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Has Control of Hypercholesterolemia and Hypertension in Type 1 Diabetes Improved Over Time?

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Has Control of Hypercholesterolemia and Hypertension in Type 1 Diabetes Improved Over Time? Clinical Care/Education/Nutrition ORIGINAL ARTICLE Has Control of Hypercholesterolemia and Hypertension in Type 1 Diabetes Improved Over Time? 1 JANICE C. ZGIBOR, PHD While primary and secondary pre- 2 ROBB R. WILSON, MA vention of complications should be para- 1 TREVOR J. ORCHARD, MD mount, reports of suboptimal levels of treatment and control of these risk factors are abundant in the literature. The pro- portion of hypertensive individuals OBJECTIVE — To determine the extent to which patients’ awareness, treatment, and control treated and controlled in the general pop- of hypertension and hypercholesterolemia have changed over time and to examine factors ulation range from 10 to 41% (4,5), while associated with awareness and treatment in a type 1 diabetes population. for people with diabetes, rates range from 11 to 23% (6–9). For hypercholesterol- RESEARCH DESIGN AND METHODS — Data from six examinations conducted over 10 years from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective study emia, reports indicate that 18–37% of of subjects with childhood-onset (Ͻ17 years of age) type 1 diabetes diagnosed between 1950 and those treated and at high risk for an event 1980 and followed since 1986, were analyzed. Hypertension and hypercholesterolemia were in the general population are controlled defined according to the concurrent Joint National Committee and National Cholesterol Edu- (10), while 16–35% of those with diabe- cation Program Adult Treatment Panel criteria, respectively. tes are controlled (8,9). Reasons for inad- equate control are often centered on lack RESULTS — Results demonstrated that awareness of both conditions has improved; however, of access to health care, yet 90% of people control is not optimal (e.g., only 32.1 and 28% of those with hypertension in 1986–1988 and with diabetes have access to a health care 1996–1998 were controlled, while for hypercholesterolemia, the rates were 0 and 5.5%, respec- Ͼ provider and have health insurance (8), tively). Stratified by age-group (18–29, 30–39, and 40 years), the youngest subjects with demonstrating a “missed opportunity” for hypercholesterolemia were least likely to be treated and controlled to goal levels. Older age and physician contact were correlates of awareness and treatment of hypertension at baseline, while preventive care. presence of renal or coronary complications was also associated with awareness and treatment of Over the past two decades, effective both hypertension and hypercholesterolemia at the 10-year follow-up. treatment options and more aggressive treatment guidelines have been intro- CONCLUSIONS — There is a considerable treatment gap, particularly for hypercholester- duced; however, little is known about the olemia. Improved treatment of both hypertension and hypercholesterolemia are clearly needed, impact of these efforts on the level of particularly hypercholesterolemia in younger age-groups who have not yet experienced long- treatment and control of hypertension term complications. and hypercholesterolemia, particularly in Diabetes Care 28:521–526, 2005 type 1 diabetes. It was our objective to determine the extent to which patients’ awareness, treatment, and control of hy- ypertension and hypercholesterol- risk factors can directly impact the occur- pertension and hypercholesterolemia has emia are important risk factors for rence of both new (1) and repeat (2) changed over time and to examine factors H the development of micro- and ma- events. Additionally, data suggest that associated with awareness and treatment crovascular complications in people with people with type 1 diabetes and renal dis- in a type 1 diabetes population. diabetes. Studies examining cardiovascu- ease may experience remission or regres- lar events among people with type 2 dia- sion of their renal disease with aggressive RESEARCH DESIGN AND betes demonstrate that controlling these antihypertensive treatment (3). METHODS — The Pittsburgh Epide- ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● miology of Diabetes Complications Study 1 2 (EDC) is an observational prospective co- From the Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania; and the Center hort study of type 1 diabetic subjects that for Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania. Address correspondence and reprint requests to Janice C. Zgibor, PhD, 601.7 Kaufmann Building, 3471 has been previously described (11). Fifth Ave., Pittsburgh, PA 15213. E-mail: [email protected]. Briefly, study participants were diagnosed Received for