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"Is Insulin Resistance A risk for Cardiovascular Disease? ''No''"

Dr. Amanda Adler (biography)
English - 2002-04-27 - 35 minutes
(51 slides)

Summary :
The many-fold increased risk of cardiovascular disease in diabetes results in cardiovascular disease being the most common complication in type 2 diabetes and the number one cause of death. Because of the association of type 2 diabetes with insulin resistance, it is logical to assess the association between insulin resistance per se and cardiovascular disease. Yet, insulin resistance appears to have more to do with the pathogenesis of type 2 diabetes than of cardiovascular disease in patients with diabetes. It is likely that factors associated with insulin resistance, i.e. the insulin resistance syndrome, rather than insulin resistance, accounts for the elevated risk of cardiovascular disease.

The notion of the association between insulin resistance and cardiovascular disease cannot be proven by studies which document an association to surrogates of cardiovascular disease, rather than cardiovascular disease itself, nor from cross-sectional studies in which implications of cause-and-effect blend. The lack of association between insulin resistance, even in univariate analyses in adequately powered studies, sheds doubt on the role of insulin resistance. The biological plausibility for factors associated with insulin resistance appear greater than those for insulin resistance. In studies in which insulin resistance has been associated with cardiovascular disease in prospective studies, the possibility of confounding remains. Not until prospective observational studies extricate the role of insulin resistance in the development of myocardial infarction and cardiovascular disease, can insulin resistance be considered culpable.

Learning objectives :
Insights into why insulin resistance syndrome, and not insulin resistance per se, is a risk for CVD.

Bibliographic references :
Epidemiology of the metabolic syndrome, 2002.

Meigs JB.

Harvard Medical School, General Medical Division, Massachusetts General Hospital, Boston, USA.

BACKGROUND: The close association of type 2 diabetes and atherosclerotic cardiovascular disease (CVD) suggests that they share a common physiologic antecedent, postulated to be tissue resistance to insulin. Insulin resistance is associated with a cluster of risk factors recognized as the metabolic syndrome. OBJECTIVE: To describe the epidemiology of the insulin resistance syndrome, also known as the metabolic syndrome.
METHODS: Overall obesity, central obesity, dyslipidemia characterized by elevated levels of triglycerides and low levels of high-density lipoprotein cholesterol, hyperglycemia, and hypertension are common traits that, when they occur together, constitute the metabolic syndrome. The World Health Organization and the National Cholesterol Education Program Adult Treatment Panel III have proposed working definitions for the syndrome based on these traits. Cross-sectional and longitudinal epidemiologic studies provide an emerging picture of the prevalence and outcomes of the syndrome.
RESULTS: National survey data suggest the metabolic syndrome is very common, affecting about 24% of US adults who are 20 to 70 years of age and older. The syndrome is more common in older people and in Mexican Americans. People with the syndrome are about twice as likely to develop CVD and over 4 times as likely to develop type 2 diabetes compared with subjects who do not have metabolic syndrome. While this syndrome may have a genetic basis, environmental factors are important modifiable risk factors for the condition. CONCLUSIONS: The metabolic syndrome is very common and will become even more common as populations age and become more obese. Treatment for component traits is known to reduce the risk for type 2 diabetes and CVD; whether risk is reduced by treatment of the syndrome, specifically, remains uncertain. Primary care physicians must recognize that the co-occurrence of risk factors for type 2 diabetes and CVD represents an extremely adverse metabolic state warranting aggressive risk factor intervention.

Am J Manag Care 2002 Sep;8(11 Suppl):S283-92; quiz S293-6


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