Diabetes mellitus and tobacco: The perfect storm

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Montes-Santiago" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Montes-Santiago" "email" => array:1 [ 0 => "julio.montes.santiago@sergas.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Complejo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diabetes mellitus y tabaco: la tormenta perfecta" ] ] "textoCompleto" => "The film “The Perfect Storm” (2000), starring George Clooney, dramatizes an actual event. In October 1991, the fishing vessel “Andrea Gail” (of Gloucester, Massachusetts) faced a “superstorm”, with waves exceeding 25m, a storm formed by the confluence of two terrible tempests: a cold one originating on land and a hot one birthed by the sea. The story of the Andrea Gail does not end well, as shown by the burial scene for the sailors at the closing of the film.Cardiovascular diseases (CVDs) constitute an authentic “superstorm” of morbidity and mortality for today's societies. The 2016 Global Burden of Disease showed that CVDs are the main cause of death and disability (approximately 18 million deaths and 353 million disability-adjusted life years [DALYs]).<a class="elsevierStyleCrossRef" href="#bib0080">1</a> However, this cardiovascular “tsunami” is formed by the confluence of numerous tempests that constitute the cardiovascular risk factors (CRFs). The INTERHEART study, which included 15152 incident cases of acute myocardial infarction (AMI) and 14820 controls in 52 countries, showed that nine CRFs were to blame for 90% of AMIs.<a class="elsevierStyleCrossRef" href="#bib0085">2</a> The two most important CRFs were hypercholesterolemia (abnormal Apo B/Apo A-1 ratio) and smoking. The other predictors of risk were diabetes mellitus (DM), arterial hypertension (AHT), abdominal obesity, psychosocial variables (such as stress and depression), physical inactivity, inadequate diet and alcohol consumption. The INTERSTROKE study (which included 10388 cases of ischemic stroke, 3059 cases of cerebral hemorrhage and 13472 controls in 32 countries) corroborated these data, showing similar CRFs responsible for 91% of such processes, although with different degrees of contribution.<a class="elsevierStyleCrossRef" href="#bib0090">3</a> AHT, physical inactivity and hypercholesterolemia were the main CRFs in the study.Numerous other studies that used the Framingham paradigm showed that CRFs were additive, i.e., that the coexistence of several CRFs raised the risk of CVD exponentially. This additivity was the conceptual basis for developing cardiovascular risk scales (Framingham, United Kingdom Prospective Diabetes Study [UKPDS], Systematic Coronary Risk Evaluation [SCORE], REGICOR for Spain, etc.), which sought to quantify the probability of CVD and whose use is widely recommended in cardiovascular prevention guidelines.<a class="elsevierStyleCrossRef" href="#bib0095">4</a> Although a recent Cochrane Review assessing the effectiveness of these scales has raised a number of issues,<a class="elsevierStyleCrossRef" href="#bib0100">5</a> the instruments are generally accepted as useful for designing, implementing and intensifying preventive and treatment measures in controlling CRFs and CVD.Not surprisingly, DM and smoking are two of the main CRFs. In 2016, 451 million individuals had DM, with 1.4 million deaths and 57 million DALYs.<a class="elsevierStyleCrossRefs" href="#bib0080">1,6</a> Smoking, for its part, causes 7.1 million deaths and 177 million DALYs.<a class="elsevierStyleCrossRefs" href="#bib0080">1,6</a> Spain is not immune to this scourge, with 4626557 individuals with DM over the age of 18 years (12% prevalence rate; 3.9% unknown), with 35541 deaths and 616000 DALYs annually and direct costs of €5809 million.<a class="elsevierStyleCrossRef" href="#bib0110">7</a> There are 10724238 individuals over the age of 18 years who smoke (27.8% prevalence rate), with 57216 deaths and 1.1 million DALYs annually.<a class="elsevierStyleCrossRefs" href="#bib0080">1,6–8</a>When the two “tempests” converge, the cardiovascular tsunami is devastating. According to INTERHEART, when DM and smoking coexist and AHT is added to the mix, the risk of AMI is 13.1 times greater (compared to 2.9 for smoking, 2.7 for DM and 1.9 for AHT, separately).<a class="elsevierStyleCrossRef" href="#bib0085">2</a> This “malignant synergy” therefore seems well established epidemiologically. However, even this concept of mere CRF additivity as the causal agent of exponentially greater damage could be insufficient. There is consistent evidence as to the relationship between smoking and the onset of DM (smokers have a 30–40% greater risk of DM than nonsmokers).<a class="elsevierStyleCrossRef" href="#bib0120">9</a> Smoking is therefore a storm that causes and feeds on the other. It is therefore surprising that the risk assessment scales such as SCORE do not account for DM, along with age and sex, AHT, cholesterol and smoking. Changes in these scales have been subsequently published to include DM but perhaps without as much dissemination as the previous scales.