22 Clinical Rounds OB.GY N.

N E W S • March 15, 2008

Metabolic Syndrome Adds Smoking May Raise Risk of

To Diabetes Stroke Risk Developing Neuropathic Pain
BY ROBERT FINN patients and 38% of the patients with B Y F R A N L O W RY havior, and people who smoke are in-
San Francisco Bureau metabolic syndrome; cortical strokes ac- Orlando Bureau volved in more dangerous behavior, or
counted for 15% and 13% of the strokes, situations where they suffer more back

P
atients with both type 2 diabetes and
metabolic syndrome have strokes
an average of 3.5 years earlier than
do those who have type 2 diabetes alone,
according to a study.
There were no significant differences
between diabetes patients with and with-
out metabolic syndrome in the type of
stroke, with lacunar stroke predominating
in both groups, wrote Imtiaz M. Shah and
colleagues from Ayr (Scotland) Hospital
(Diabetes Res. Clin. Prac. 2008;79:e1-4).
The retrospective study involved 151
patients with metabolic syndrome and
type 2 diabetes, and a control group of 92
patients with diabetes alone. All patients
had experienced a stroke between Sep-
tember 1996 and August 2004. Patients
were considered to have metabolic syn-
drome if they had two or more of the fol-
lowing additional risk factors: obesity, low
HDL cholesterol, elevated triglycerides, or
hypertension.
Patients with metabolic syndrome ex-
perienced their stroke at an average of 71.7
years of age, compared with 75.2 years
among the control group, a statistically sig-
nificant difference. Other than the defin-
ing characteristics of metabolic syndrome,
the only other significant difference be-
tween the groups was in the proportion
taking statins, which was 40% among pa-
respectively; and intracerebral hemor- O R L A N D O — In a community sample
rhage accounted for the remaining 2% of 205 adults with chronic pain of any
and 5% of the strokes. A multivariate type, neuropathic pain was documented
analysis revealed no statistically signifi- in almost two-thirds of those who
cant differences between the groups in smoked, compared with one-third of
stroke subtypes. those who did not smoke, Dr. Todd G.
The results emphasize the importance Call reported at the annual meeting of
of aggressive management of patients the American Academy of Pain Medi-
with both metabolic syndrome and type 2 cine.
diabetes because of their high vascular risk “The results were a little bit of a sur-
state, the investigators wrote. They also prise to us, but it appears that smoking
noted that lacunar stroke has been associ- seems to confer a greater risk of neuro-
ated with endothelial dysfunction, and pathic pain. We’re not quite sure why
that ACE inhibition, angiotensin receptor that is. It’s too early to say. The study re-
blockade treatment, and statins have all ally wasn’t designed to look at that, but
been shown to reverse endothelial dys- it’s worth looking into further,” Dr. Call
function. of the Mayo Medical School, Rochester,
The investigators stated that they had no Minn., said in an interview.
conflicts of interest. ■ Dr. Call and his colleagues sought to
validate a method of screening for neu-
ropathic pain in adults with chronic pain
Metabolic Syndrome Associated living in the community.
With Earlier Occurrence of They identified a subset of adults with
Stroke in Diabetic Patients self-reported nerve pain, and confirmed
Age (years) the diagnosis according to scores on the
self-reported Leeds Assessment of Neu-
75.2
71.7 ropathic Symptoms and Signs pain scale
and select ICD-9-CM codes associated
with neuropathic pain on chart review.
They also assessed smoking status.
Neuropathic pain was confirmed in 75
of the 205 patients. The remaining 130
E LSEVIER G LOBAL M EDICAL N EWS
injuries,” he said. “At any rate, our find-
ing just gives one more reason for doc-
tors to tell their pain patients to quit
smoking.”
In another study from the Mayo Clin-
ic, Dr. Susan Moeschler reported that fe-
males attending the Mayo Clinic’s pain
center had higher pain intensity scores if
they smoked, compared with female
nonsmokers and smoking and non-
smoking males.
Compared with 131 female nonsmok-
ers, the 14 female smokers were more
likely to be unemployed and less likely to
have completed high school.
Smokers also reported greater pain
intensity, which was more likely to in-
terfere with their mood, personal rela-
tionships, sleep, and enjoyment of life,
according to Borderline Personality In-
ventory subscales. Among the 85 men in
the study, 22 of whom were smokers,
smoking status was not related to any de-
mographic, pain intensity, or mood in-
terference differences.
“These findings suggest that female
smokers with painful conditions have
greater affective distress than other male
smokers and other subsets of patients,”
Dr. Moeschler said.
Dr. Call and colleagues’ study was
supported by an unrestricted grant from

