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25-04-2018 | Lipid-lowering medications | Article

Real-life achievement of lipid-lowering treatment targets in the DIAbetes and LifEstyle Cohort Twente: systemic assessment of pharmacological and nutritional factors

Journal: Nutrition & Diabetes

Authors: Christina M. Gant, S. Heleen Binnenmars, Manon Harmelink, Sabita S. Soedamah-Muthu, Stephan J. L. Bakker, Gerjan Navis, Gozewijn D. Laverman

Publisher: Nature Publishing Group UK

Abstract

Background/Objectives

Lowering low-density lipoprotein cholesterol (LDLc) in type 2 diabetes mellitus is of paramount importance in preventing cardiovascular disease. However, treatment targets for LDLc are often not reached. We studied the prevalence of LDLc target achievement in a real-life population of type 2 diabetes mellitus patients in secondary care, and investigated whether in those not on target, there is room for intensifying pharmacological and lifestyle management according to current treatment guidelines.

Subjects/Methods

We performed a cross-sectional analysis in the DIAbetes and LifEstyle Cohort Twente-1 (DIALECT-1; n = 450, age 63 ± 9 years, 58% men, diabetes duration 11 (7–18) years). At baseline, we determined plasma LDLc concentration, pharmacological treatment (i.e., statin use), and lifestyle (physical activity and dietary intake). Patients were divided according to LDLc < 1.8, LDLc 1.8–2.5, and LDLc > 2.5 mmol/l. Dietary intake was collected from a validated Food Frequency Questionnaire (177 items) and we determined guideline adherence for different food groups. Physical activity was assessed with the Short Questionnaire to ASsess Health enhancing behavior.

Results

LDLc data were available in 428 type 2 diabetes mellitus patients. LDLc ≤ 2.5 mmol/l was achieved in 317 patients (76%). In total, 76% of patients used statins, in those with LDLc > 2.5 mmol/l, this was 44%. Adherence to lifestyle guidelines was not different between the LDLc groups and was as follows: body mass index 6%, physical activity 59%, vegetables 7%, fruit 28%, legumes 59%, nuts 14%, dairy 19%, fish 36%, tea 8%, fats 66%, red meat 12%, processed meat 2%, alcohol 71%, sweetened beverages 34%, and sodium 12%.