<a class="elsevierStyleCrossRef" href="#bib0125">10</a>The study by Luque-Ramírez and Sanz de Burgoa<a class="elsevierStyleCrossRef" href="#bib0130">11</a> added new evidence on the deleterious association between DM and smoking or, if one prefers, the positive effect that smoking cessation has on the prognosis of DM. This research study is welcome as it provides clarity to the Spanish situation, which presents lower CVD mortality than other countries but remains the main cause of death. In 2016, there were 119778 deaths due to CVD (29.2% of the total) and more than 500000 hospitalizations due to atherothrombosis/CRF-related processes (survey on hospital morbidity and causes of death [INE, 2016]). A financial prospective study in six European countries estimated that approximately 950000 deaths due to CVD will have occurred in Spain between 2014 and 2020 and that the expenses for morbidity and mortality in 2020 will be €8800 million (14% increase).<a class="elsevierStyleCrossRef" href="#bib0135">12</a> It therefore appears that smoking cessation, along with controlling other CRFs, is the most cost-effective measure.However, smoking cessation is not easy. As the 2017 Report on Tobacco Use Policies warns,<a class="elsevierStyleCrossRef" href="#bib0140">13</a> the situation needs to be improved, because smoking cessation programs appear to have decreased and have not recovered since the financial crisis. Another problem is the fragmentation of care and the organizational chaos in the various autonomous communities of Spain (where, for example, some smoking cessation units depend on mental health departments, while others depend on addiction departments).It appears abundantly clear that the most effective approach for fighting CVD is multifactorial and coordinated. Despite the threatening storms, clear skies can be glimpsed if certain correct actions are taken. The CIFARC study showed, for example, that coordination by an internist in controlling CRFs was an effective approach and prevented the dispersion of healthcare.<a class="elsevierStyleCrossRef" href="#bib0145">14</a> During 1998–2005, 8530 deaths by ischemic heart disease were prevented in Spain, attributable both to the implementation of preventive measures (cholesterol control, hypertension control, etc.) and to more appropriate treatments in the acute phase. However, this is overshadowed by certain dark clouds, such as the growing incidence of DM and obesity (“diabesity”).<a class="elsevierStyleCrossRef" href="#bib0150">15</a> The percentage of smoking continues to decrease (current rate of use, 22%; National Health Survey 2017), however the upturn in the young is worrisome. In 2016, 184600 students between the ages of 14 and 18 years started to smoke (50000 more than in 2014; 2016/2017 ESTUDES survey, Ministry of Health, Spain).The task is huge and carries the risk of setbacks, but there are data indicating we are heading in the right direction. It is up to the researchers of articles, such as the one by Luque-Ramírez and Sanz de Burgoa, and their readers to continue being the driving forces in this direction." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Montes-Santiago J. Diabetes mellitus y tabaco: la tormenta perfecta. 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implementing and intensifying preventive and treatment measures in controlling CRFs and CVD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Not surprisingly&#44; DM and smoking are two of the main CRFs&#46; In 2016&#44; 451 million individuals had DM&#44; with 1&#46;4 million deaths and 57 million DALYs&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;6</span></a> Smoking&#44; for its part&#44; causes 7&#46;1 million deaths and 177 million DALYs&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;6</span></a> Spain is not immune to this scourge&#44; with 4<span class="elsevierStyleHsp" style=""></span>626<span class="elsevierStyleHsp" style=""></span>557 individuals with DM over the age of 18 years &#40;12&#37; prevalence rate&#59; 3&#46;9&#37; unknown&#41;&#44; with 35<span class="elsevierStyleHsp" style=""></span>541 deaths and 616<span class="elsevierStyleHsp" style=""></span>000 DALYs annually and direct costs of &#8364;5809 million&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> There are 10<span class="elsevierStyleHsp" style=""></span>724<span class="elsevierStyleHsp" style=""></span>238 individuals over the age of 18 years who smoke &#40;27&#46;8&#37; prevalence rate&#41;&#44; with 57<span class="elsevierStyleHsp" style=""></span>216 deaths and 1&#46;1 million DALYs annually&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;6&#8211;8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">When the two &#8220;tempests&#8221; converge&#44; the cardiovascular tsunami is devastating&#46; According to INTERHEART&#44; when DM and smoking coexist and AHT is added to the mix&#44; the risk