Margaret A.WinkerMDIndividualAuthorPhil B.FontanarosaMD, Senior EditorsIndividualAuthor
To the Editor.—The study by Dr Purnell and colleagues1 also has important implications for rethinking the role of intensive glucose control with insulin in type 2 diabetes. Previous clinical trials2,3 and now the study by Purnell et al1 suggest that treatments that raise insulin levels, increase weight and worsen cardiovascular risk factors despite improving glycemia. In 3 European cohorts totaling 17,000 nondiabetic working men, the all-cause mortality was significantly greater for those who had the highest glucose intolerance but not high enough for a diagnosis of diabetes.4 Duration rather than severity of glycemia is a greater risk factor for coronary artery disease (CAD), suggesting a shared underlying pathophysiologic process, endothelial cell dysfunction. Enderle et al5 suggest that a longer period of undetected diabetes rather than poor glucose control impairs endothelial-dependent vasodilatation in type 2 diabetes.
Freedland ES. Excessive Weight Gain and Effects on Lipids With Intensive Therapy of Type 1 Diabetes. JAMA. 1998;280(23):1991-1992. doi:10-1001/pubs.JAMA-ISSN-0098-7484-280-23-jbk1216