Overweight is an independent risk factor for cardiovascular disease in Chinese populations

In the last decade of the 20th century, cardiovascular disease was the leading cause of death in China, accounting for one‐third of the total deaths. In comparison with western populations, the mean body weight or body mass index (BMI) of the Chinese population was lower, but showed an increasing trend. Whether the variation within lower levels of BMI or waist circumference was associated with other risk factors of cardiovascular disease, and whether they contribute independently to the risk of cardiovascular disease in the Chinese population, was investigated in this study. In keeping with a uniform study design, in each of 14 study populations at different geographical locations and with different characteristics, the incidence rates of stroke, coronary heart disease (CHD) and the causes of death were monitored in ≈100 000 residents from 1991 to 1995 using the MONICA procedure. Risk factors were surveyed in a random cluster sample of 1000 subjects (35–59 years of age) from each population under surveillance using internationally standardized methods and a centralized system to ensure quality control. Among the risk factors, body weight, height, and waist and hip circumferences were measured. Cross‐sectional stratified analyses were used to analyse the relationship of BMI (kg m^?2) or waist circumference to other metabolic risk factors. Ten cohorts among the 14 study populations with 24 734 participants were surveyed from 1982 to 1985 as a baseline for further study and were followed‐up for 9 years taking the events of stroke, CHD and different causes of death as end‐points. Cox regression models were used to explore the association of BMI with the relative risks of stroke, CHD and total death. The survey in 14 random samples with a total number of 19 741 subjects showed that the mean BMI (20.8–25.1) and waist circumference (67.8–86.7 cm) were much lower than those of western populations. There was, however, variation in the anthropometric measurements among populations within China. Thus, rates of overweight varied from 2.7% to 48.1% and obesity from 0% to 9.5% on the basis of the World Health Organization (WHO) classification, but these values were lower than those found in western populations. Data from the 10 cohort samples compared with baseline data in the early 1980s showed that the mean BMIs increased significantly in eight populations during the early 1990s with the differences ranging from 0.5 to 2.5 kg m^?2. Despite the lower level of BMI and the lower rate of overweight, cross‐sectional analyses showed that the prevalence of hypertension, high fasting serum glucose, high serum total cholesterol and low high‐density lipoprotein cholesterol (HDL‐C) and their clustering were all raised with increases in BMI or waist circumference. The prospective cohort study showed that the BMI was one of the independent risk factors for stroke and CHD in Chinese populations. Hence, in a Chinese population characterized by lower levels of BMI and great variability in rates of overweight, variation of BMI was significantly related to the prevalence of other metabolic risk factors and their clustering. Overweight was one of the independent risk factors for stroke and CHD, both at population and individual levels. Given the increasing trends of BMI in the last 10 years, during the period of economic transition there is a need to encourage the population to adopt healthy dietary habits and to increase their physical activity. Health education and health promotion are important for the prevention and non‐pharmacological therapy of cardiovascular disease in China.     

Relation of fibrinogen to cardiovascular events is independent of preclinical cardiovascular disease: the Strong Heart Study

Background It is unclear whether fibrinogen predicts cardiovascular events independently of echocardiographic cardiovascular abnormalities and traditional risk factors. Methods We studied 2671 American Indians who participated in the second Strong Heart Study examination (1993-1995) and were observed for an average of 50 ± 6 months. Participants with baseline overt coronary artery disease or a plasma creatinine level ≥3 mg/dL were excluded. Left ventricular hypertrophy, elevated arterial stiffness, and subnormal myocardial contractility were assessed by echocardiography. Results Prevalences of echocardiographic abnormalities and cardiovascular event rates were higher with higher fibrinogen levels. Incident cardiovascular events (n = 158) and deaths (n = 64) were more frequent in participants with elevated fibrinogen levels (>400 mg/dL) than in participants with lower fibrinogen levels, as was the prevalence of echocardiographic abnormalities (both P < .01). Incident cardiovascular fatal and nonfatal events and cardiovascular deaths were 4 and 8 times higher, respectively, in participants with both elevated fibrinogen levels and echocardiographic abnormalities than in participants with neither echocardiographic abnormalities nor elevated fibrinogen levels. However, participants with fibrinogen levels >400 mg/dL had a 2 times greater relative risk of cardiovascular events or mortality, independent of both risk factors and echocardiographic abnormalities. Conclusions In a population-based sample of adults without clinical evidence of coronary artery disease at baseline, fibrinogen levels predicted cardiovascular events independent of traditional risk factors, left ventricular hypertrophy, elevated arterial stiffness, and subnormal myocardial systolic function. (Am Heart J 2003;145:467-74.)     

