Abstract-Diabetes has been shown to increase the risk of coronary heart disease in all populations studied. However, there is a lack of information on the relative importance of diabetes-associated risk factors for cardiovascular disease (CVD), especially the role of lipid levels, because low density lipoprotein (LDL) cholesterol often is not elevated in diabetic individuals. Key Words: low density lipoprotein cholesterol Ⅲ coronary heart disease Ⅲ diabetes mellitus Ⅲ insulin resistance Ⅲ Indians, North American M acrovascular complications are the leading causes of morbidity and mortality in diabetic patients; Ͼ60% of diabetic patients die of cardiovascular diseases. 1 In all populations studied, individuals with diabetes have a greatly increased risk of coronary heart disease (CHD) compared with nondiabetic individuals, 2 and risk of cardiovascular disease (CVD) death in diabetic individuals may be as high as that in nondiabetic individuals with previous myocardial infarction. 3 Despite this, there is insufficient information on the relative importance of CVD risk factors in persons with diabetes and strategies for risk factor reduction. Only a few population-based studies in the United States have followed individuals with diabetes. Post hoc analysis of the Multiple Risk Factor Intervention Trial (MRFIT) data set indicated that for men with diabetes, serum cholesterol level, systolic blood pressure, and cigarette smoking were significant predictors of CVD mortality. 4 The Framingham Study evaluated both men and women with diabetes and found that smoking, 5 hypertension, 5 and elevated triglycerides 6,7 were significant independent predictors of CVD. An analysis of diabetic individuals in the Rancho Bernardo cohort stressed the role of cigarette smoking in CVD deaths in older men and women

OBJECTIVE -To estimate incidence rates of diabetes and associated risk factors among participants of the Strong Heart Study. RESEARCH DESIGN AND METHODS -Of the 4,549Strong Heart Study participants examined at baseline, 3,638 returned for a similar examination after an average of 4 years. The 1985 World Health Organization criteria for diabetes were used to identify new diabetes cases. Rates of diabetes among participants who did not have diabetes at baseline examination were determined. The relationships between the incidence rates of diabetes and a number of risk factors measured at baseline examination were studied.RESULTS -Significant variables associated with the development of diabetes included triglycerides, obesity, fasting plasma glucose, insulin, and degree of American Indian blood among participants with NGT at baseline. For those with IGT at baseline, significant predictors included fasting plasma glucose, 2-h glucose, BMI, degree of American Indian blood, and albuminuria.CONCLUSIONS -The high incidence rates found in this study were alarming. To slow down the rapid increase of this disease in the American Indian population, preventive programs must be designed and implemented. Patients with IGT should be treated with diabetes medication or put on a rigid weight-reduction program to reduce the risk of progression to diabetes. Diabetes Care 25:49 -54, 2002D iabetes is a major cause of morbidity and mortality in American Indians, in whom the prevalence rates are several times higher than those in the general U.S. population. Previous reports showed that age-adjusted prevalence rates of diabetes in American Indians (aged 45-74 years) from Arizona, Oklahoma, and South/North Dakota ranged from 38 to 72% (1). Rates were higher in women than in men. Most of the available data have been from cross-sectional studies. To obtain a thorough understanding of the etiology of diabetes, well-designed longitudinal studies are needed.Except for the longitudinal study of Pima Indians, there is a paucity of longitudinal studies and incidence data among American Indians; this has impeded the understanding of the cause of diabetes in this population. Moreover, existing published incidence data are difficult to compare because of the nonuniform methodologies used in sampling and ascertaining cases of diabetes. Differences in criteria used to define "American Indian" also add to the problem of comparing incidence data.The Strong Heart Study (SHS) was conducted to estimate the prevalence and incidence of cardiovascular disease (CVD) in 13 Indian communities/tribes in three geographic areas (Arizona, Oklahoma, and South/North Dakota) and to identify its risk factors. The baseline examination of the SHS was conducted between 1988 and 1991. Personal data and clinical information, including fasting glucose and 2-h glucose tolerance test, were obtained from a personal interview and physical examination. The participants were followed and a second personal interview and physical examination were conducted between 1993 and 1995. Th...

Background-National vital event data suggest that cardiovascular disease (CVD) mortality rates are lower for American Indians and Alaska Natives (AIAN) than for the general US population, but these data are disproportionately flawed for AIAN because of racial misclassification. Methods and Results-Vital event data adjusted for racial misclassification and published by the Indian Health Service were used to compare trends in CVD mortality from 1989 to 1991 to 1996 to 1998 between AIAN, US all-races, and US white populations. Without misclassification accounted for, AIAN initially had the lowest mortality rates from major CVD, but by the end of the study, their rates were the highest. Adjustment for misclassification revealed an early and rapidly growing disparity between CVD mortality rates among AIAN compared with rates in the US all-races and white populations. By 1996 to 1998, the age-and misclassification-adjusted number of CVD deaths per 100 000 among AIAN was 195.9 compared with age-adjusted rates of 166.1 and 159.1 for US all races and whites, respectively. The annual percent change in CVD mortality for AIAN was 0.5 compared with Ϫ1.8 in the other groups. Regardless of racial misclassification, the most striking and widening disparities were found for middle-aged AIAN, but CVD mortality among AIAN Ն65 years of age was lower than in the other populations. Conclusions-A previously underrecognized disparity in CVD mortality exists for AIAN, particularly among middle-aged adults. Moreover, these disparities are increasing. Efforts to reduce CVD mortality in AIAN must begin before the onset of middle age.

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Overall, unfavorable changes in CVD risk factors were seen in the aging participants and will likely be reflected in worsening morbidity and mortality.