Conclusions

In type 2 diabetes mellitus patients in secondary health care, the target LDLc is achieved by three quarters of patients. Increasing statin treatment could be a first step to improve LDLc. In addition, there are ample opportunities for lifestyle management through increasing adherence to lifestyle guidelines.
Literature
1.
Rana, J. S., Liu, J. Y., Moffet, H. H., Jaffe, M. & Karter, A. J. Diabetes and prior coronary heart disease are not necessarily risk equivalent for future coronary heart disease events. J. Gen. Intern. Med. 31, 387–393 (2016).CrossRefPubMed
2.
Emerging Risk Factors Collaboration, Sarwar, N. et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 375, 2215–2222 (2010).CrossRef
3.
Colhoun, H. M. et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 364, 685–696 (2004).CrossRefPubMed
4.
de Vries, F. M., Denig, P., Pouwels, K. B., Postma, M. J. & Hak, E. Primary prevention of major cardiovascular and cerebrovascular events with statins in diabetic patients: a meta-analysis. Drugs 72, 2365–2373 (2012).CrossRefPubMed
5.
de Vries, F. M., Kolthof, J., Postma, M. J., Denig, P. & Hak, E. Efficacy of standard and intensive statin treatment for the secondary prevention of cardiovascular and cerebrovascular events in diabetes patients: a meta-analysis. PLoS ONE 9, e111247 (2014).CrossRefPubMedPubMedCentral
6.
Burggraaf, B. & Castro Cabezas, M. Interventions in type 2 diabetes mellitus and cardiovascular mortality-An overview of clinical trials. Eur. J. Intern. Med. 42, 1–15 (2017).CrossRefPubMed
7.
Cholesterol Treatment Trialists’ (CTT) Collaborators, Mihaylova, B. et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 380, 581–590 (2012).CrossRef
8.
Piepoli, M. F. et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur. Heart J. 37, 2315–2381 (2016).CrossRefPubMedPubMedCentral
9.
Kwaliteitsinstituut voor de Gezondheidszorg CBO and Nederlands Huisartsen Genootschap (NHG). Multidisciplinaire Richtlijn Cardiovascular Risicomanagement (Herziening 2011). (Bohn Stafleu van Loghum, Houten, The Netherlands, 2011).
10.
De Cosmo, S. et al. Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative. Nephrol. Dial. Transplant. 30, 1526–1533 (2015).CrossRefPubMed
11.
Heintjes, E. et al. Characterization and cholesterol management in patients with cardiovascular events and/or type 2 diabetes in the Netherlands. Curr. Med. Res. Opin. 33, 91–100 (2017).CrossRefPubMed
12.
Kotseva, K. et al. Lifestyle and risk factor management in people at high risk of cardiovascular disease. A report from the European Society of Cardiology European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) IV cross-sectional survey in 14 European regions. Eur. J. Prev. Cardiol. 23, 2007–2018 (2016).CrossRefPubMed
13.
Gitt, A. K. et al. Persistent lipid abnormalities in statin-treated patients and predictors of LDL-cholesterol goal achievement in clinical practice in Europe and Canada. Eur. J. Prev. Cardiol. 19, 221–230 (2012).CrossRefPubMed
14.
Poggio, R. et al. Associations between dietary patterns and serum lipids, apo and C-reactive protein in an adult population: evidence from a multi-city cohort in South America. Br. J. Nutr. 117, 548–555 (2017).CrossRefPubMed
15.
Gadgil, M. D., Anderson, C. A., Kandula, N. R. & Kanaya, A. M. Dietary patterns are associated with metabolic risk factors in South Asians living in the United States. J. Nutr. 145, 1211–1217 (2015).CrossRefPubMedPubMedCentral
16.
Vitale, M. et al. Influence of dietary fat and carbohydrates proportions on plasma lipids, glucose control and low-grade inflammation in patients with type 2 diabetes-The TOSCA.IT Study. Eur. J. Nutr. 55, 1645–1651 (2016).CrossRefPubMed
17.
Gant C. M., et al. Integrated Assessment of Pharmacological and Nutritional Cardiovascular Risk Management: Blood Pressure Control in the DIAbetes and LifEstyle Cohort Twente (DIALECT). Nutrients 9, pii: E709 https://​doi.​org/​10.​3390/​nu9070709.​
18.
von Elm, E. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 4, e296 (2007).CrossRef
19.
Wendel-Vos, G. C., Schuit, A. J., Saris, W. H. & Kromhout, D. Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity. J. Clin. Epidemiol. 56, 1163–1169 (2003).CrossRefPubMed
20.
