Reasons to recommend lifestyle changes in type 2 diabetes mellitus and obesity
Nat. Rev. Cardiol.
Reasons to recommend lifestyle changes in type?2 diabetes mellitus and obesity
Rainer Spiegel 0
0 Heidelberg University Hospital, Department of Internal Medicine I (Endocrinology, Nephrology, Osteology) and Clinical Chemistry , Im Neuenheimer Feld 410, 69210 Heidelberg , Germany
NATURE REVIEWS | CARDIOLOGY
In her Research Highlight (Diabetes: Look
AHEAD published: weight loss not linked
to fewer cardiovascular events in patients
with type?2 diabetes. Nat. Rev. Cardiol. 10,
429 ),1 Bryony M. Mearns focuses
on data from the randomized, multicentre
Look AHEAD study,2 where intensive life?
style modifications were not linked to fewer
cardiovascular events during a 10?year
follow? up period in patients with type?2 dia?
betes mellitus and obesity. This finding has
important implications in various clinical
fields, including cardiology, endocrinology,
and nephrology. Clinicians often suggest life?
style modifications with the aim of reducing
coronary heart disease. On the basis of the
new evidence, the question arises whether
lifestyle modifications, such as weight loss,
should still be recommended in the absence
of a demonstrated reduction in cardio?
vascular events. As a clinician with a par?
ticular interest in cardiology, endocrinology,
and nephrology, I would still suggest lifestyle
modifications for three reasons.
First, the reduction of cardiovascular
events is not the only reason that clini?
cians suggest lifestyle modifications. An
equally important reason is to prevent
end? stage renal disease, which is linked to
obesity, hypertension, and type?2 diabetes,3,4
and has not been addressed in the Look
Second, evidence demonstrates a link
between a decrease in glomerular filtra?
tion rate and atherosclerosis.5?10 Given that
decreased renal function is a risk factor
for atherosclerosis,4?10 and also linked to
type?2 diabetes and obesity,3,4 its neglect in
the Look AHEAD study2 implies that not
all risk factors have been controlled for.
Investigators in future studies will need to
incorporate renal function to judge whether
a link exists between weight loss and cardio?
vascular events in patients with type? 2
diabetes and obesity.
Third, the question arises as to why par?
ticipants in the Look AHEAD study2 did
not benefit from intensive lifestyle modifi?
cations in terms of cardiovascular events.
One possible reason could be that, upon
recruitment, atherosclerosis was already
present in a large proportion of the study
participants. The aim of lifestyle modifica?
tions, however, is to prevent premature onset
of atherosclerosis, as this preventive step is
likely to reduce the incidence of cardio?
vascular events. Therefore, starting lifestyle
modifications at a much earlier stage than in
the Look AHEAD study2 (where the young?
est participants were aged 45?years, and the
mean age was slightly >58?years) is vital.
Modifications should optimally happen
before diabetes and obesity develop. Healthy
lifestyles could be encouraged at the com?
munity level, in schools, and by local health
centres, with a focus on children and ado?
lescents?that is, long before people are
referred to a cardiologist for treatment.
The author declares no competing interests.