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Arch Intern Med. Objective To examine sex-specific associations between cardiovascular risk factors, a parental history of diabetes, and type 2 diabetes mellitus DM. Methods The study is based on men and women aged 35 to 74 years who participated in one of the 3 MONICA Monitoring of Trends and Determinants in Cardiovascular Disease Augsburg surveys between andwho were free of DM at baseline and returned a follow-up questionnaire in Sex-specific hazard ratios HRs were estimated from Cox proportional hazard models.
A total of cases of incident DM among men and 85 cases among women were registered during the follow-up period. The age-standardized incidence rate was 5. In multivariable survival analyses, age, body mass index, and a positive parental history of diabetes were important independent risk factors for DM in both sexes. High-density lipoprotein cholesterol level was inversely associated with DM in men and women. For other risk factors, sex-related differences were observed. Systolic blood pressure HR per 10 mm Hg increase, 1.
Conclusions In men and women, most variables predicting future diabetes in the present study are also known to be important risk factors for cardiovascular disease and arteriosclerosis. However, there are sex-related dissimilarities that seem to be involved in disease development. WORLDWIDE, there are at present approximately million people with diabetes, the majority of them with type 2 diabetes, and it is estimated that this will reach more than million by Type 2 diabetes has a strong genetic component, which is much greater than in type 1 diabetes.
Diabetic women have a 3- to 6-fold and diabetic men a 2- to 4-fold increased risk of myocardial infarction. Still, the environment-gene interactions as mechanisms for the development of type 2 diabetes are not fully clarified, justifying further studies on predictors of diabetes. Moreover, prevention programs depend on the identification of potentially modifiable risk factors. In this connection, it is of great interest whether cardiovascular risk factors are predictors of type 2 diabetes and whether these risk factors are similar in men and women.
As shown in Table 1few studies have provided data on various cardiovascular risk factors and subsequent diabetes in both sexes within the same study population. To our knowledge, the MONICA Monitoring of Trends and Determinants in Cardiovascular Disease Augsburg Cohort Study is the first prospective population-based study that assessed the sex-specific incidence of type 2 diabetes mellitus in a middle European population that is characterized by a relatively low risk of cardiovascular morbidity and mortality.
To answer the question of whether the risk factors for type 2 diabetes mellitus are similar in both sexes, all analyses were performed separately for men and women. In the meantime, participants men and women had died and vital status could not be assessed for 56 persons 31 men and 25 women who had moved to a foreign country or to an unknown location. A questionnaire assessing the health status was mailed to the remaining 12 living persons men and women with known addresses in A total of subjects men and women returned the questionnaire total response rate, Participants who did not know whether they had diabetes at baseline examination were included in the group of nondiabetic persons.
An additional 21 new cases of diabetes were excluded because these participants reported a manifestation of diabetes before the MONICA baseline study in the follow-up questionnaire. Finally, the prospective analyses comprised nondiabetic MONICA participants men and women aged 35 to 74 years. Baseline information on sociodemographic variables, smoking habits, physical activity level, medication use, parental history of disease, menopause, and alcohol consumption were gathered by trained medical staff mainly nurses during a standardized face-to-face interview. In addition, all participants underwent an extensive standardized medical examination including collection of a nonfasting blood sample.
Body mass index BMI was calculated as weight in kilograms divided by the square of height in meters. For the present analysis, the of the second and third measurements were averaged. Angina pectoris was defined as pain after exercise retrosternally, in the left arm, and in the left side of the chest and was categorized according to Rose et al.
Subjects were ased to the positive parental history category if at least 1 parent had diabetes. If neither parent had diabetes, subjects were ased to the negative parental history category. Subjects who answered "I don't know" for both parents or those who answered "I don't know" for one parent and "no" for the other parent were ased to the unknown parental history category. A regular smoker was defined as a subject who currently smoked at least 1 cigarette per day. Each subject was asked how much beer, wine, and spirits he or she had drunk on the workday and during the weekend.
This information was used to calculate the alcohol consumption in grams per day. Alcohol intake in men came mainly from beer, whereas wine was the main contributor of alcohol intake in women; intake of distilled spirits was very low in both sexes. The detailed method has been described elsewhere.
The physical activity level was estimated by means of 2 separate 4-category interview questions asking about the time per week spent on sports activities during leisure time in summer and winter.
The winter and summer responses were combined to define one sport variable, whereby a participant was considered active if he or she participated in sports in summer and in winter and for more than 1 hour per week in at least 1 season. A participant was classified as inactive if he or she was less active during leisure time. The HDL cholesterol was precipitated with phosphotungstic acid and magnesium ions. Regular internal and external quality control measures for serum total cholesterol and HDL cholesterol measurements were performed before and during the data-gathering phase of the survey.
Serum uric acid was measured by the uricase method in surveys 1 and 2. The main outcome was the development of type 2 diabetes mellitus during the follow-up period. Subjects were classified as diabetic if they reported a diagnosis of diabetes or if they were taking antidiabetic medication. The same definition was used to exclude subjects with preexisting diabetes from enrollment. A total of persons men and 83 women reported the development of diabetes during the follow-up period. Another 3 persons 1 man and 2 women reported having no diabetes although they took antidiabetic drugs; these subjects were classified as diabetic for the analyses presented in this article.
Although type 1 diabetes can occur at any age, it is rare beyond 35 years of age. In this study, all participants were 35 years old or older at study entry, and only 12 diabetic persons were treated with insulin only; therefore, it can be assumed that most of the newly diagnosed diabetes in this study population was type 2 diabetes.