Feunekes, G. I., Van Staveren, W. A., De Vries, J. H., Burema, J. & Hautvast, J. G. Relative and biomarker-based validity of a food-frequency questionnaire estimating intake of fats and cholesterol. Am. J. Clin. Nutr. 58, 489–496 (1993).CrossRefPubMed
21.
van den Berg, E. et al. Dietary acid load and metabolic acidosis in renal transplant recipients. Clin. J. Am. Soc. Nephrol. 7, 1811–1818 (2012).CrossRefPubMedPubMedCentral
22.
Rijksinstituut voor Volksgezondheid en Milieu. NEVO-tabel (Dutch food composition table): Nederlands voedingsstoffenbestand. 2013;4.0.
23.
Beukers M., Geurts M., van Rossum C. T. M. MEMO: Inname van nutriënten door de Nederlandse bevolking Resultaten van VCP 2007-2010 samen met NEVO-2013, 2016.
24.
Helfand, M., Carson, S. & Kelley, C. Drug Class Review on HMG-CoA Reductase Inhibitors (Statins): Final Report. (Oregon Health & Science University, Portland, Oregon, Portland (OR), 2006).
25.
Health Council of the Netherlands. Dutch Dietary Guidelines 2015. (Health Council of the Netherlands, The Hague, 2015).
26.
Nederlandse Diabetes Federatie. NDF Voedingsrichtlijn Diabetes 2015. (Nederlandse Diabetes Federatie, Amersfoort, 2015).
27.
van Rossum C. T. M., et al. Voedselconsumptie in 2012-2014 vergeleken met de Richtlijnen goede voeding 2015. RIVM Letter report 2017-0095 (2016).
28.
van Rossum C. T. M., et al. MEMO Voedselconsumptie in 2012-2014 vergeleken met de Schijf van Vijf 2016. MEMO-VCP 17-03 (2017).
29.
van Rossum C. T. M., et al. The diet of the Dutch results of the first two years of the Dutch National Food Consumption Survey 2012-2016. RIVM Letter report 2016-0082 (2016).
30.
Gezondheidsenquete/Leefstijlmonitor CBS, RIVM. Beweeggedrag bij personen van 12 jaar en ouder in 2015. (Rijksinstituut voor volksgezondheid en milieu (RIVM), Bilthoven, The Netherlands, 2015).
31.
Prince, S. A. et al. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J. Behav. Nutr. Phys. Act. 5, 56–5868-5-56 (2008).CrossRefPubMedPubMedCentral
32.
Weng, T. C., Yang, Y. H., Lin, S. J. & Tai, S. H. A systematic review and meta-analysis on the therapeutic equivalence of statins. J. Clin. Pharm. Ther. 35, 139–151 (2010).CrossRefPubMed
33.
de Vries, F. M., Voorham, J., Hak, E. & Denig, P. Adherence to standard-dose or low-dose statin treatment and low-density lipoprotein cholesterol response in type 2 diabetes patients. Curr. Med Res Opin. 31, 2197–2206 (2015).CrossRefPubMed
34.
Ho, P. M. et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch. Intern. Med. 166, 1836–1841 (2006).CrossRefPubMed
35.
Jackevicius, C. A., Mamdani, M. & Tu, J. V. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 288, 462–467 (2002).CrossRefPubMed
36.
Nielsen, S. F. & Nordestgaard, B. G. Negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality: a nationwide prospective cohort study. Eur. Heart J. 37, 908–916 (2016).CrossRefPubMed
37.
Matthews, A. et al. Impact of statin related media coverage on use of statins: interrupted time series analysis with UK primary care data. BMJ 353, i3283 (2016).CrossRefPubMedPubMedCentral
38.
Reiner, Z. et al. Treatment potential for dyslipidaemia management in patients with coronary heart disease across Europe: findings from the EUROASPIRE III survey. Atherosclerosis 231, 300–307 (2013).CrossRefPubMed
39.
Ridker, P. M. et al. Rosuvastatin to prevent vascular events in men and women with elevated C-reactive protein. N. Engl. J. Med. 359, 2195–2207 (2008).CrossRefPubMed
40.
Reiner, Z. Resistance and intolerance to statins. Nutr. Metab. Cardiovasc Dis. 24, 1057–1066 (2014).CrossRefPubMed
41.
Sahebkar, A. et al. Lipid-modifying effects of nutraceuticals: An evidence-based approach. Nutrition 32, 1179–1192 (2016).CrossRefPubMed
42.
Authors/Task Force Members, Catapano, A. L. et al. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias: The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) developed with the special contribution of the European Assocciation for Cardiovascular Prevention & Rehabilitation (EACPR). Atherosclerosis 253, 281–344 (2016).CrossRef
43.
Bates, T. R., Connaughton, V. M. & Watts, G. F. Non-adherence to statin therapy: a major challenge for preventive cardiology. Expert Opin. Pharmacother. 10, 2973–2985 (2009).CrossRefPubMed
