Correspondence
Multifactorial Intervention and Cardiovascular Disease in Type 2 Diabetes
N Engl J Med 2003; 348:1925-1927May 8, 2003
- Article
To the Editor:
Gæde et al. (Jan. 30 issue)1 unintentionally demonstrate that for many patients, treatment of type 2 diabetes amounts to benign neglect. This is illustrated by the absence of a meaningful reduction in glycosylated hemoglobin, total cholesterol, or systolic blood pressure in the conventionally treated group over the eight-year duration of the trial.
The management of many aspects of type 2 diabetes should be straightforward. For some time, effective drugs have been available, with strong evidence that should support their use.2-4 This information has been widely disseminated, particularly within the diabetes community. Yet in a country with universal health coverage and in a study in which two thirds of the patients were referred to diabetes specialists, these interventions were not used. This is puzzling, but the study clearly demonstrates the huge benefits that would accrue if diabetes specialists were to move from their traditional role as archivists of the complications of a chronic disease to a new, more challenging role as therapeutic interventionists.
4 ReferencesSuliman A. Ahmed, M.B., M.R.C.P.I.
Diarmuid Manning, M.B., M.R.C.P.I.
Colm McGurk, M.D., M.R.C.P.
St. Luke's Hospital, Kilkenny, Ireland
colmt_mcgurk@lineone.net 1
Gaede P ,Vedel P ,Larsen N ,Jensen GVH ,Parving H-H ,Pedersen O . Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383-393
Full Text | Web of Science | Medline2
UK Prospective Diabetes Study (UKPDS) Group
CrossRef | Web of Science | Medline3
UK Prospective Diabetes Study (UKPDS) Group
CrossRef | Web of Science4
Pyorala K ,Pedersen TR ,Kjekshus J ,Faergeman O ,Olsson AG ,Thorgeirsson G . Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease: a subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care 1997;20:614-620[Erratum, Diabetes Care 1997;20:1048.]
CrossRef | Web of Science | Medline
To the Editor:
I disagree with the contention of Gæde et al., reiterated in the accompanying editorial,1 that the different interventions most responsible for the reduction in cardiovascular events could not be determined. Since there was no weight loss or increase in minutes of exercise per week in either the conventional-therapy group or the intensive-therapy group, diet and exercise could not have accounted for the difference in outcomes. Likewise, the modest decrease in the number of smokers was similar in the two groups. In contrast to this absence of difference in lifestyle variables was the markedly higher use of medications in the intervention group, leading to superior control of blood sugar, blood pressure, and cholesterol, as well as greater aspirin use.
Recommending a change in lifestyle is politically correct, but therapeutically, it is an exercise in futility. High-risk patients need to have more medications prescribed and be persuaded to take them. Too many patients regard drugs as dangerous chemicals instead of the relatively safe and beneficial substances we know them to be.
1 ReferencesMayer M. Bassan, M.D.
Clalit Health Services, Jerusalem 94110, Israel
yoedba@hotmail.com 1
Solomon CG . Reducing cardiovascular risk in type 2 diabetes. N Engl J Med 2003;348:457-459
Full Text | Web of Science | Medline
Author/Editor Response
Ahmed et al. point out the unsuccessful treatment of risk factors in the conventional-therapy group during the trial, despite national treatment guidelines with well-defined goals and despite universal health coverage in Denmark. This clearly demonstrates that the main challenge in the care of patients with type 2 diabetes today is continued education and motivation of both the physician and the patient. Any hint of therapeutic nihilism should be resisted.
A reduction in the incidence of late diabetic complications through the implementation of lifestyle education as a sole treatment has never been demonstrated in type 2 diabetes, yet it is recommended as part of the “therapeutic package.” As Dr. Bassan points out, there was no weight loss with intensive therapy, nor was the increase in weekly exercise time greater in the intensive-therapy group than in the conventional-therapy group. The only measured differences in lifestyle between the two groups were in the intake of daily calories from fat and in the proportion of saturated and unsaturated fatty acids. The limited effect of lifestyle education is in accordance with what we previously reported on the basis of the first four years of the Steno-2 Study.1 However, it should be emphasized that the intensive-therapy group was prescribed a diet with considerably more vegetables and fish than was the conventional-therapy group and that these foods may have beneficial effects on cardiovascular end points, beyond those measured as changes in, for instance, energy intake or serum lipids. Thus, diets that are naturally high in n–3 fatty acids, α-linolenic acid, and flavonoids have proved beneficial for the secondary prevention of cardiovascular disease, even though no effects were seen on traditional markers of risk, such as serum lipids and blood pressure.2,3
Because the Steno-2 Study was not designed to compare various kinds of interventions, we cannot rule out the possibility that even minor changes in lifestyle may have had an effect on the overall outcome of the trial. However, given the available scientific evidence, we completely agree that high-risk patients with type 2 diabetes in whom treatment goals are not reached should continuously be motivated to adhere to a tailored and relevant regimen of polypharmacy; this is a sine qua non.
3 ReferencesPeter Gæde, M.D.
Hans-Henrik Parving, M.D., D.M.Sc.
Oluf Pedersen, M.D., D.M.Sc.
Steno Diabetes Center, 2820 Gentofte, Denmark
oluf@steno.dk 1
Gaede P ,Beck M ,Vedel P ,Pedersen O . Limited impact of lifestyle education in patients with Type 2 diabetes mellitus and microalbuminuria: results from a randomized intervention study. Diabet Med 2001;18:104-108
CrossRef | Web of Science | Medline2
de Lorgeril M ,Renaud S ,Mamelle N , et al. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet 1994;343:1454-1459[Erratum, Lancet 1995;345:738.]
CrossRef | Web of Science | Medline3
Lemaitre RN ,King IB ,Mozaffarian D ,Kuller LH ,Tracy RP ,Siscovick DS . n-3 Polyunsaturated fatty acids, fatal ischemic heart disease, and nonfatal myocardial infarction in older adults: the Cardiovascular Health Study. Am J Clin Nutr 2003;77:319-325
Web of Science | Medline
