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Vol. 68. Issue 2.
Pages 151-153 (February 2015)
Scientific letter
DOI: 10.1016/j.rec.2014.09.006
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Obesity and Vascular Events in Type 2 Diabetes Mellitus
Obesidad y episodios vasculares en la diabetes mellitus tipo 2
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Claudia Mill??n Longo, Marta Garc??a Montero, Daniel Tebar M??rquez, Luis Beltr??n Romero, Jos?? R. Banegas, Juan Garc??a Puig
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juangarciapuig@gmail.com

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Servicio de Medicina Interna, Unidad Metab??lico-Vascular, Hospital Universitario La??Paz, Madrid, Spain
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Table. Characteristics of Obese and Normal-Weight Patients With Type 2 Diabetes Mellitus
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To the Editor,

Obesity is a vascular risk factor implicated in the pathogenesis of type 2 diabetes mellitus (DM2). There has been some debate about whether obesity in patients with DM2 is associated with greater1 or less2 mortality with respect to patients of normal weight with DM2 (the obesity paradox in DM2). In principle, the association between body mass index (BMI) and mortality could be mediated by vascular risk factors, target organ lesions, and vascular events, although we are not aware of studies that have investigated these variables in patients with DM2 and different BMIs. We compared the frequency of vascular events and their associated factors in obese patients with DM2 and those of normal weight with DM2.

This was an observational study conducted in the outpatient clinic of the Metabolic-Vascular Unit of La Paz University Hospital, Madrid, Spain in 2013. We selected all patients with DM2 (according to the American Diabetes Association criteria) attended at least once in the calendar year with a full clinical work-up. Patients had to have a BMI of 30 kg/m2 or more (obesity) or less than 25kg/m2 (normal weight). Weight and height were measured during the first appointment of the year using a height rod and digital scales, calibrated every 6 months (AENOR quality control, UNE-EN ISO 9001 standard). Height was measured to the nearest centimeter and weight was measured in kilograms to 1 decimal place, with the patient wearing no coat, jacket, or shoes. We recorded demographic variables, vascular risk factors, target organ lesions, cardiovascular events, laboratory data, and DM-related treatments, according to the criteria defined in the REACH study,3 which included patients from Spain. Glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.

For qualitative variables, the 2 groups, obese and normal-weight patients, were compared with the Pearson chi-square test using a continuity correction or the Fisher exact test when the number of measurements in the sample was small. The Student t test for independent samples was used for quantitative variables. The relationship between events in the 2 BMI groups, adjusted for age, sex, smoking, and blood pressure, was studied with binomial logistic regression. P < .05 was considered statistically significant.

Overall, 94 patients with DM2 were included: 79 with BMI of 30kg/m2 or more and 15 with BMI less than 25kg/m2 (Table). The number of patients with at least 1 vascular event was significantly higher among obese patients (n = 29 [37%]) compared with normal-weight patients (n = 1 [7%], P = .032). Most of the vascular events affected the heart (ischemic heart disease or heart failure, 18/30 patients [60%]). On multivariate analysis, the association between obesity and vascular events remained significant (P = .035). Despite a shorter duration of diabetes (P < .05), a greater proportion of obese patients had hypertension (P = .043) than normal-weight patients. A greater proportion of obese patients had left ventricular hypertrophy (P = .004), metabolic syndrome, and chronic stage III renal failure (glomerular filtration rate of 30-60mL/min/1.73 m2; P = .042).

Table.

Characteristics of Obese and Normal-Weight Patients With Type 2 Diabetes Mellitus