Haptoglobin 2-2 phenotype is a risk factor for type 2 diabetes in Ghana

We have investigated the role of haptoglobin gene polymorphisms in 129 type 2 diabetic patients and 87 non-diabetic subjects, classified by the ADA criteria, in Ghana. The diabetic subjects were recruited consecutively from the National Diabetic Management and Research Center of the University of Ghana Medical School, Korle-Bu, Accra, Ghana and were categorized by their haptoglobin phenotypes. The haptoglobin 2 allele was determined to be a risk factor for type 2 diabetes in Ghana (OR = 6.1, 95% CI = 1.8-21.2; P = .0.001) while the Hp1 allele appeared protective (OR = 0.56, 95% CI = 0.31-1.0; P = .06). The deleterious role of the Hp2 allele was further evidenced by the reduced risk associated with Hp2-1M mutant heterozygotes, who produce less Hp2 protein than the normal Hp2-1 heterozygote. (OR = 0.52, 95% CI = 0.27-1.0; P = 0.06). The subjects with the homozygous Hp2 allele were also hypertensive and overweight. There was no difference (p > 0.05) in the levels of triglycerides, total cholesterol, LDL and HDL between diabetic subjects with different haptoglobin phenotypes.We conclude that hypertensive and overweight individuals with the Hp2-2 phenotype in Ghana are at a high risk of developing type 2 diabetes and may require a more aggressive management.     

代谢综合征在缺血性卒中患者心脑血管事件发生中的作用

Objective To explore the association between metabolic syndrome (MS) and risk of cardiovascular disease events (CVD) in patients with ischemic stroke. Method A total of 1087 patients with ischemic stroke were enrolled from 5 community-based medical centres and underwent baseline evaluation on risk factors of stroke during the period of Jar. 2003 to Dec. 2006. After baseline survey, all patients were followed up until Dec 31, 2008 and new CVD events were recorded. MS was defined using CDS criteria. Proportional hazard models were used to assess the HRus and 95% CI of CVD events associated with MS and other components. Results The prevalence of MS was 40. 4% at baseline. During an average follow-up of 3.5 years, 178 patients developed new CVD events. After adjusted for age, gender, smoking,drinking, marriage status, education level, hospitalization, recurrence of stroke, stroke duration,depression, cognition impairment and ADL, MS remains the independent predictor for the risk of CVD events. Compared with patients with non-MS, the risk of CVD events increased by 44% (HR:1.44, 95%CI:1.06-1.95 ). The risk of CVD also increased with the number of MS components. Compared with patients with 1 or less than 1 components of MS, the risk of CVD events increased by 30% (HR:1. 30,95%CI:0.83-2.04) in those with 2 components and by 69% ( HR: 1.69,95% CI: 1.11-2.56) in those with 3or more components of MS. Hypertension and hyperglycemia and impaired fasting glucose also served as independent risk factors for CVD event ( all P ＜ 0. 001 ) . Conclusions MS was independently associated with increased risk of CVD events in patients with ischemic stroke. There was a dose-response relationship between the numbers of MS components and the risk of CVD event.     

代谢综合征在缺血性卒中患者心脑血管事件发生中的作用

目的 探讨缺血性卒中患者合并代谢综合征(metabolic syndrome,MS)与心血管(cardiovascular disease,CVD)事件发病的关系.方法于2003年1月至2006年12月期间对北京市5家二级医院所属的社区卫生服务中心/站就诊的首次或二次缺血性卒中患者进行登记,进行基线调查,随后进行随访,记录CVD事件发病情况,随访截止到2008年12月31日.采用2004年中华医学会糖尿病学分会关于代谢综合征的建议定义MS,用COX比例风险模型计算风险比(HR)和95%可信区间(95%CI),并控制各种混杂因素.结果共入选1087例缺血性卒中患者,基线调查时MS患病率为40.4%.随访时间平均3.5年,共有178例患者新发CVD事件.结果显示,MS是CVD事件发生的独立预报因素,在控制了年龄、性别、吸烟、饮酒、婚姻、文化程度、就诊医院、卒中次数、卒中病程、抑郁状态、认知功能、ADL依赖等因素后,MS组CVD事件发病危险是非MS组的1.44倍(HR:1.44,95% CI:1.06～1.95);结果还显示,与仅有1个MS组分的患者相比,存在2个、3个以上MS组分的患者,其CVD事件发病的危险分别增加了30%(HR:1.30,95%CI:0.83～2.04)和69%(HR:1.69,95% CI:1.11～2.56).MS各组分中,高血糖和高血压是CVD事件发病的独立危险因素,危险分别增加了78%(HR:1.78,95%CI:1.26～2.52)和91%(HR:1.91,95%CI:1.11～3.30).结论 MS是缺血性卒中患者发生CVD事件的独立危险因素,CVD事件的发生与代谢组分异常的数量呈剂量反应关系.

