• diabetes
• atherogenesis
• coronary heart disease

The excessive cardiovascular morbidity and mortality associated with diabetes (sometimes termed “the burden of heart disease in diabetes”) has been recognised for a long time. Because of this, I have suggested that diabetes should be defined as a state of premature cardiovascular death which is associated with chronic hyperglycaemia and may also be associated with blindness and renal failure. This was first placed in context by the Framingham study, where middle aged people with diabetes had an increased coronary heart disease morbidity and mortality that could not be explained by the traditional cardiovascular risk factors of smoking, age, raised cholesterol, raised blood pressure, or obesity.¹ This suggested a possible unique role for diabetes as a risk factor for the development of cardiovascular disease. Women with diabetes had the same prevalence of cardiovascular problems as men with diabetes, greatly increasing the risk compared to non-diabetic women, leading to the phrase “women with diabetes loose the protection of their gender”. An excess of congestive cardiac failure was also noted that could not be explained by the presence of coronary heart disease, adding support to the existence of a possible “diabetic cardiomyopathy”.

From a critical perspective, however, this study was guilty of many of the problems that have affected research in this area ever since. A combination of patients with type 1 and type 2 diabetes was studied, and no attempt was made to classify the type of diabetes in an individual subject. The diagnostic criteria for diabetes were not consistent within the various publications from the Framingham study, leading to differing numbers of patients with diabetes in different publications. The number of subjects with diabetes was very small, which may have exaggerated the risks of some of the end points, such as cardiac failure in women with diabetes. The small number …