  All  DM2+obesity (BMI ≥ 30.0 kg/m2DM2+normal weight (BMI < 25.0 kg/m2Pa 
Patients included  94  79 (84)  15 (16)   
Age, mean (SD), y  65 (10)  65 (10)  64 (10)  .812 
Male  64 (68)  56 (71)  8 (53)  .229 
Duration of DM2, mean (SD), mo  96 (98)  107 (98)  139 (98)  <.05 
Vascular risk factors         
Smoker  13 (14)  10 (13)  3 (20)  .452 
Hypertension  87 (93)  75 (95)  12 (80)  .043 
Dyslipidemia  71 (76)  59 (75)  12 (80)  .661 
Metabolic syndrome  80 (85)  72 (91)  8 (53)  .001 
Organ damage         
LVH  27 (30)b  27 (37)c  .004 
Microalbuminuria  24 (26)d  21 (27)e  3 (20)  .752 
GFR < 60 mL/min/1.73 m2  26 (28)f  25 (33)g  1 (7)  .042 
Patients with vascular event  30 (32)h  29 (37)  1 (7)  .022 
Cerebrovascular event  10  10  .001 
Cardiac event  18  18  .001 
Coronary event  14  14  .001 
Heart failurei  10  10  .001 
Kidney failure  10  10  .002 
Peripheral artery disease  1j  .850 
Number of events per patient (all), mean (SD)  0.6 (1.0)  0.7 (1.1)  0.1 (0.5)  .006 
Physical examination         
BMI, mean (SD)  32 (5)  33.5 (3.5)  23.5 (1.3)  <.001 
SBP, mean (SD), mmHg  136 (14)  137 (13)  134 (16)  .513 
DBP, mean (SD), mmHg  79 (9)  80 (9)  75 (9)  .030 
Laboratory analysis         
Glucose, mean (SD), mg/dL  149 (48)  146 (46)  160 (57)  .292 
HbA1c, mean (SD), %  6.9 (1.1)  6.9 (1.1)  7.1 (1.1)  .446 
Cholesterol, mean (SD), mg/dL  170 (44)  170 (45)  173 (42)  .809 
Triglycerides, mean (SD), mg/dL  176 (115)  185 (122)  126 (47)  .070 
HDL-C, mean (SD), mg/dL  46 (12)  45 (12)  51 (11)  .094 
LDL-C, mean (SD), mg/dL  98 (35)  97 (34)  100 (41)  .795 
Non-HDL cholesterol, mean (SD), mg/dL  124 (44)  125 (44)  122 (42)  .843 
Treatments         
Insulin  20 (21)  16 (20)  4 (27)  .731 
Oral antidiabetic agents  80 (85)  70 (89)  10 (67)  .029 
Antihypertensives  81/87 (93)  70/75 (93)  11/12 (92)  .990 
Two or more drugs  63/87 (72)  58/75 (77)  5/12 (42)  .038 
Lipid-lowering agents  87 (93)  72 (91)  15 (100)  .231 

BMI, body mass index; DBP, diastolic blood pressure; DM2, type 2 diabetes mellitus; GFR, glomerular filtration rate; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; LVH, left ventricular hypertrophy; SBP, systolic blood pressure.

a

Comparison between obese patients with DM2 and normal-weight patients with DM2.

b

Of the 87 patients with hypertension.

c

Measured in 70 out of 75 patients with hypertension.

d

Measured in 93 out of 94 patients.

e

Measured in 78 out of 79 patients.

f

Measured in 92 out of 94 patients.

g

Measured in 77 out of 79 patients.

h

Sum of vascular events is > 30 because some patients had more than 1 event.

i

Of the 10 patients with heart failure, the cause was ischemic in 6 and nonischemic in 4.

j

Only 1 patient with normal weight had chronic renal failure and peripheral artery disease.

Unless otherwise indicated, the data are expressed as No. (%).

In the study, obese patients with DM2 had a higher frequency of vascular events than normal-weight patients with DM2, as well as a higher frequency of hypertension and target organ lesions. In more than half the patients with a vascular event, the heart was affected (60%) and all these patients were obese. The association between obesity and vascular events was maintained in the multivariate analysis. This finding does not support the concept of the obesity paradox in DM21,2 (apparent benefit of obesity). The study was designed to verify whether the worse prognosis of obese patients with DM2 compared with patients with normal weight1 was associated with a greater frequency of risk factors, organ damage, and vascular events. As such, the results cannot be extrapolated to all patients with DM2, given that this was not a population-based sample.

Among the study strengths, we highlight that the diagnosis of DM2 and target organ involvement, as well as assessment of the vascular events, were assessed by the same team, based on written medical records according to accepted criteria.3 Moreover, the characteristics of our series are very similar to those of other populations from different autonomous regions of Spain (mean age, 67 years; frequency of vascular events, 32%).4–6 Among the study limitations, we should highlight that we analyzed a case series, with all patients available in the clinic during 1 year. Despite the small sample size, the results help to stress that obesity in patients with diabetes is associated with vascular events and that these may be associated with hypertension and its complications, especially in the case of cardiac events.

FUNDING

Health Research Grant from the Instituto de Salud Carlos III (FIS, 08/0009 and 11/0598), and the Spanish Primary Care Network (2009/70) and RECAVA (RD/12/0042/0024).

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Copyright © 2014. Sociedad Española de Cardiología
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Revista Española de Cardiología (English Edition)

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