al.: Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr 2000, 71:921–930.PubMedGoogle Scholar
  38. 38.
    Jacobs DR Jr, Meyer KA, Kushi LH, Folsom AR: Whole-grain intake may reduce the risk of ischemic heart disease death in postmenopausal women: the Iowa Women’s Health Study. Am J Clin Nutr 1998, 68:248–257.PubMedGoogle Scholar
  39. 39.
    Liu S, Stampfer MJ, Hu FB, et al.: Whole-grain consumption and risk of coronary heart disease: results from the Nurses' Health Study. Am J Clin Nutr 1999, 70:412–419.PubMedGoogle Scholar
  40. 40.
    Rimm EB, Williams P, Fosher K, et al.: Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. BMJ 1999, 319:1523–1528.PubMedGoogle Scholar
  41. 41.
    Rajpathak SN, Freiberg MS, Wang C, et al.: Alcohol consumption and the risk of coronary heart disease in postmenopausal women with diabetes: Women's Health Initiative Observational Study. Eur J Nutr 2009 Oct 13 (Epub ahead of print).Google Scholar
  42. 42.
    Rimm EB, Klatsky A, Grobbee D, Stampfer MJ: Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits? BMJ 1996, 312:731–736.PubMedGoogle Scholar
  43. 43.
    Koivisto VA, Tulokas S, Toivonen M, et al.: Alcohol with a meal has no adverse effects on postprandial glucose homeostasis in diabetic patients. Diabetes Care 1993, 16:1612-1614.CrossRefPubMedGoogle Scholar
  44. 44.
    Hu FB, Stampfer MJ, Solomon C, et al.: Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med 2001, 134:96–105.PubMedGoogle Scholar
  45. 45.
    Gregg EW, Gerzoff RB, Caspersen CJ, et al.: Relationship of walking to mortality among US adults with diabetes. Arch Intern Med 2003, 163:1440–1447.CrossRefPubMedGoogle Scholar
  46. 46.
    Tanasescu M, Leitzmann MF, Rimm EB, Hu FB: Physical activity in relation to cardiovascular disease and total mortality among men with type 2 diabetes. Circulation 2003, 107:2435–2439.CrossRefPubMedGoogle Scholar
  47. 47.
    Hardman A: Physical activity and cardiovascular risk. J Cardiovasc Risk 1995, 2:285–288.CrossRefPubMedGoogle Scholar
  48. 48.
    Aiello LP, Cahill MT, Wong JS: Systemic considerations in the management of diabetic retinopathy. Am J Ophthalmol 2001, 132:760–776.CrossRefPubMedGoogle Scholar
  49. 49.
    Gaede P, Vedel P, Larsen N, et al.: Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003, 348:383–393.CrossRefPubMedGoogle Scholar
  50. 50.
    •• Gaede P, Lund-Andersen H, Parving HH, Pedersen O: Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008, 358:580–591. This paper presented the results from the Steno-2 study on mortality. The Steno-2 study was the first randomized trial to evaluate the effect of intensified multifactorial intervention on risk of CVD in patients with diabetes. The data indicated that this approach resulted in better management of CVD risk factors and a significant reduction in CVD mortality compared with the conventional treatment.CrossRefPubMedGoogle Scholar
  51. 51.
    Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002, 360:7–22.CrossRefGoogle Scholar
  52. 52.
    Lauritzen T, Griffin S, Borch-Johnsen K, et al.: The ADDITION study: proposed trial of the cost-effectiveness of an intensive multifactorial intervention on morbidity and mortality among people with type 2 diabetes detected by screening. Int J Obes Relat Metab Disord 2000, 24(Suppl 3):S6–S11.PubMedGoogle Scholar
  53. 53.
    •• Janssen PG, Gorter KJ, Stolk RP, Rutten GE: Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study. Br J Gen Pract 2009, 59:43–48. This article provides results from the ADDITION study showing that intensive multifactorial intervention results in the improvement in levels of traditional CVD risk factors among newly diagnosed patients with diabetes.CrossRefPubMedGoogle Scholar
  54. 54.
    •• Pi-Sunyer X, Blackburn G, Brancati FL, et al.: Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care 2007, 30:1374–1383. The article provides results from the Look AHEAD study on cardiovascular risk profile changes at 1 year. It demonstrated that the intensive multifactorial intervention led to a greater weight loss and a significant improvement in CVD risk factors compared with the control group.CrossRefPubMedGoogle Scholar
  55. 55.
    Gaede P, Pedersen O: Multi-targeted and aggressive treatment of patients with type 2 diabetes at high risk: what are we waiting for? Horm Metab Res 2005, 37(Suppl 1):76–82.CrossRefPubMedGoogle Scholar
  56. 56.
    Gaede P, Valentine WJ, Palmer AJ, et al.: Cost-effectiveness of intensified versus conventional multifactorial intervention in type 2 diabetes: results and projections from the Steno-2 study. Diabetes Care 2008, 31:1510–1515.CrossRefPubMedGoogle Scholar
  57. 57.
    Hoerger TJ, Zhang P, Segel JE, et al.: Improvements in risk factor control among persons with diabetes in the United States: evidence and implications for remaining life expectancy. Diabetes Res Clin Pract 2009, 86:225–232.CrossRefPubMedGoogle Scholar
  58. 58.
    Leal J, Gray AM, Clarke PM: Development of life-expectancy tables for people with type 2 diabetes. Eur Heart J 2009, 30:834–839.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Swapnil N. Rajpathak
    • 1
  • Vikas Aggarwal
    • 1
  • Frank B. Hu
    • 2
  1. 1.Department of Epidemiology and Population Health, Albert Einstein College of MedicineNew YorkUSA
  2. 2.Departments of Nutrition and EpidemiologyHarvard School of Public HealthBostonUSA

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