Re: Diabetic women at a higher risk of dying

"glass318" <glass318@xxxxxxxxx> wrote in message
news:1185847441.858160.47050@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
A recent cohort study using NHANES I,II, and III data has unearthed
what seems to be a very disturbing trend for diabetic women. To be
published in the August 7th issue of the "Annals of Internal Medicine".

Hi glass318,
thank you for drawing attention to this article.
A very interesting and an intruiging problem I would say.

I would like to make a few things explicit first ,if you don't mind.

Science....
This is how it works :

1) Read all experiments on your subject.

2) Put them all in your mind AT THE SAME TIME so that you can consider them
ALL AT THE SAME TIME and make a logical explanation , hypothesis ,that
includes as many facts from ALL the experiments as possible.We are only
human ,all facts is generally not possible :(

3)Try to design a new experiment that proves that your current hypothesis is
WRONG.Or try to design an experiment that does a logical PREDICTION of a NEW
FACT that has not yet experimentally been verified.

4)Restart at 1) not depending on what your results are

So from this a number of things follow logically.Frequently it is noticed
here in asd that : "for any experiment you can find an experiment that finds
the exact opposite" . Yes of course :

1) You must not consider one isolated experiment , you must consider them
ALL.

2) The experiments are always correct ; the interpretation of the facts
depends on you.Your interpretation of the facts can only be considered by
other scientists if you are an expert.If you have put ALL THE CURRENT
INFORMATION IN YOUR HEAD AT THE SAME TIME SO THAT YOU CAN CONSIDER THEM ALL
AT THE SAME TIME.Sorry for the capitals,this is a non-binary group so I
cannot increase the font and change the colour to red.Who are the experts ?
Science is not a religion , anyone with a working brain can become an
expert.So clearly anyone that has the motivation of reading all the
experiments and thinking about them becomes an expert.This person must have
a lot of motivation because this is a lot of work.A very good motivation to
become an expert on a desease is ..... having a desease.So experts on
diabetes are here.Look for Jefferson , Quentin , Alan , Susan and others.In
the literature you will find also experts with a desease who made a
scientific career in finding the cause.I know two myself.

3) Science will always move on.There will always be experiments that do not
yet fit in any hypothesis

4) The concept "truth" is not part of science.Science is all about finding
the most efficient way to manipulate the physical reality around us.The
iterative method above is the best way humanity has found sofar to
accomplish this.The core business of science is to make more and more
precise errors.








Here is my comment on your link:
I must read the whole experiment (See above "Science" for why) so the next
time you post a link it would be very helpful to post a direct link to the
Database where I can find it.Please post a full reference to the article or
,even better, a Pubmed link.

Fortunately the Annals of Internal Medicine has a good advance search
capability and an advanced publication feature on his website.For the
non-technical readers I posted an abstract of the SUMMARIES FOR
PATIENTS.There is no explanation of the results there , probably because the
specialists have not yet decided what the result means :(

Next I posted an abstract of an editorial by Nanette K. Wenger, MD .She is
an expert in the field so the best answer comes from her(See above "Science"
for why).I think she comes up with more than one very plausible explanation.

Next ,as a service to the people who want to find out for themselves ,I
posted the abstract in the Pubmed Database(See above "Science" for why).

Next here is my personal contribution :
when I had red the whole article (See above "Science" for why) it struck me
that the number of not white women had increased so much :

From Table 1 on page 3
Not White people with Diabetes (%)

NHANES I NHANES II NHANES III

Men 11.9 15.5 21.4
Women 14.7 17.2 33.9

This only struck me because yesterday a saw a news item on the TV.The Dutch
government wants to make a new law that actually makes discrimination of
male dokters a punishable act.The Dutch docters association worries that non
white women don't get medical care because their husbands only want to have
their spouses investigated by a female dokter.Serendipity...


==================================================

SUMMARIES FOR PATIENTS
Deaths among U.S. Adults with and Without Diabetes
7 August 2007 | Volume 147 Issue 3
Summaries for Patients are a service provided by Annals to help patients
better understand the complicated and often mystifying language of modern
medicine.

Summaries for Patients are presented for informational purposes only. These
summaries are not a substitute for advice from your own medical provider. If
you have questions about this material, or need medical advice about your
own health or situation, please contact your physician. The summaries may be
reproduced for not-for-profit educational purposes only. Any other uses must
be approved by the American College of Physicians.