Abstract：

Objective To explore the association between metabolic syndrome (MS) and risk of cardiovascular disease events (CVD) in patients with ischemic stroke. Method A total of 1087 patients with ischemic stroke were enrolled from 5 community-based medical centres and underwent baseline evaluation on risk factors of stroke during the period of Jar. 2003 to Dec. 2006. After baseline survey, all patients were followed up until Dec 31, 2008 and new CVD events were recorded. MS was defined using CDS criteria. Proportional hazard models were used to assess the HRus and 95% CI of CVD events associated with MS and other components. Results The prevalence of MS was 40. 4% at baseline. During an average follow-up of 3.5 years, 178 patients developed new CVD events. After adjusted for age, gender, smoking,drinking, marriage status, education level, hospitalization, recurrence of stroke, stroke duration,depression, cognition impairment and ADL, MS remains the independent predictor for the risk of CVD events. Compared with patients with non-MS, the risk of CVD events increased by 44% (HR:1.44, 95%CI:1.06-1.95 ). The risk of CVD also increased with the number of MS components. Compared with patients with 1 or less than 1 components of MS, the risk of CVD events increased by 30% (HR:1. 30,95%CI:0.83-2.04) in those with 2 components and by 69% ( HR: 1.69,95% CI: 1.11-2.56) in those with 3or more components of MS. Hypertension and hyperglycemia and impaired fasting glucose also served as independent risk factors for CVD event ( all P ＜ 0. 001 ) . Conclusions MS was independently associated with increased risk of CVD events in patients with ischemic stroke. There was a dose-response relationship between the numbers of MS components and the risk of CVD event.     

代谢综合征在缺血性卒中患者心脑血管事件发生中的作用

Objective To explore the association between metabolic syndrome (MS) and risk of cardiovascular disease events (CVD) in patients with ischemic stroke. Method A total of 1087 patients with ischemic stroke were enrolled from 5 community-based medical centres and underwent baseline evaluation on risk factors of stroke during the period of Jar. 2003 to Dec. 2006. After baseline survey, all patients were followed up until Dec 31, 2008 and new CVD events were recorded. MS was defined using CDS criteria. Proportional hazard models were used to assess the HRus and 95% CI of CVD events associated with MS and other components. Results The prevalence of MS was 40. 4% at baseline. During an average follow-up of 3.5 years, 178 patients developed new CVD events. After adjusted for age, gender, smoking,drinking, marriage status, education level, hospitalization, recurrence of stroke, stroke duration,depression, cognition impairment and ADL, MS remains the independent predictor for the risk of CVD events. Compared with patients with non-MS, the risk of CVD events increased by 44% (HR:1.44, 95%CI:1.06-1.95 ). The risk of CVD also increased with the number of MS components. Compared with patients with 1 or less than 1 components of MS, the risk of CVD events increased by 30% (HR:1. 30,95%CI:0.83-2.04) in those with 2 components and by 69% ( HR: 1.69,95% CI: 1.11-2.56) in those with 3or more components of MS. Hypertension and hyperglycemia and impaired fasting glucose also served as independent risk factors for CVD event ( all P ＜ 0. 001 ) . Conclusions MS was independently associated with increased risk of CVD events in patients with ischemic stroke. There was a dose-response relationship between the numbers of MS components and the risk of CVD event.     