Thus, the term type 2 diabetes is used throughout this article. The mean follow-up period was 7. All analyses were performed separately for men and women. Incidence rates were based on person-years from the date of baseline examination until the diagnosis of diabetes or the date when the questionnaire was filled in as the censoring date. They were calculated by dividing the of incident cases by person-years in each age group.
Age-standardized incidence was calculated by direct standardization with the use of the population of the Federal Republic of Germany in as the standard population weights: years, 0. General linear models were used for comparison of diabetic and nondiabetic subjects means and prevalences were adjusted for age and survey.
Cox proportional hazards analysis was used 44 to determine the age- survey- and BMI-adjusted as well as the multivariable adjusted relative risk of type 2 diabetes mellitus. As a potential confounder, the variable survey was forced into the multivariable models. This assumption was met for all variables. ificance tests were 2-tailed, and P values less than. All analyses were performed with SAS software version 6. In total, incident cases of diabetes among men and 85 cases among women were registered in the to year-old study population between and ; men and women remained nondiabetic.
The diabetic persons were treated as follows: 12 persons received insulin only; received tablets only; 16 received insulin and tablets; and 62 were only following a specific diet. Two diabetic persons declared that they received no antidiabetic treatment, and an additional 3 had missing values for antidiabetic treatment. There was a male predominance in the incidence of diabetes; the age-standardized incidence rate of diabetes was 5. Table 3 describes the age- and survey-adjusted baseline characteristics of subjects by conversion status to type 2 diabetes mellitus at follow-up separately in men and women.
In both sexes, subjects who converted to type 2 diabetes were ificantly older and had higher BMI, systolic and diastolic blood pressure, and uric acid values than subjects who remained nondiabetic. In addition, future diabetic subjects had lower HDL cholesterol levels. ificantly more prediabetic subjects were actual hypertensive, and ificantly more reported angina pectoris and a positive parental history of diabetes. Prediabetic men had ificantly higher total cholesterol values and were more often regular smokers, and the percentage with a high daily alcohol intake was also increased compared with nondiabetic men.
ificantly more prediabetic women drank no alcohol and were physically inactive during leisure time in comparison with nondiabetic women. Since age and BMI are important predictors of diabetes and were strongly correlated with most other potential risk factors, age and BMI- and of the remaining risk factors that was independent of age and BMI Table 4. A positive parental history of diabetes showed a strong positive association with diabetes in both sexes. Actual hypertension was also associated with diabetes in both sexes but the effect was stronger in women. The HDL cholesterol level was inversely associated with diabetes in men and women.
Systolic as well as diastolic blood pressure was related to diabetes in men only. Total cholesterol level, an unknown parental history of diabetes, smoking, and a high daily alcohol intake were also associated with a higher risk of diabetes in men only. In contrast, uric acid level and physical inactivity during leisure time were related to diabetes in women only Table 4. To investigate which of the baseline characteristics identified as risk factors in the analysis were also independent predictors of diabetes, a backward stepwise multiple logistic regression analysis was performed.
Table 5 shows the from the fully adjusted models for men and women. Furthermore, the variable actual hypertension was also omitted in the multivariable model. Age men and women: HR per 1 year increase, 1. A positive parental history of diabetes was also a strong predictor for the development of type 2 diabetes in both sexes men: HR, 2.
In men, the association with an unknown parental history of diabetes was no longer ificant in the multivariable model. Systolic blood pressure was independently associated with diabetes in men only HR per 10—mm Hg increase, 1. Furthermore, regular smoking HR, 1.
These findings were unchanged if the factors shown to be independently associated with diabetes were examined in a separate analysis in which 77 men and 61 women with preexisting coronary heart disease, ie, persons with a diagnosis of either myocardial infarction or angina pectoris at baseline examination, were excluded data not shown. To our knowledge, the MONICA Augsburg Cohort Study is the first prospective population-based study to assess the sex-specific incidence of type 2 diabetes mellitus in a middle European population characterized by a relatively low risk of cardiovascular morbidity and mortality.
High systolic blood pressure, regular cigarette smoking, and high daily alcohol intake predicted diabetes in men only, whereas high uric acid values and physical inactivity during leisure time were associated with a higher risk of diabetes in women only. The MONICA Augsburg Cohort Study is one of the few studies that examined the association between a variety of cardiovascular risk factors and the incidence of diabetes in both sexes in the same study population. This facilitates the comparison between men and women, since one can be sure that the same methods have been used to determine risk factors in both sexes.
While both men and women have been examined in some other studies, 20212531 the Framingham Study 20 and the Finnmark Study 25 were the only ones that assessed the impact of several risk factors on the incidence of diabetes. Thus, for most risk factors, one has to rely on from different studies to compare the effects in men and women, which makes comparisons more difficult.
Concerning the predictive importance of low HDL cholesterol levels, contradictory were reported from the Framingham Study, 20 which showed ificant effects in men only, and from the Finnmark Study, 25 which demonstrated a ificant predictive relevance in women only.
Similar have been observed in 3 other prospective cohort studies in men. In contrast to systolic blood pressure, in the present study, actual hypertension was strongly associated with diabetes in men and women. Thus, the low impact of systolic blood pressure in women might be attributed to the fact that more women with actual hypertension had controlled blood pressure values in comparison with men.Independent black women sex workers in Augsburg
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