Correspondence
Multifactorial Intervention and Mortality in Type 2 Diabetes
N Engl J Med 2008; 358:2292-2293May 22, 2008
- Article
To the Editor:
In their article on aggressive multiagent treatment of risk factors for diabetic complications, Gæde et al. (Feb. 7 issue)1 comment that there were no differences in smoking status between the intensive-therapy and conventional-therapy groups. Because smoking is such an important and preventable cause of diabetic complications, it would be important to know the actual rates of smoking in the two study groups, whether smoking-cessation treatments were provided in either group, whether these interventions were similar in the two groups or more intensive in the intensive-therapy group, and whether there were any differences in the percentages of smokers who were able to quit. To achieve the best possible outcomes, aggressive tobacco-cessation treatment should be a core component of intensive diabetes care.
1 ReferencesSteven A. Schroeder, M.D.
University of California, San Francisco, San Francisco, CA 94143-1211
schroeder@medicine.ucsf. edu 1
Gaede P ,Lund-Andersen H ,Parving H-H ,Pedersen O . Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358:580-591
Full Text | Web of Science | Medline
To the Editor:
Reduction of glycated hemoglobin values to the range of 7.0 to 7.9% has been associated with reduced cardiovascular events in both type 1 and type 2 diabetes.1 A large study with a goal of lowering glycated hemoglobin levels to less than 6.0% was recently stopped because of higher mortality in the group of patients randomly assigned to receive strict blood glucose control.2 The median glycated hemoglobin level was 6.4% in the strict-control group and 7.5% in the standard-care group. Although an increase in cardiovascular events has not been observed in the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial, the goal for glycated hemoglobin was less than 6.5%, not less than 6.0%, as in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. A reduction in the low-density lipoprotein cholesterol level to 83 mg per deciliter, a reduction in blood pressure to 131/73 mm Hg, and an average glycated hemoglobin level of 7.9% after the first 8 years of the study had widespread cardiovascular benefits. The improved lipid levels and blood pressure seem to be the most important factors for reducing cardiovascular risk. Did Gæde et al. observe any association between the number of hypoglycemic events and the number of cardiovascular events?
2 ReferencesJohn A. Tayek, M.D.
Harbor–UCLA Medical Center, Torrance, CA 90509
jtayek@ladhs.org 1
The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group
Full Text | Web of Science | Medline2
Action to Control Cardiovascular Risk in Diabetes. ACCORD study announcement. (Accessed April 22, 2008, at http://www.accordtrial.org/web/public/index.cfm.)
Author/Editor Response
We have previously published results regarding lifestyle interventions in the Steno-2 Study.1 At baseline, 40% of patients in the intensive-therapy group, as compared with 35% in the conventional-therapy group, were smokers. In the intensive-therapy group, structured smoking-cessation programs with consultations in groups of up to 14 patients (spouses included) were carried out throughout the follow-up period. Nicotine substitution was offered without cost to all participants. No structured programs were offered to the patients in the conventional-therapy group. At the end of the 7.8-year intervention trial, six patients in the intensive-therapy group had stopped smoking, as compared with five in the conventional-therapy group, and none of the patients in the conventional-therapy group had participated in any structured program. During the observational part of the study, there was a further decrease in the number of smokers in both groups; 22% of patients in the intensive-therapy group were smokers at the end of follow-up, as compared with 18% in the conventional-therapy group. However, these numbers are blurred by the large number of deaths among participants. We agree with Dr. Schroeder that smoking cessation is of utmost importance in the treatment of diabetes. Yet even structured smoking-cessation programs, as used in the Steno-2 Study, appear to achieve, at best, modest results. A more efficient approach, which might benefit the larger community, not only people with type 2 diabetes, might be to increase bans on smoking in public areas.2
Dr. Tayek points out the potential risk of an association between hypoglycemic events and mortality. We did not see such an association in the Steno-2 Study. On the contrary, a significant association between symptomatic hypoglycemia and reduced risks of both total and cardiovascular-related deaths was observed in the conventional-therapy group. A nonsignificant trend was seen in the intensive-therapy group. This was the case even for a reduction in total mortality among patients with major hypoglycemic episodes (P=0.075).
2 ReferencesPeter Gæde, M.D., D.M.Sc.
Hans-Henrik Parving, M.D., D.M.Sc.
Oluf Pedersen, M.D., D.M.Sc.
Steno Diabetes Center, 2820 Copenhagen, 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
Cesaroni G ,Forastiere F ,Agabiti N ,Valente P ,Zuccaro P ,Perucci CA . Effect of the Italian smoking ban on population rates of acute coronary events. Circulation 2008;117:1183-1188
CrossRef | Web of Science | Medline