Remnant-like particle (RLP) cholesterol is an independent cardiovascular disease risk factor in women: results from the Framingham Heart Study

Remnants of triglyceride-rich lipoproteins (TRL) of both intestinal and liver origin are considered to be atherogenic, but separation of remnant lipoproteins from other TRL is difficult. An assay has been developed that allows immunoseparation of remnant-like particles (RLP) and measurement of cholesterol (RLP-C) and triglyceride (RLP-TG). We measured RLP-C and RLP-TG in fast plasma samples obtained from 1567 women participating in cycle 4 of the Framingham heart study (FHS). When values from 83 women with cardiovascular disease (CVD) were compared with the values from 1484 women without disease, concentrations in women with CVD were found to be significantly higher for both RLP-C (0.215+/-0.102 vs. 0.186+/-0.162 mmol/l; +15.6%; P<0.0001) and RLP-TG (0.319+/-0.352 vs. 0.251+/-0. 716 mmol/l; +27.0%; P<0.0002). Logistic regression analysis revealed that RLP-C was significantly associated with prevalent CVD in women (P<0.002) after adjustment with other major risk factors. In conclusion, we have documented that RLP-C is an independent risk factor for CVD in women, and provides significantly more information than do triglycerides.     

Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study

The relationship between the degree of obesity and the incidence of cardiovascular disease (CVD) was reexamined in the 5209 men and women of the original Framingham cohort. Recent observations of disease occurrence over 26 years indicate that obesity, measured by Metropolitan Relative Weight, was a significant independent predictor of CVD, particularly among women. Multiple logistic regression analyses showed that Metropolitan Relative Weight, or percentage of desirable weight, on initial examination predicted 26-year incidence of coronary disease (both angina and coronary disease other than angina), coronary death and congestive heart failure in men independent of age, cholesterol, systolic blood pressure, cigarettes, left ventricular hypertrophy and glucose intolerance. Relative weight in women was also positively and independently associated with coronary disease, stroke, congestive failure, and coronary and CVD death. These data further show that weight gain after the young adult years conveyed an increased risk of CVD in both sexes that could not be attributed either to the initial weight or the levels of the risk factors that may have resulted from weight gain. Intervention in obesity, in addition to the well established risk factors, appears to be an advisable goal in the primary prevention of CVD.     

Prehypertension, diabetes, and cardiovascular disease risk in a population-based sample: the Strong Heart Study

There are few data about the impact of the recently-defined category of prehypertension (systolic blood pressure 120 to 139 mm Hg or diastolic blood pressure 80 to 89 mm Hg) on cardiovascular disease incidence. It is also unknown whether this association differs between individuals with or without diabetes. A total of 2629 Strong Heart Study participants free from hypertension and cardiovascular disease at baseline examination were followed for 12 years to observe incident cardiovascular disease. Approximately 42% of the 2629 participants had diabetes. We assessed the prevalence of prehypertension and the hazard ratios of incident cardiovascular disease associated with prehypertension. Prehypertension was more prevalent in diabetic than nondiabetic participants (59.4% versus 48.2%, P<0.001 adjusted for age). Compared with nondiabetic participants with normal blood pressure, the hazard ratios of cardiovascular disease were 3.70 (95% confidence interval: 2.66, 5.15) for those with both prehypertension and diabetes, 1.80 (1.28, 2.54) for those with prehypertension alone and 2.90 (2.03, 4.16) for those with diabetes alone. Impaired glucose tolerance or impaired fasting glucose also greatly increased the cardiovascular disease risk in prehypertensive people. Clinical investigation of more aggressive interventions, such as drug treatment for blood pressure control for prehypertensive individuals with impaired fasting glucose, impaired glucose tolerance, or diabetes is warranted.     

主动脉脉搏波传导速度升高与冠心病发病的相关性

目的:探讨脉搏波传导速度(PWV)对冠心病(CHD)的预测价值。方法:患者分为非CHD组(97例)和CHD组(114例)。比较2组患者CHD危险因素以及各动脉段PWV的差异,采用Logistic回归分析比较上述危险因素在CHD发病中的作用。结果:CHD组患者的性别构成、年龄、高血压、糖尿病、血脂异常、吸烟等显著多于非CHD组(P<0.05),CHD组踝肱指数显著低于非CHD组。CHD组患者的心-左右股动脉段PWV和心-左右桡动脉段PWV显著大于非CHD组(P<0.01),而左右股-踝动脉段PWV在CHD组和非CHD组差异无统计学意义。Logistic回归分析发现,患高血压、糖尿病、血脂异常、吸烟以及心-股动脉段PWV升高、踝肱指数降低等与CHD的发生显著相关(P<0.05)。结论:同高血压、糖尿病、血脂异常、吸烟一样,心-右股动脉段PWV显著增高以及踝肱指数降低也是CHD发病的危险因素。     

