Showing papers by "Richard Kahn published in 2006"

Preventing Cardiovascular Disease and Diabetes A Call to Action From the American Diabetes Association and the American Heart Association

Abstract: Excess body weight has become a major public health problem in the U.S., with nearly two-thirds of adults either overweight or obese.1 The steady gain in the prevalence of obesity over the last 25 years has affected our entire population—no racial or ethnic group, no region of the country, and no socioeconomic group has been spared.2 Perhaps most worrisome is the observation that the rise in the rate of obesity has been greatest in children and minorities, which suggests that future generations of Americans, and our fastest growing populations, may bear the ultimate burden of this condition.3 Overweight or obesity results in a wide range of elevated risk factors and many fatal and nonfatal conditions.4 Paradoxically, although we have witnessed decades in which heart disease and stroke have steadily declined and cancer mortality has at worse remained stable,5 the prevalence of diabetes has soared.6 The increase in diabetes can largely be attributed to weight gain,7,8 and it threatens the enormous advances in disease prevention we have seen.3,9,10 Among individuals with diabetes, cardiovascular disease (CVD) is the leading cause of morbidity and mortality9,11; adults with diabetes have a two- to fourfold higher risk of CVD compared with those without diabetes.12,13 Diabetes is also accompanied by a significantly increased prevalence of hypertension and dyslipidemia.14 It is reasonable to postulate that in many individuals, excess weight gives rise to diabetes, hypertension, and dyslipidemia, thereby leading to frank CVD.15–17 This seemingly simple algorithm is undoubtedly more complex because (1) many studies …

Preventing Cardiovascular Disease and Diabetes A call to action from the American Diabetes Association and the American Heart Association

Abstract: Excess body weight has become a major public health problem in the U.S., with nearly two-thirds of adults either overweight or obese (1). The steady gain in the prevalence of obesity over the last 25 years has affected our entire population—no racial or ethnic group, no region of the country, and no socioeconomic group has been spared (2). Perhaps most worrisome is the observation that the rise in the rate of obesity has been greatest in children and minorities, which suggests that future generations of Americans, and our fastest growing populations, may bear the ultimate burden of this condition (3). Overweight or obesity results in a wide range of elevated risk factors and many fatal and nonfatal conditions (4). Paradoxically, although we have witnessed decades in which heart disease and stroke have steadily declined and cancer mortality has at worse remained stable (5), the prevalence of diabetes has soared (6). The increase in diabetes can largely be attributed to weight gain (7,8), and it threatens the enormous advances in disease prevention we have seen (3,9,10). Among individuals with diabetes, cardiovascular disease (CVD) is the leading cause of morbidity and mortality (9,11); adults with diabetes have a two- to fourfold higher risk of CVD compared with those without diabetes (12,13). Diabetes is also accompanied by a significantly increased prevalence of hypertension and dyslipidemia (14). It …

The Metabolic Syndrome (Emperor) Wears No Clothes

Abstract: There are several key features of the metabolic syndrome that virtually all interested individuals and organizations agree upon. First, that certain “metabolic” factors tend to associate with each other more often than chance would dictate. Second, these risk factors taken alone or in any possible combination are associated with an elevated risk for cardiovascular disease (CVD) and diabetes. Third, there is no definitive treatment for the “syndrome” per se. Rather, therapy is individualized according to the degree to which any specific risk factor(s) is present in a patient, and everyone with any risk factor(s) should be given lifestyle modification counseling. Finally, despite over 10,000 articles on the subject, there is much missing information. It is this last fact that has lead to the concern and consternation voiced by some organizations (1) and individuals (2–6). That is, the basic question is whether we know enough about this constellation of risk factors to warrant adopting a unique clinical construct that has value to either physicians or patients. After all, the fundamental purpose of a medical label (diagnosis) is to inform physicians and/or patients to take (or not take) action that would otherwise be different. In this issue of Diabetes Care (7) and recently elsewhere (8), Scott Grundy, MD, PhD, perhaps the chief proponent of the syndrome as a clinical construct, defends its existence with a variety of arguments. Although he suggests the basic disagreement is one of “differences in perspectives and biases [between the] cardiovascular and diabetes communities” (7) and that it may boil down to “how to integrate the metabolic syndrome into concepts of insulin resistance, pre-diabetes, and type 2 diabetes” (8), in fact, the issues are much more fundamental, speak to the lack of a solid evidence base, and raise concerns that are critical to a core premise …

Commentary on the Results and Clinical Implications of the PROactive Study

Abstract: T hiazolidinediones (TZDs), or glitazones, are a relatively new class of oral drugs that are used to treat type 2 diabetes.1-4 They lower blood glucose by targeting insulin resistance, one of the major underlying causes of the disease. In addition to their ability to lower blood glucose, TZDs also display a wide range of effects on lipids, blood pressure, weight, and other cardiovascular and metabolic risk factors. As with all other drugs, they can be associated with undesirable side effects. By virtue of their glucose-lowering properties, all such agents will significantly reduce the risk of the microvascular complications associated with diabetes. On the other hand, no glucose-lowering agent has clearly been shown to significantly reduce macrovascular disease. Since TZDs, in general, have a net favorable impact on blood lipid levels, may be associated with a reduction in blood pressure, and have positive effects on other physiological parameters associated with vascular disease (e.g., decreasing vascular inflammation, reducing insulin resistance), they have the potential to slow the progression of cardiovascular disease (CVD) in addition to lowering blood glucose. Because of the above favorable actions of TZDs, the Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) was initiated to assess the effects of pioglitazone (Actos; Takeda Pharmaceuticals and Eli Lilly) on the secondary prevention of macrovascular events in type 2 diabetic patients. PROactive was a randomized, double-blind, placebo-controlled study in 5,238 patients with type 2 diabetes who were managed with diet and/or glucose-lowering medications and who had a history of macrovascular disease.5 Male or female patients, aged 35-75 years, were randomized to receive placebo or pioglitazone titrated over 2 months to its maximally approved dosage (45 mg/day). Because study participants had preexisting CVD and diabetes of long duration (average 8 years), virtually all subjects at the time of enrollment …

The Metabolic Syndrome: Time for a Critical Appraisal: Joint Statement From the American Diabetes Association and the European Association for the Study of Diabetes: Response to Citrome et al., Giugliano and Esposito, Cheţa, and Psaty et al.

Abstract: Citrome et al. (1) seem to agree with our review (2) of all the shortcomings associated with the metabolic syndrome, yet they claim it is somehow still an aid in identifying risk factors and in the “ongoing education of practitioners,” both of which may improve health care. This seems perplexing because what must occur prior to making the “diagnosis” is knowledge of the components, and thus, a priori, the provider must be familiar with the cardiovascular disease (CVD) risk factors that comprise the concept and that the factors must be monitored. Moreover, many other CVD risk factors (e.g., LDL …

The Metabolic Syndrome (Emperor) Wears No Clothes: Response to Oda

Abstract: The possible inclusion of C-reactive protein (CRP) in the metabolic syndrome algorithm highlights the problems of the construct itself. If the syndrome is supposed to be a predictive tool for future cardiovascular events, then we should …