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Risks of Intensive Management of NIDDM: The Insulin Hypothesis |

Do Non-Insulin-dependent Diabetes Mellitus and Cardiovascular Disease Share Common Antecedents?

Michael P. Stern, MD
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From the University of Texas Health Science Center, San Antonio, Texas. For the current author address, see end of text. Note: This article is one of a series of articles comprising an Annals of Internal Medicine supplement entitled “Risks and Benefits of Intensive Management in Non-Insulin-dependent Diabetes Mellitus: The Fifth Regenstrief Conference.” To view a complete list of the articles included in this supplement, please view its Table of Contents. Requests for Reprints: Michael Stern, MD, Department of Medicine, University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78284.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1996;124(1_Part_2):110-116. doi:10.7326/0003-4819-124-1_Part_2-199601011-00006
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Recent evidence suggests that non–insulin-dependent diabetes mellitus (NIDDM) and cardiovascular disease, rather than being related as underlying disease and complication, share common genetic and environmental antecedents, that is, they “spring from the same soil.” Fetal and early-life nutritional deficiencies appear to predispose persons to both NIDDM and cardiovascular disease in later life. The insulin resistance syndrome, including abdominal obesity, may constitute the intermediate link between fetal and early-life nutritional deficiency and later disease. The insulin resistance syndrome includes insulin resistance, hyperinsulinemia, abdominal obesity, dyslipidemia with high triglyceride and low high-density lipoprotein cholesterol levels, and hypertension. Each element of the insulin resistance syndrome has been firmly established as a risk factor for development of diabetes. In addition, most of these elements are also well-recognized cardiovascular risk factors, although the weight of evidence now suggests that hyperinsulinemia itself is not. This last point is significant because of concern that aggressive insulinization of diabetic patients, which has been proved to reduce microvascular complications, might paradoxically increase the risk for large-vessel atherosclerosis. Available clinical trials suggest that this fear is unwarranted, but definitive trials are needed to resolve this important clinical question.

Figures

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Figure 1.
Prevalence of the insulin resistance syndrome by ethnicity and tertile of birth weight in 562 patients from the San Antonio Heart Study.

The insulin resistance syndrome is defined as two or more of the following: hypertension; diabetes or impaired glucose tolerance; high triglyceride level (> 2.8 mmol/L); or low high-density lipoprotein cholesterol level (< 0.9 mmol/L). (From reference 7 with permission.).

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Figure 2.
Schema for the “common soil” hypothesis for NIDDM and cardiovascular disease.
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