Lewis blood group phenotype as an independent risk factor for coronary heart disease (the NHLBI Family Heart Study)

In the Copenhagen Male Study, men with Lewis blood group phenotype Le(a-b-) were found to have increased risk for coronary heart disease (CHD); such a relation has not been confirmed in men, and has not been evaluated in women. In the NHLBI Family Heart Study, we determined the Lewis blood type of 1,620 white subjects (790 male and 830 female subjects). The Lewis(a-b-) phenotype was found in 142 subjects (8.8%), 6.3% of subjects from randomly chosen families and 9.7% of subjects from families found to be at high risk for CHD. A history of CHD was present in 39.1% of men with Le(a-b-) versus 27.2% of men with other Lewis types; for women, the corresponding numbers were 12.3% versus 9.4%, respectively. In multivariate analysis, adjusting for age, sex, and risk group, the odds ratio for CHD was 2.0 (95% confidence interval = 1.2 to 3.1) for Le(a-b-) versus other Lewis groups. Mean values for body mass index, blood pressure, total cholesterol, low-density lipoprotein and high-density lipoprotein cholesterol, glucose, insulin, homocysteine, and fibrinogen were not significantly different between Le(a-b-) subjects and others, but triglycerides (p = 0.002) were higher in the Le(a-b-) subjects. However, inclusion of all risk factors in multivariate analysis did not diminish the increased risk for CHD associated with the Le(a-b-) phenotype. We conclude that the Le(a-b-) phenotype is associated with an increased risk for CHD; its effect does not appear to act predominantly through conventional cardiovascular risk factors. At present, mechanisms of effect are unknown.     

Lipoprotein(a) is an independent risk factor for cardiovascular disease in hemodialysis patients.

BACKGROUND. Although serum lipoprotein(a) [Lp(a)] is an independent risk factor for atherosclerosis in the general population and Lp(a) levels are increased in hemodialysis patients, an association of Lp(a) with the risk of clinical events attributed to atherosclerosis has not been established in the chronic hemodialysis patient population. We therefore determined the association between Lp(a) levels and the risk of clinical events of presumed atherosclerotic etiology in a prospective study of an outpatient hemodialysis population. METHODS AND RESULTS. Lp(a) was measured by radioimmunoassay in a baseline cardiovascular disease risk assessment in a consecutive series of 129 hemodialysis patients. The relation between baseline Lp(a) and clinical events of presumed atherosclerotic etiology was determined during 48 months of follow-up. Hemodialysis patients had a median Lp(a) concentration that was approximately four times as high as the median Lp(a) concentration in normal controls and twice as high as the levels in controls with angiographic evidence of coronary artery disease [median Lp(a), 38.4 versus 16.9 mg/dl; p less than 0.001]. Baseline Lp(a) levels were no different in participants with or with no history of a previous clinical event at the time of the baseline examination. However, baseline Lp(a) concentration (p less than 0.001) and a history of atherosclerotic clinical events (p = 0.001) were associated with clinical events during the period of follow-up. In contrast, baseline serum total cholesterol, triglyceride, high density lipoprotein cholesterol, low density lipoprotein cholesterol, age, gender, race, or duration of hemodialysis were unrelated to this risk in the prospective study. Stepwise multiple logistic regression analysis demonstrated that serum Lp(a) concentration (p = 0.001) and the presence of a previous clinical event (p = 0.004) were the only independent contributors to the risk of a clinical event during the period of follow-up. CONCLUSIONS. Lp(a) is an independent risk factor for clinical events attributed to atherosclerotic cardiovascular disease in patients receiving chronic hemodialysis treatment of end-stage renal disease.     