publication 30 June 2004 and accepted in revised form 14 December 2004. between 1950 and 1980 and seen within T.J.O. has received consulting fees from AstraZeneca and Merck Schering Plough and has received grant 1 year of diagnosis at Children’s Hospital support from Merck Schering Plough. Abbreviations: CAD, coronary artery disease; DSP, distal symmetric polyneuropathy; EDC, Pittsburgh of Pittsburgh. Although this population is Epidemiology of Diabetes Complications Study; LEAD, lower-extremity arterial disease; ON, overt nephrop- clinic based, it has been shown to be epi- athy; PR, proliferative retinopathy. demiologically representative of the type A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion 1 diabetes population of Allegheny factors for many substances. County, Pennsylvania (12). A total of 658 © 2005 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby subjects participated in the baseline exam marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. (1986–1988). While attendance at Chil- DIABETES CARE, VOLUME 28, NUMBER 3, MARCH 2005 521 Hypercholesterolemia and hypertension control Table 1—Definitions for hypertension and hypercholesterolemia during the 10-year follow-up period in the EDC Exams 1–4 (1986–1993) Exams 5 and 6 (1994–1998) Hypertension Case definition Ͼ140/90 mmHg or treatment with antihypertensive 130/85 mmHg or treatment with antihypertensive medication* medication* Goal for treatment Ͻ140/90 mmHg Ͻ130/85 mmHg Hypercholesterolemia Case definition Above LDL cholesterol goal or treatment with anihyperlipidemic medication† Goal for treatment ● LDL cholesterol Ͻ160 mg/dl if less than two risk factors‡ ● Ͻ160 mg/dl if less than two risk factors§ ● Initiate medication therapy if Ͼ190 mg/dl ● Initiate medication therapy if Ͼ190 mg/dl or or ● LDL cholesterol Ͻ130 mg/dl if CAD or two or more risk factors‡ ● Ͻ130 mg if two or more risk factors ● Initiate medication therapy if Ͼ160 mg/dl ● Initiate medication therapy if Ͼ160 mg/dl or ● Ͻ100 mg /dl if CAD ● Initiate medication therapy if Ͼ130 mg/dl *Antihypertensive medications include ACE inhibitors, ␤-blockers, calcium channel blockers, diuretics, and other antihypertensives. Subjects also had to indicate that the reason for taking the medication was hypertension. If the reason was not hypertension, subjects were not considered to be taking an antihypertensive medication. If no reason was listed, the presumption was antihypertensive use. †Lipid-lowering medications include HMG-COA reductase inhibitors, fish oil (more than six capsules per day), bile acid resins, probucol, and niacin Ն750 mg/day. ‡Male sex, smoker, hypertension, family history of premature coronary heart disease, HDL cholesterol Ͻ35 mg/dl, diabetes, cerebrovascular or peripheral vascular disease, and BMI Ͼ45 kg/m2. §Male age Ͼ45 years, female age Ͼ55 or postmenopausal without hormone replacement therapy, family history of premature coronary heart disease, smoker, hypertension, HDL cholesterol Ͻ35 mg/dl, and diabetes. dren’s Hospital was one of the eligibility Hypercholesterolemia and level of control bumin excretion rate Ͼ200 ␮g/min on criteria, the EDC participants subse- were defined for the time period studied two of three timed urine samples or, in the quently received their diabetes care in the according to the concurrent National absence of urine, serum creatinine Ͼ2 general community, with ϳ50% receiv- Cholesterol Education Program Adult mg/dl, renal failure, or transplant. Distal ing care from diabetes specialists (13). Treatment Panel (22,23), as outlined in symmetric polyneuropathy (DSP) was The present cross-sectional analyses rep- Table 1. considered present if on examination, ac- resent data available for adults (age Ͼ18 Patient awareness of hypertension cording to the Diabetes Control and Com- years) followed for the first 10 years (six was defined by a positive response to the plications Trial protocol (25), the examination periods) of the EDC. question “has a physician ever told you participant had at least two of the follow- that you had high blood pressure?” Pa- ing: symptoms consistent with DSP, de- Primary outcomes tient awareness of hypercholesterolemia creased or absent deep tendon reflexes, Blood pressure was measured with a ran- was defined by a positive response to the and signs of sensory loss. At the 4-year dom zero sphygmomanometer, accord- question “has a physician ever told you that follow-up exam and thereafter (i.e., for ing to the Hypertension Detection and you had high cholesterol/triglycerides?” 101 of 108 incident subjects), DSP was Follow-up Program protocol (14). Case confirmed (CDSP) by the presence of a definition of hypertension and level of Data collection and variable vibratory threshold above the age-specific control were defined
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