Disturbed Chylomicron Metabolism in Type 2 Diabetes - A Preventable Cause of Atherosclerosis?

Diabetes remains a fascinating condition to observe and treat, at least for the authors. The rewards of observing patients who remain free of complications many, many years after diagnosis is however negated by seeing the terrible consequences of diabetic complications which occur, not only in patients who have had the disease for many years but also in those who are found to have the disease when they first present with complications. The evolution of diabetes care has been fueled by new pharmaceutical agents and the large trials that have followed demonstrating benefit. There have of course been occasional trials that have upset patients, diabetologists and people looking after diabetes as well as the pharmaceutical industry. An example early in my career as a diabetologist was the University Group diabetes program (UGDP) [1] which suggested harm rather than benefit from the sulphonylurea Tolbutamide and the biguanide Phenformin. The controversy which this trial caused was truly amazing involving the Supreme Court in the United States. Not many trials have been scrutinized by a national supreme court. A more recent example is the ACCORD study [2] which set out to examine the benefit of reducing blood sugar to below 6mmol/l. This study was stopped early because, although there was a reduction in myocardial infarction there was an increase in mortality. These trials have resulted in a magnificent increase in speculative literature and new consensus statements from lots of different bodies enthusiastic about giving advice through guidelines. The Annals of Internal Medicine is to be congratulated on publishing a paper written by Davidof “Music lessons; what Musicians can teach Doctors”[3]. The care of diabetes is certainly both an art and a science in 2011 and this article should re-enforce the diabetologist to be secure in practicing art as well as science in the management of diabetes. Cardiovascular disease is unfortunately the major cause of death in patients with diabetes. For example in the San Antonia Heart Study Halfner et al [4] demonstrated the increased risk of cardiovascular mortality in patients with diabetes but without a previous MI was the same as that of non diabetic patients who already have had MI although another study disputed this [5]. A third prospective study in Finland demonstrated similar results to the San Antonia Study [6] and a metanalysis in 2009 confirmed this relationship [7]. Looking at the situation in a different way it has been shown that diabetic patients have a life expectancy 8-15 years less than non-diabetic people. Recently a prospective study of men aged 60 – 69 years followed up for 9 years was reported [8]. The authors found that only