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Lettere-Letters: Comments and Responses
Open Access

Comment on Cheng et al. Trends and Disparities in Cardiovascular Mortality Among U.S. Adults With and Without Self-Reported Diabetes, 1988–2015. Diabetes Care 2018;41:2306–2315

Valeria Manicardi, Massimo Vicentini, Paola Ballotari, Francesco Venturelli, Paolo Giorgi Rossi
DOI: 10.2337/dc18-2175 Published 1 April 2019
Valeria Manicardi
Diabetes Registry, Azienda Unità Sanitaria Locale – IRCCS Reggio Emilia, Reggio Emilia, Italy
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Massimo Vicentini
2Epidemiology Unit, Azienda Unità Sanitaria Locale – IRCCS Reggio Emilia, Reggio Emilia, Italy
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  • ORCID record for Massimo Vicentini
  • For correspondence: massimo.vicentini@ausl.re.it
Paola Ballotari
3Osservatorio Epidemiologico, ATS Val Padana, Mantua, Italy
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Francesco Venturelli
2Epidemiology Unit, Azienda Unità Sanitaria Locale – IRCCS Reggio Emilia, Reggio Emilia, Italy
4Specialization School of Hygiene and Preventive Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
5Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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Paolo Giorgi Rossi
2Epidemiology Unit, Azienda Unità Sanitaria Locale – IRCCS Reggio Emilia, Reggio Emilia, Italy
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We read with great interest the recently published article by Cheng et al. (1). The authors note that there was a dramatic increase in prevalence (age-standardized) between the 1980s and 2010 (3% and 9%, respectively) in the population with diabetes compared with the population without, along with a decrease in the excess risk of cardiovascular disease (CVD). The authors attribute this excess risk reduction to an improvement in primary and secondary diabetes care.

However, it must be remembered that the diabetes diagnostic criteria have changed over the years. In 1997, the fasting blood glucose threshold for diagnosis went from 140 to 126 mg/dL, precisely in view of the increased risk of CVD in patients with blood glucose levels between 126 and 140 mg/dL (2). This change, combined with more frequent screening in the population at an ever-younger age (3) and greater disease awareness in the population (4), means that self-reported diabetes no longer describes the same disease described in the 1980s.

This phenomenon implies not only that some individuals with diabetes in the 1980s were included in the healthy population (which mathematically has a minimal impact on the CVD incidence comparison between the population with and without diabetes, as the authors rightly note in their discussion of the study’s limitations), but mainly that the population with diabetes in the 1980s suffered from much more severe disease (the relationship between blood glucose level and cardiovascular risk showed a dose-response effect). Diabetes was also usually diagnosed later, and therefore patients were at higher risk of complications, as demonstrated by the phenomenon of “legacy” (metabolic memory) (5), than was the case with diabetes diagnosed in the 2000s.

The change in definition and the increased ability to diagnose this condition at least partially justify the dramatic prevalence increase, which is probably also due to a real increase in diabetes and its causes, such as obesity. These changes also justify the reduction of excess risk through a dilution effect of the denominator of the population with diabetes, which progressively includes people with lower blood glucose levels and a shorter duration of prediagnosis disease and therefore less risk. Nevertheless, the change in diagnostic criteria and the increase in diagnosis of a subgroup of the population with diabetes with fewer complications do not impact the reduction of the cardiovascular risk gap between women and men in this population, compared with the gap existing in the general population. The main findings of Cheng et al. are thus valid and worth investigating further to understand underlying mechanisms.

Article Information

Acknowledgments. The authors thank Jacqueline Costa for language editing.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

  • © 2019 by the American Diabetes Association.
http://www.diabetesjournals.org/content/license

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.

References

    1. Cheng YJ,
    2. Imperatore G,
    3. Geiss LS, et al
    . Trends and disparities in cardiovascular mortality among U.S. adults with and without self-reported diabetes, 1988–2015. Diabetes Care 2018;41:2306–2315
    1. Scandinavian Simvastatin Survival Study Group
    . Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–1389
    1. Siu AL; U.S. Preventive Services Task Force
    . Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163:861–868
    1. Zhang N,
    2. Yang X,
    3. Zhu X,
    4. Zhao B,
    5. Huang T,
    6. Ji Q
    . Type 2 diabetes mellitus unawareness, prevalence, trends and risk factors: National Health and Nutrition Examination Survey (NHANES) 1999–2010. J Int Med Res 2017;45:594–609
    1. Laiteerapong N,
    2. Ham SA,
    3. Gao Y, et al
    . The legacy effect in type 2 diabetes: impact of early glycemic control on future complications (the Diabetes & Aging Study). Diabetes Care 2019;42:416–426

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© 2021 by the American Diabetes Association. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548.