A weighty problem

If only we could do for diabetes what we have done in the past decade for hyperlipidemia. Statins have made this problem at least treatable in most patients. One pill drops low-density lipoprotein cholesterol levels and reduces the risk of cardiovascular events. Where are the pills to reduce the risk of cardiovascular events (CVEs) in patients with diabetes or enhance weight loss in patients prone to developing diabetes?

The study by Levantesi and colleagues analyzed the Gruppo Italiano por lo Studio della Sopravvivenza nell’Infarto Mio­cardico (GISSI-Prevenzione) trial database, as­sessed the prevalence and the prognostic role of the metabolic syndrome (METS), and studied diabetes in patients with previous myocardial infarction (MI).¹ Amazingly, 50% of patients enrolled in the study had either type 2 diabetes or METS. Both groups had a higher risk of death and CVEs compared with a control population over 3.5 years of follow-up. Diabetic patients, however, were more likely to be hospitalized for congestive heart failure and to die during the last 2.5 years of follow-up, which suggests diabetes prevention would be life-saving in post-MI patients.

Weight becomes critical in patients with METS. Those who gained weight had a significant risk of developing diabetes; those who lost weight had a significantly lower risk. Independently, weight change did not show any significant effect on the risk of CVEs. Weight loss may be too little, too late or the follow-up time may not have been long enough to accurately evaluate its benefit on CVEs, but the reduction in the incidence of diabetes should be enough stimulus for patients and clinicians to aggressively address.

Weight loss is not easy. It often involves major lifestyle changes in diet and exercise, and it is even more difficult to maintain achieved weight loss. The success of the current lipid-lowering campaign is entirely due to the ability to treat patients pharmaceutically with once-a-day medications that have little-to-no side effects. Would weight loss be so easy? The closest thing to successful pharmacologic therapy for weight loss, fen-phen, was removed from the market in 1997 when serious side effects came to light.² So until the next great pharmaceutical breakthrough, we must engage patients in dietary changes that require significant willpower and motivation.

Primary and even secondary reduction in CVEs would seem to be a powerful incentive, but it didn’t work for lipids in the era before statins. Reduction in the development of diabetes may prove to be an easier sell. Enough studies have shown the association between METS and multiple bad outcomes that if Root Boy Slim were still alive, he might revise his little ditty³: Dare to be fat, Fat’s where it’s at, Having a ball with cholesterol, C’mon y’all, Fat don’t matter at all!

Sorry, it does matter. In fact, it is a matter of life and death.