The full report is titled "Mortality Trends in Men and Women with Diabetes,
1971-2000." It is in the 7 August 2007 issue of Annals of Internal Medicine
(volume 147). The authors are E.W. Gregg, Q. Gu, Y.J. Cheng, K.M.V. Narayan,
and C.C. Cowie.

What is the problem and what is known about it so far?
The pancreas makes insulin, a substance that helps to store energy from
food. Diabetes mellitus interferes with the body's ability to store energy
from food. Type 1 diabetes mellitus (also called juvenile diabetes) occurs
when the pancreas stops making insulin. Type 2 diabetes mellitus (also
called adult-onset diabetes) occurs when the body makes plenty of insulin
but cannot use it normally. In both types, the result is high blood sugar
levels. Over time, high blood sugar levels can lead to blindness, kidney
failure, nerve damage, and heart disease. Fortunately, good care with diet,
exercise, and medications to control blood sugar, blood pressure, and
cholesterol levels can prevent the development of complications. People with
diabetes generally do not live as long as people without diabetes. Since the
1970s, death rates have decreased in the United States, which means that
people are living longer than they used to. Whether death rates have
decreased the same amount in people with and people without diabetes,
however, is not known.

Why did the researchers do this particular study?
To compare changes in death rates since the 1970s in people with and without
diabetes.

Who was studied?
Almost 20, 000 people who participated in 1 of 3 national surveys about
health that took place in 1971-1974, 1976-1980, and 1988-1994.

How was the study done?
The survey asked people whether they had diabetes. The researchers then
followed the people for up to 12 years to see who was still living and who
had died. Next, they compared the numbers of deaths in people with and
without diabetes from the 1990s with those from the 1980 and 1970s. They
also compared deaths in men and women.

What did the researchers find?
When the researchers looked at the entire group without separating people
with from people without diabetes, they found that death rates decreased
from 1971 to 2000. When they looked only at the people with diabetes, they
found that death rates declined in parallel in diabetic and nondiabetic men.
However, the death rates in diabetic women did not decrease. In fact, the
differences between nondiabetic and diabetic women doubled over the time of
the study.

What were the limitations of the study?
The researchers used patient self-report to determine whether the patient
had diabetes instead of checking blood sugar levels. Many people who have
diabetes are not aware that they have it, and some people might think they
have diabetes when they really don't.

What are the implications of the study?
Despite U.S. trends that show reduced death rates since 1971, people with
diabetes continue to have a higher risk for dying earlier than do people
without the disease. The problem is greatest among women with diabetes.
Research to understand these differences should be a priority.

==================================================

EDITORIAL
Heightened Cardiovascular Risk in Diabetic Women: Can the Tide Be Turned?
Nanette K. Wenger, MD
7 August 2007 | Volume 147 Issue 3

The diabetic woman is at heightened risk for all-cause, cardiac, and
coronary heart disease (CHD) mortality. So concluded the authors of a 1999
study of sex-specific comparisons of enrollees in the First National Health
and Nutrition Examination Survey (NHANES I) (1971-1975) and the NHANES I
Epidemiologic Follow-up Survey (NHEFS) (1982-1984) (1). The purpose of the
study was to determine age-adjusted cardiac mortality rates in 2 time
periods by using 2 cohorts from the NHANES I national probability sample.
One cohort was followed from 1971 to 1974 for a mean of 9.1 years, and the
other was followed from 1982 to 1984 for a mean of 8.7 years. Compared with
cardiac mortality in the 1971-1974 cohort, cardiac mortality in the
1982-1984 cohort declined by 36.4% in nondiabetic men, 13.1% in diabetic
men, and 27% in nondiabetic women-but increased by 23% in diabetic women.
An article in this issue (2) underscores the diabetic woman's continued
heightened risk for both all-cause and cardiac mortality. Gregg and
colleagues compared all-cause and cardiovascular mortality rates in adults
with and without self-reported diabetes from the NHANES I (1971-1975), II
(1976-1980), and III (1988-1994) cohorts as determined through 1986, 1992,
and 2000, respectively. Cardiovascular deaths declined over the 3 decades in
diabetic (26.4, 17.1, and 12.8 deaths per 1000 persons per year,
respectively) and nondiabetic men (9.6, 6.5, and 4.7 deaths per 1000 persons
per year, respectively) and in nondiabetic women (4.7, 3.1, and 2.3 deaths
per 1000 persons per year, respectively) but remained essentially unchanged
for diabetic women (10.5, 9.1, and 9.4 deaths per 1000 persons per year,
respectively). The authors concluded that diabetic women have not benefited
from the changes that dramatically improved the cardiovascular disease
outlook for others.

