Cardiovascular disease down in diabetics

Experts suspect this finding may be the result of more aggressive medical care but expressed caution because not all reasons for this trend may be healthy.

By Victoria Stagg Elliott — Posted Nov. 26, 2007

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The percentage of adults with diabetes who say they also have cardiovascular disease has declined since 1997, according to a paper published in the Nov. 2 Morbidity and Mortality Weekly Report.

Researchers analyzed data collected by the Centers for Disease Control and Prevention's National Health Interview Survey and found that the rate of CVD in this patient population, which is estimated to include 21 million people, had declined from 36.6% in 1997 to 32.5% in 2005.

"These findings are certainly encouraging. We need to continue our efforts to prevent cardiovascular disease with renewed energy and commitment now that we're seeing this trend," said Nilka Rios Burrows, MPH, lead author and an epidemiologist at the CDC's Division of Diabetes Translation.

Physicians and public health policymakers hope that this observation represents a true reduction in the disease that causes 65% of the deaths among patients with diabetes.

If it is real, these numbers may indicate that all the prescriptions for drugs to lower blood pressure and cholesterol as well as recommendations for aspirin therapy -- both of which are included in so many guidelines -- are starting to pay off.

"Doctors are being more proactive in managing diabetes. Patients are getting that it's a serious condition and that they need to take care of it," said John Buse, MD, PhD, the American Diabetes Assn.'s president for medicine and science.

The finding also may be the result of better self-care on the part of patients. Another paper in the same MMWR analyzed data from the Behavioral Risk Factor Surveillance System and concluded that 63.4% of all adults with diabetes checked their blood sugar at least once daily in 2005. This tally represented a significant increase from the 40.6% found in 1997 and exceeded the Healthy People 2010 target of 61%.

"People are taking better advantage of a tool that can aid in making critical decisions about how to treat their diabetes," said Dr. Liping Pan, lead author on that paper and a CDC health scientist.

The other views

Many who work in this area, though, also suggest that these numbers may not be all good news. The cardiovascular disease rate declined for adults older than 35 but not across all demographic groups.

African-Americans had the most dramatic decrease, from 36.3% to 27.1%. But no statistically significant drop was recorded for those age 65 to 74, men and Caucasians. And, although the percentage of those with diabetes who have cardiovascular disease has gone down, the actual size of this population has grown -- a development attributed to the aging of the population and increasing rates of obesity.

Some experts also suggest that the reduction in this percentage may not necessarily represent a true change in the number of people with diabetes who have cardiovascular damage. Rather, it may be a reflection of the push for earlier diagnosis of diabetes.

"It could be that patients are getting the message and taking care of business and doctors are being more aggressive," said Dr. Buse, who is also a professor of medicine and division chief of endocrinology at the University of North Carolina School of Medicine in Chapel Hill. "Alternatively, it might be because we're screening for diabetes and actually detecting it early, when a patient is less likely to have cardiovascular disease."

Other physicians expressed doubts about the accuracy of these numbers, because this study assessed the rate of cardiovascular disease based on survey answers unconfirmed by medical testing. People who said they didn't have cardiovascular disease still may have it but not know it.

"I'm encouraged in that it's possible that there may actually be less symptomatic heart disease. This study suggests that, but doesn't prove that. The weakness of the study is that it's self-reported. Most diabetes patients will have some evidence of coronary heart disease if you look hard enough," said Richard Hellman, MD, president of the American Assn. of Clinical Endocrinologists.

More concerns stemmed from the data regarding blood glucose self-monitoring. The increase is being explained by the fact that testing equipment has become technologically more convenient and most insurers cover it.

Those who treat diabetes say that, although the numbers indicate that more people with diabetes are checking their blood sugar every day, this pattern does not necessarily mean that these patients are doing what they need to. Some patients do not need to self-monitor that often, but others should be testing more than once a day. This necessity is particularly important for those on insulin. About 86.7% of these patients check their blood sugar at least once a day, and many experts say this percentage is not high enough.

"More people are doing some monitoring, but this doesn't tell us if they're monitoring appropriately or if the right people are monitoring," said Robert Rushakoff, MD, who is a clinical professor of medicine in the Division of Endocrinology and Metabolism at the University of California, San Francisco.

In addition, this paper found that a level of education beyond a high school diploma, health insurance, regular doctor visits and diabetes-specific education increased the chance that a patient would check their blood sugar regularly. Being male reduced that chance.

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Progress against No. 1 killer of diabetics

Public health officials and physicians are cautiously optimistic because the percentage of diabetics who also have cardiovascular disease has declined, even though the actual numbers of those who have both conditions have grown, according to a Centers for Disease Control and Prevention analysis of data from a National Health Interview Survey.

The trend for diabetes and cardiovascular disease:

Diabetics age 35+ with CVD Age-adjusted prevalence
1997 4.2 million 36.6%
1998 4.1 million 35.8%
1999 4.2 million 34.2%
2000 4.5 million 33.9%
2001 4.9 million 34.0%
2002 5.2 million 34.2%
2003 5.2 million 33.0%
2004 5.6 million 32.8%
2005 5.7 million 32.5%

Source: Morbidity and Mortality Weekly Report, Nov. 2

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External links

"Self-Monitoring of Blood Glucose Among Adults with Diabetes -- United States, 1997-2006," Morbidity and Mortality Weekly Report, Nov. 2 (link)

"Prevalence of Self-Reported Cardiovascular Disease Among Persons Aged ≥ 35 Years with Diabetes -- United States, 1997-2005," MMWR, Nov. 2 (link)

Diabetes, American Medical Association's Minority Affairs Consortium (link)

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