44.
Cannon, C. P. et al. Ezetimibe added to statin therapy after acute coronary syndromes. N. Engl. J. Med. 372, 2387–2397 (2015).CrossRefPubMed
45.
Grundy, S. M. et al. Effectiveness and tolerability of simvastatin plus fenofibrate for combined hyperlipidemia (the SAFARI trial). Am. J. Cardiol. 95, 462–468 (2005).CrossRefPubMed
46.
Stein, E. A. et al. Effect of a monoclonal antibody to PCSK9, REGN727/SAR236553, to reduce low-density lipoprotein cholesterol in patients with heterozygous familial hypercholesterolaemia on stable statin dose with or without ezetimibe therapy: a phase 2 randomised controlled trial. Lancet 380, 29–36 (2012).CrossRefPubMed
47.
Sullivan, D. et al. Effect of a monoclonal antibody to PCSK9 on low-density lipoprotein cholesterol levels in statin-intolerant patients: the GAUSS randomized trial. JAMA 308, 2497–2506 (2012).CrossRefPubMed
48.
Simo, R. et al. Long-term changes in cardiovascular risk markers during administration of exenatide twice daily or glimepiride: results from the European exenatide study. Cardiovasc. Diabetol. 14, 116 (2015). 015-0279-z.CrossRefPubMedPubMedCentral
49.
Russo, G. T. et al. Twelve-month treatment with Liraglutide ameliorates Visceral Adiposity Index and common cardiovascular risk factors in type 2 diabetes outpatients. J. Endocrinol. Invest. 38, 81–89 (2015).CrossRefPubMed
50.
Rizzo, M. et al. Liraglutide decreases carotid intima-media thickness in patients with type 2 diabetes: 8-month prospective pilot study. Cardiovasc. Diabetol. 13, 49–2840-13-49 (2014).CrossRefPubMedPubMedCentral
51.
Marso, S. P. et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N. Engl. J. Med. 375, 311–322 (2016).CrossRefPubMedPubMedCentral
52.
Anabtawi, A., Moriarty, P. M. & Miles, J. M. Pharmacologic treatment of dyslipidemia in diabetes: a case for therapies in addition to statins. Curr. Cardiol. Rep. 19, 62 (2017). 017-0872-8.CrossRefPubMed
53.
Multiple risk factor intervention trial research group. Risk factor changes and mortality results. JAMA 248:1465–1477 (1982).
54.
Kendall, C. W. & Jenkins, D. J. A dietary portfolio: maximal reduction of low-density lipoprotein cholesterol with diet. Curr. Atheroscler. Rep. 6, 492–498 (2004).CrossRefPubMed
55.
Jenkins, D. J. et al. Effect of a dietary portfolio of cholesterol-lowering foods given at 2 levels of intensity of dietary advice on serum lipids in hyperlipidemia: a randomized controlled trial. JAMA 306, 831–839 (2011).CrossRefPubMed
56.
Eussen, S. R. et al. Effects of n-3 fatty acids on major cardiovascular events in statin users and non-users with a history of myocardial infarction. Eur. Heart J. 33, 1582–1588 (2012).CrossRefPubMedPubMedCentral
57.
Witkamp, R. et al. Kennissynthese voeding als behandeling van chronische ziekten.. (ZonMW, Den Haag, 2017).
58.
Dunkler, D. et al. Modifiable lifestyle and social factors affect chronic kidney disease in high-risk individuals with type 2 diabetes mellitus. Kidney Int. 87, 784–791 (2015).CrossRefPubMed
59.
Knowler, W. C. et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N. Engl. J. Med. 346, 393–403 (2002).CrossRefPubMed
60.
Bibbins-Domingo, K. et al. Projected effect of dietary salt reductions on future cardiovascular disease. N. Engl. J. Med. 362, 590–599 (2010).CrossRefPubMedPubMedCentral
61.
Wong, M. M. et al. The science of salt: a regularly updated systematic review of salt and health outcomes (December 2015-March 2016). J. Clin. Hypertens. (Greenwich) 19, 322–332 (2017).CrossRef
62.
Fox, C. S. et al. Update on prevention of cardiovascular disease in adults with type 2 diabetes mellitus in light of recent evidence: a scientific statement from the American Heart Association and the American Diabetes Association. Diabetes Care 38, 1777–1803 (2015).CrossRefPubMedPubMedCentral
63.
Zomer, E. et al. Interventions that cause weight loss and the impact on cardiovascular risk factors: a systematic review and meta-analysis. Obes. Rev. 17, 1001–1011 (2016).CrossRefPubMed
64.
Glenney, S. S. et al. Effect of exercise training on cardiac biomarkers in at-risk populations: a systematic review. J. Phys. Act. Health 14, 1–30 (2017).CrossRef

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