The results of these 2 studies are difficult to explain. The decline in CHD
deaths in the total U.S. population has been attributed to both major
coronary risk factor reduction and evidence-based medical treatments of
established CHD (3). Some have attributed the paradoxical increase in deaths
in diabetic women to differential application-or differential effects-of
risk factor control strategies and CHD therapies. Although the NHANES data
set did not contain enough information to test these hypotheses directly,
other evidence exists. The purpose of this editorial is to discuss this
evidence.

Are women with CHD and diabetes less likely to receive appropriate care? The
answer appears to be "yes." Analysis of 2005 Health Effectiveness Data and
Information Set (HEDIS) cardiovascular disease and diabetes measures showed
sex disparities for ambulatory preventive care. In 2 commercial managed care
plan measures and 5 Medicare managed care plan measures, statistically
significant disparities disadvantaged women. Suboptimal cholesterol control
after acute cardiac events was common in diabetic and nondiabetic women (4).
According to the authors, eliminating sex disparities in cholesterol control
in diabetic women could potentially reduce major cardiac events by 4800
events to 10 000 events annually nationwide. The analysis did not include
uninsured patients, who are likely to be more vulnerable. Another analysis
of quality of cardiovascular and diabetes care in managed care plan
enrollees used 11 HEDIS measures to draw the same conclusion about
low-density lipoprotein cholesterol control in diabetic persons, which was
19% less likely in women enrolled in Medicare plans and 16% less likely in
women enrolled in commercial plans (5). These findings are important at a
population level, because elderly women represent the fastest-growing
population segment. The rates of prescribing ß-blockers after myocardial
infarction and angiotensin-converting enzyme inhibitors for heart failure
were also lower in women.

Sex disparities disadvantaging women with established CHD are also
prominent, regardless of diabetic status. Women receive CHD diagnoses later
in their illness, have fewer preventive interventions, and receive less
guideline-based therapies at hospital admission and at discharge after an
acute coronary event. In the northern New England coronary artery bypass
graft (CABG) surgery database, diabetes contributed statistically
significantly to the sex-based excess of CABG deaths among women (6). In the
National Registry for Myocardial Infarction (NRMI) (1994-2002), black
persons and women with myocardial infarction received less reperfusion
therapy and coronary angiography. The disparity was greatest for black
women, who had an 11% excess mortality rate. The NRMI ethnicity and sex gap
in treatment has persisted in recent years (7). Younger women (age <50
years) have greater mortality rates than do age-matched men after both
myocardial infarction and CABG surgery, which raises a new concern. The age
at diagnosis of diabetes is falling in women, perhaps because of the obesity
epidemic. Will the progressively longer duration of diabetes further
accelerate the adverse clinical outcomes in younger women?

These sex disparities reflect care of acute CHD. Disparities also exist for
office-based care, as shown in another study using HEDIS quality measures in
commercial managed care settings. Lipid control was worse in women, with
disparities of 5% to 9% in women with diabetes, a history of cardiovascular
disease, or both. Ethnicity (African American and Latino/a) and lower
socioeconomic status also adversely affected cardiovascular care (8).
Disparities also exist in Medicare managed care. According to HEDIS quality
measures, women had worse cholesterol control than men and African-American
diabetic patients had greater gaps in care and health outcomes than did
white diabetic patients (9), with African-American diabetic women at the
greatest disadvantage.

These sex disparities have consequences. Diabetic patients have a doubled
incidence of myocardial infarction and stroke and less favorable survival
rates after cardiovascular events. A 2007 Scientific Statement from the
American Heart Association and the American Diabetes Association (10)
highlights that treating diabetic patients with established CHD for
dyslipidemia, hypertension, and hypercoagulability (as well as percutaneous
interventions and cardiovascular surgery for acute coronary syndromes)
improves event-free survival. This statement also recommends primary
preventive strategies, because up to 80% of diabetic patients develop
macrovascular disease and many succumb to it.

