The risk of death from cardiovascular disease is substantially increased among those with:

journal article

Elizabeth A. Spencer, Kirstin L. Pirie, Richard J. Stevens, Valerie Beral, Anna Brown, Bette Liu, Jane Green and Gillian K. Reeves

European Journal of Epidemiology

Vol. 23, No. 12 (2008)

, pp. 793-799 (7 pages)

Published By: Springer

https://www.jstor.org/stable/40284085

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Abstract

To compare the effect of potentially modifiable lifestyle factors on the incidence of vascular disease in women with and without diabetes. In 1996-2001 over one million middle-aged women in the UK joined a prospective study, providing medical history, lifestyle and sociodemographic information. All participants were followed for hospital admissions and deaths using electronic recordlinkage. Adjusted relative risks (RRs) and incidence rates were calculated to compare the incidence of coronary heart disease and stroke in women with and without diabetes and by lifestyle factors. At recruitment 25,915 women (2.1% of 1,242,338) reported current treatment for diabetes. During a mean follow-up of 6.1 years per woman, 21,928 had a first hospital admission or death from coronary heart disease ( RR for women with versus without diabetes = 3.30, 95% CI 3.14-3.47) and 7,087 had a first stroke (RR = 2.47, 95% CI 2.24- 2.74). Adjusted incidence rates of these conditions in women with diabetes increased with duration of diabetes, obesity, inactivity and smoking. The 5-year adjusted incidence rates for cardiovascular disease were 4.6 (95% CI 4.4-4.9) per 100 women aged 50-69 in non-smokers with diabetes, 5.9 (95% CI 4.6- 7.6) in smokers with diabetes not using insulin and 11.0 (95% CI 8.3- 14.7) in smokers with diabetes using insulin. Nonsmoking women with diabetes who were not overweight or inactive still had threefold increased rate for coronary disease or stroke compared with women without diabetes. Of the modifiable factors examined in middle aged women with diabetes, smoking causes the greatest increase in cardiovascular disease, especially in those with insulin treated diabetes.

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European Journal of Epidemiology, published for the first time in 1985, serves as a forum on the epidemiology of communicable and non-communicable diseases and their control. The results of epidemiologic studies are essential arguments for action in the field of public health policies and efforts are made to bring the journal to the decision makers' attention. The journal is also a source of material for those who are actively engaged in teaching epidemiology. The journal covers the different fields of epidemiology, a science which has always been multidisciplinary by nature: contributions are encouraged from the fields of public health planning and control, economy, preventive medicine, clinical trials, vaccinology, psychology, molecular biology, mathematical modelization and computer sciences.

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Cardiovascular disease rates have substantially increased worldwide, with a near doubling of prevalence, from 271 million to 523 million people, reported between 1990 and 2019. Cardiovascular disease remains the leading cause of adult death around the world and, in some areas, an increase has occurred among younger age groups, suggesting that the aging population is not the only factor in the increasing prevalence.1 Identifying those at high risk of cardiometabolic disease and developing interventions to prevent or delay disease onset will reduce the high burden of disease on health care systems. Meta-analyses2,3 have found that low birth weight and preterm gestational age are associated with increased risk of cardiometabolic syndrome, but these analyses have been limited by the inclusion of studies with self-reported questionnaires regarding birth weight and gestational age as well as inconsistent definitions of low birth weight. Most population-based studies have focused on cardiometabolic outcomes in adults who were born extremely preterm (<28 weeks’ gestation) or very preterm (<32 weeks’ gestation). However, several studies,4-6 including the study by Yoshida-Montezuma et al4 elsewhere in JAMA Network Open, have attempted to assess cardiometabolic risk among those born late preterm (34-36 weeks’ gestation).

The retrospective cohort study by Yoshida-Montezuma et al4 reports an association of late preterm birth (34-36 weeks’ gestation) and moderately preterm birth (<34 weeks’ gestation) with cardiometabolic risk (CMR) score during childhood. The study is novel for its assessment of the association between late preterm gestational age and childhood CMR score.4

Yoshida-Montezuma et al4 statistically isolate late preterm birth from common fetal and maternal variables. Extremes of in utero growth associated with being born both small and large for gestational age as well as maternal factors, including diabetes, hypertension, and thromboembolism, may influence the decision to induce preterm labor. However, these variables may also be independently associated with increased risk of cardiometabolic disease later in life.

In fact, the authors4 report those born late preterm were more likely to have older mothers with non-European ethnicity and lower family income. The mothers of infants born late preterm were also more likely to have pregnancies complicated by diabetes, hypertension, and preeclampsia or eclampsia. The statistical analyses controlled for potential in utero and maternal confounding variables. A total of 1742 children with CMR data were matched to their birth data. The public health registers of Ontario, Canada, which were used to collect maternal and newborn data, were audited against medical records and found to have greater than 90% agreement. Additional disease registries were used to identify diabetes and hypertension in mothers, further limiting the potential for error and allowing the authors to control for these potential confounding variables in the analyses. Compared with full-term birth (≥39 weeks’ gestation), both late preterm and moderately preterm birth were associated with a higher mean CMR score at ages 3 to 12 years. As a continuous variable, each additional week of gestational age was associated with a lower mean CMR score.4

The CMR score may better identify potential risk of disease through multiple measures rather than assessment of individual risk factors; however, standardization of CMR scores during childhood remains a substantial challenge. Kamel et al7 performed a review of publications from 2007 to 2016, noting wide variability in components of the CMR score, with some studies including as few as 3 variables and others as many as 11 variables. Yoshida-Montezuma et al4 used The Applied Research Group for Kids (TARGet Kids!) data set, which included the 5 most common components of the CMR score reported in the review,7 waist circumference z score, log triglyceride level, glucose level, systolic blood pressure, and inverse high-density lipoprotein cholesterol level. Standardizing and validating CMR scores would strengthen future studies and allow for analyses to be conducted across studies.

The findings of the Yoshida-Montezuma et al4 study highlight the importance of gestational age, including late preterm birth, as an independent risk factor for future cardiometabolic disease. A similar cohort study5 from northern Finland also controlled for maternal risk factors and noted an association between late preterm delivery and the development of metabolic syndrome in adults. Another recent publication6 of a Swedish national cohort that controlled for gestational weight and multiple parental factors noted that late preterm delivery was associated with increased risk of hemorrhagic and ischemic stroke in adults aged 18 to 43 years. All of these studies4-6 emphasize the need to optimize maternal health and prevent preterm deliveries, even when they occur relatively late in gestation. The studies are limited by their lack of ethnically diverse populations, and additional studies are needed to confirm the significance of late preterm birth across all populations.

When reporting late preterm birth as an independent risk factor for future cardiometabolic disease, Yoshida-Montezuma et al4 note the potential to impact long-term health among this group of patients. Future controlled studies are necessary to understand whether early screening and therapeutic interventions directed at those born late preterm have the ability to reduce the risk and burden of cardiometabolic disease.

Published: May 27, 2022. doi:10.1001/jamanetworkopen.2022.14385

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Iacono L et al. JAMA Network Open.

Corresponding Author: Molly O. Regelmann, MD, Division of Pediatric Endocrinology and Diabetes, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave, Bronx, NY 10467 ().

Conflict of Interest Disclosures: None reported.

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