Parental history is an independent risk factor for coronary artery disease: the Framingham Study

Family history of CAD, defined as parental death by CAD, was found to be a significant independent predictor of CAD in a logistic regression model controlling for standard risk factors and length of follow-up among the 5209 participants in the Framingham Study. Persons with a positive parental history have a 29% increased risk of CAD, and the strength of the association between parental history and CAD is similar to that found for other standard risk factors such as systolic blood pressure, cholesterol level, and cigarette smoking. No evidence was found that persons with a family history of CAD have a decreased capacity to cope with the deleterious effects of known risk factors; that is, no significant interaction was found between any of the risk factors and parental history of CAD. Among men with low risk for CAD by risk-factor profile (i.e., nonsmoking, thin, nonhypertensive persons), more than two thirds of those who experience CAD have a positive parental history. This study suggests that CAD among persons who are predicted to be at low risk by standard risk factors may have a substantial genetic component and that the risk associated with parental history may not be reduced by modification of these factors. Nevertheless, among persons with a positive family history, those with a favorable risk profile are at substantially less risk for CAD than those with an unfavorable risk profile.     

Low free testosterone is an independent risk factor for Alzheimer's disease

The purpose of this study was to assess pituitary gonadotropins and free testosterone levels in a larger cohort of men with Alzheimer's disease (AD, n=112) and age-matched controls (n=98) from the Oxford Project to Investigate Memory and Ageing (OPTIMA). We measured gonadotropins (follicle stimulating hormone, FSH, and luteinizing hormone, LH), sex hormone binding globulin (SHBG, which determines the amount of free testosterone) and total testosterone (TT) using enzyme immunoassays. AD cases had significantly higher LH and FSH and lower free testosterone levels. LH, FSH and SHBG all increased with age, while free testosterone decreased. Low free testosterone was an independent predictor for AD. Its variance was overall explained by high SHBG, low TT, high LH, an older age and low body mass index (BMI). In controls, low thyroid stimulating hormone levels were also associated with low free testosterone. Elderly AD cases had raised levels of gonadotropins. This response may be an attempt to normalize low free testosterone levels. In non-demented participants, subclinical hyperthyroid disease (a risk factor for AD) which can result in higher SHBG levels, was associated with low free testosterone. Lowering SHBG and/or screening for subclinical thyroid disease may prevent cognitive decline and/or wasting in men at risk for AD.     

Biomarkers of cardiovascular disease: contributions to risk prediction in individuals with diabetes

Cardiovascular disease is a leading cause of death, especially in individuals with diabetes mellitus, whose risk of morbidity and mortality due to cardiovascular disease is markedly increased compared with the general population. There has been growing interest in the identification of biomarkers of cardiovascular disease in people with diabetes. The present review focuses on the current and potential contributions of these biomarkers to predicting cardiovascular risk in individuals with diabetes. At present, certain biomarkers and biomarker combinations can lead to modest improvements in the prediction of cardiovascular disease in diabetes beyond traditional cardiovascular risk factors. Emerging technologies may enable the discovery of novel biomarkers and generate new information about known biomarkers (such as new combinations of biomarkers), which could lead to significant improvements in cardiovascular disease risk prediction. A critical question, however, is whether improvements in risk prediction will affect processes of care and decision making in clinical practice, as this will be required to achieve the ultimate goal of improving clinical outcomes in diabetes.     

Risk factors for cardiovascular disease in individuals with diabetes

Coronary heart disease (CHD) is the leading cause of death among individuals with diabetes. However, information on CHD and its association with known risk factors in populations with high rates of diabetes is limited. The purpose of the Strong Heart Study is to quantify CHD and its risk factors among three geographically diverse groups of American Indians who have a high prevalence of diabetes. The study group consisted of 4549 adults between 45 and 74 years of age in 13 Indian communities in Arizona, Oklahoma, and South and North Dakota. Rates of diabetes ranged from 33% to 72% in men and women in the three centers. The prevalence rates of definite myocardial infarction (MI) and definite CHD were higher in man than in women in all three centers (P<0.0001) and higher in those with diabetes (P=0.002 andP=0.0003 in women and men, respectively). Diabetes was associated with a relatively greater increase in prevalence of MI (PR=3.8 vs 1.9) and CHD (PR=4.6 vs 1.8) in women than in men. Logistic regression analysis indicated that prevalent CHD was significantly related to age, diabetes, hypertension, albuminuria, percent body fat, smoking, high concentrations of plasma insulin, and low concentrations of high-density lipoprotein (HDL)-cholesterol. These findings from the baseline Strong Heart Study examination emphasize the relative importance of diabetes-associated variables as risk factors for CHD among populations with high rates of diabetes.Invited lecture presented during the 6th International Milano Meeting on Diabetes held in Milan on 21–23 March, 1996