Although sex disparity in access to care and intensity of risk reduction is
a plausible explanation for worse cardiovascular disease outcomes in
diabetic women, it may not be the entire answer. For example, cardiovascular
risk factors might be more common, more likely to cluster, or more severe in
diabetic women than in diabetic men. This intriguing possibility is
suggested by the more powerful effect of statistical risk factor adjustment
in women. A meta-analysis of 10 prospective studies (11) of the impact of
diabetes on the sex-based differential in CHD risk identified a
statistically significant greater relative risk for CHD death for diabetic
women versus diabetic men. The increased risk persisted after statistical
adjustment for other cardiac risk factors and after exclusion of patients
with previous coronary events, suggesting that diabetes per se-not greater
risk factor aggregation, severity, or treatment resistance-selectively
disadvantaged diabetic women. By contrast, another meta-analysis (12)
concluded that statistical adjustment for classic coronary risk factors
eliminated the sex-based difference in the impact of diabetes on death,
suggesting that differences in risk factors other than diabetes per se are
responsible for sex-based differences in outcomes. Clearly, controversy
about sex differences in the impact of CHD risk factors persists, but
clearly modifiable cardiac risk factors seem to at least partially explain
inconsistencies among studies.

Finally, what are postmillennial cardiovascular mortality trends for women?
Before 2000, cardiovascular mortality rates decreased serially in the United
States in men but not in women (1, 3). However, annual cardiovascular
mortality rates declined in women each year from 2000 to 2004. The National
Heart, Lung, and Blood Institute (13) attributes this decrease of almost 17
000 deaths from 2003 to 2004 to improved medical and surgical therapies
rather than to decreased cardiovascular disease incidence. Pivotal questions
remain. Gregg and colleagues' data set ends in 2000. Have diabetic women
participated in the favorable cardiovascular survival trend for women since
2000? Do benefits extend to racial or ethnic subsets of women and to younger
as well as older women? If so, what interventions have made a difference?
Recent examination of sex-specific effects of diabetes on outcomes of
percutaneous coronary interventions showed that diabetic women had greater
improvement in percutaneous coronary intervention outcomes than nondiabetic
women, so that diabetes is no longer a risk factor for adverse percutaneous
coronary intervention outcomes in women (14). A final question: Would more
aggressive use of invasive interventions reduce cardiovascular disease
mortality rates among diabetic women?

We lack an evidence-based comprehensive strategy for improving
cardiovascular outcomes in diabetic women. Until we do, a prudent clinical
approach involves 2 steps. First, we must recognize that diabetic women are
at excess risk for developing CHD. Second, we must take an aggressive,
guideline-based approach to CHD risk factor management.

==================================================

Ann Intern Med. 2007 Jun 18; [Epub ahead of print]
Mortality Trends in Men and Women with Diabetes, 1971-2000.Gregg EW, Gu Q,
Cheng YJ, Narayan KM, Cowie CC.

BACKGROUND: Whether mortality rates among diabetic adults or excess
mortality associated with diabetes in the United States has declined in
recent decades is not known. OBJECTIVE: To examine whether all-cause and
cardiovascular disease mortality rates have declined among the U.S.
population with and without self-reported diabetes. DESIGN: Comparison of 3
consecutive, nationally representative cohorts. SETTING: Population-based
health surveys (National Health and Nutrition Examination Surveys I, II, and
III) with mortality follow-up assessment. PATIENTS: Survey participants age
35 to 74 years with and without diabetes. MEASUREMENTS: Diabetes was
determined by self-report for each survey (1971-1975, 1976-1980, and
1988-1994), and mortality rates were determined through 1986, 1992, and 2000
for the 3 surveys, respectively. RESULTS: Among diabetic men, the all-cause
mortality rate decreased by 18.2 annual deaths per 1000 persons (from 42.6
to 24.4 annual deaths per 1000 persons; P = 0.03) between 1971 to 1986 and
1988 to 2000, accompanying decreases in the nondiabetic population.
Cardiovascular disease mortality trends paralleled those of all-cause
mortality, with 26.4 annual deaths per 1000 persons in 1971 to 1986 and 12.8
annual deaths per 1000 persons in 1988 to 2000 (P = 0.06). Among women with
diabetes, however, neither all-cause nor cardiovascular disease mortality
declined between 1971 to 1986 and 1988 to 2000, and the all-cause mortality
rate difference between diabetic and nondiabetic women more than doubled
(from a difference of 8.3 to 18.2 annual deaths per 1000 persons). The
reduction in mortality rates among diabetic men eliminated the sex
difference in rates among diabetic adults that was observed in earlier
surveys. Limitations: Diabetes was assessed by self-report, and statistical
power to examine the factors explaining mortality trends was limited.
CONCLUSIONS: Progress in reducing mortality rates among persons with
diabetes has been limited to men. Diabetes continues to greatly increase the
risk for mortality, particularly among women.

PMID: 17576993

hth
Gys



.

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