of AMI is 13&#46;1 times greater &#40;compared to 2&#46;9 for smoking&#44; 2&#46;7 for DM and 1&#46;9 for AHT&#44; separately&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> This &#8220;malignant synergy&#8221; therefore seems well established epidemiologically&#46; However&#44; even this concept of mere CRF additivity as the causal agent of exponentially greater damage could be insufficient&#46; There is consistent evidence as to the relationship between smoking and the onset of DM &#40;smokers have a 30&#8211;40&#37; greater risk of DM than nonsmokers&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> Smoking is therefore a storm that causes and feeds on the other&#46; It is therefore surprising that the risk assessment scales such as SCORE do not account for DM&#44; along with age and sex&#44; AHT&#44; cholesterol and smoking&#46; Changes in these scales have been subsequently published to include DM but perhaps without as much dissemination as the previous scales&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The study by Luque-Ram&#237;rez and Sanz de Burgoa<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> added new evidence on the deleterious association between DM and smoking or&#44; if one prefers&#44; the positive effect that smoking cessation has on the prognosis of DM&#46; This research study is welcome as it provides clarity to the Spanish situation&#44; which presents lower CVD mortality than other countries but remains the main cause of death&#46; In 2016&#44; there were 119<span class="elsevierStyleHsp" style=""></span>778 deaths due to CVD &#40;29&#46;2&#37; of the total&#41; and more than 500<span class="elsevierStyleHsp" style=""></span>000 hospitalizations due to atherothrombosis&#47;CRF-related processes &#40;survey on hospital morbidity and causes of death &#91;INE&#44; 2016&#93;&#41;&#46; A financial prospective study in six European countries estimated that approximately 950<span class="elsevierStyleHsp" style=""></span>000 deaths due to CVD will have occurred in Spain between 2014 and 2020 and that the expenses for morbidity and mortality in 2020 will be &#8364;8800 million &#40;14&#37; increase&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> It therefore appears that smoking cessation&#44; along with controlling other CRFs&#44; is the most cost-effective measure&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">However&#44; smoking cessation is not easy&#46; As the 2017 Report on Tobacco Use Policies warns&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> the situation needs to be improved&#44; because smoking cessation programs appear to have decreased and have not recovered since the financial crisis&#46; Another problem is the fragmentation of care and the organizational chaos in the various autonomous communities of Spain &#40;where&#44; for example&#44; some smoking cessation units depend on mental health departments&#44; while others depend on addiction departments&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">It appears abundantly clear that the most effective approach for fighting CVD is multifactorial and coordinated&#46; Despite the threatening storms&#44; clear skies can be glimpsed if certain correct actions are taken&#46; The CIFARC study showed&#44; for example&#44; that coordination by an internist in controlling CRFs was an effective approach and prevented the dispersion of healthcare&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> During 1998&#8211;2005&#44; 8530 deaths by ischemic heart disease were prevented in Spain&#44; attributable both to the implementation of preventive measures &#40;cholesterol control&#44; hypertension control&#44; etc&#46;&#41; and to more appropriate treatments in the acute phase&#46; However&#44; this is overshadowed by certain dark clouds&#44; such as the growing incidence of DM and obesity &#40;&#8220;diabesity&#8221;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> The percentage of smoking continues to decrease &#40;current rate of use&#44; 22&#37;&#59; National Health Survey 2017&#41;&#44; however the upturn in the young is worrisome&#46; In 2016&#44; 184<span class="elsevierStyleHsp" style=""></span>600 students between the ages of 14 and 18 years started to smoke &#40;50<span class="elsevierStyleHsp" style=""></span>000 more than in 2014&#59; 2016&#47;2017 ESTUDES survey&#44; Ministry of Health&#44; Spain&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The task is huge and carries the risk of setbacks&#44; but there are data indicating we are heading in the right direction&#46; It is up to the researchers of articles&#44; such as the one by Luque-Ram&#237;rez and Sanz de Burgoa&#44; and their readers to continue being the driving forces in this direction&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Montes-Santiago J&#46; Diabetes mellitus y tabaco&#58; la tormenta perfecta&#46; Rev Clin Esp&#46; 2018&#59;218&#58;421&#8211;423&#46;</p>"
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