tients with metabolic syndrome and 24%
among the control group.
Lacunar stroke, an indication of small-
vessel disease, was responsible for 44% of
strokes in both control patients and 44%
of strokes in patients with metabolic syn-
drome. Transient ischemic attacks ac-
counted for 39% of the strokes in control
patients had chronic, nociceptive pain. AstraZeneca Pharmaceuticals LP and
Type 2 diabetes Type 2 diabetes
Overall, 13% of the participants smoked, the U.S. National Institutes of Health. Dr.
plus metabolic alone but among patients in the neuropathic Call said he had no financial conflicts of
syndrome (n = 92) pain subset, 21% were smokers. interest.
(n = 151) Dr. Call speculated that there might be Dr. Moeschler and colleagues’ study
Source: Diabetes Research and Clinical something about nicotine that causes was supported by institutional funds
Practice chronic ischemia or nerve damage. from the Mayo Clinic’s Department of
“Or perhaps it’s more a matter of be- Anesthesia. ■

Insulin Restriction May Shorten Life Span in Type 1 Diabetes

BY BRUCE K. DIXON Women reporting insulin restriction showed distinct Causes of death for 16 of 163 women reporting ap-
Chicago Bureau clinical differences from those reporting appropriate in- propriate insulin use included cancer (1), cardiac events
sulin use. (11), diabetic ketoacidosis (1), sepsis (2), and unknown

W omen with type 1 diabetes who take less insulin than

prescribed may be raising their risk of complications
and shortening their life spans, researchers reported.
Because of various psychosocial variables, more than
half of adult patients do not achieve the American Dia-
betes Association’s glycemic targets, explained Ann E.
Goebel-Fabbri, Ph.D., of the Joslin Diabetes Center and
Harvard Medical School, both in Boston, and her associ-
ates. Chief among the implicated variables are general
psychological distress, diabetes-specific distress, fear of hy-
poglycemia, concern about weight gain, and related eat-
ing-disorder behaviors.
In this 11-year study, the largest to examine the long-
term effect of insulin restriction on the morbidity and
mortality of women with type 1 diabetes, insulin re-
striction at baseline conveyed more than a threefold in-
crease in the relative risk of death, said the authors (Di-
abetes Care 2008;31:1-5).
At baseline, the cohort included 234 women aged 13-
60 years who had had a diagnosis of type 1 diabetes for
at least 1 year, and who agreed to be followed up. Of
those, 26 women died during the study period.
Mean age at follow-up was 45 years, with a range of 24-
72 years.
At baseline, insulin restricters were significantly
younger (aged 32 vs. 36 years) and had higher hemoglo-
bin A1c values (9.6% vs. 8.3%). However, there were no
differences between the two groups with regard to base-
line body mass index (BMI) or diabetes duration, the au-
thors said.
Predictably, insulin restricters reported significantly
lower scores on the baseline measure of diabetes self-care
behaviors, and they scored higher on baseline measures
of diabetes distress; fear of hypoglycemia; general psy-
chological symptoms; eating disorder symptoms, such as
bulimia; and the Eating Disorders Inventory, the re-
searchers explained.
In addition, women who said at baseline that they re-
stricted insulin were significantly more likely to report
nephropathy and foot problems at follow-up, the re-
searchers said, adding that self-reported rates of retinopa-
thy, neuropathy, and cardiovascular complications at fol-
low-up did not differ between groups.
Causes of death for 10 of 71 women reporting insulin
restriction included perforated bowel with gastroparesis
(1), cancer (1), cardiac events (3), hypoglycemia (1), renal
failure (2), sepsis (1), and suicide in the context of
retinopathy-related blindness (1).
causes (1), Dr. Goebel-Fabbri noted in an interview.
Comparisons of both groups of deceased women
found that those who had restricted insulin died at a sig-
nificantly younger age, and had higher baseline hemo-
globin A1c values, poorer diabetes self-care behaviors, in-
creased levels of diabetes-specific distress, and higher
scores on measures of bulimia and other eating disorder
symptoms, the scientists reported.
Compared with their living counterparts, deceased in-
sulin restricters at baseline had higher BMI and hemo-
globin A1c values and reported more symptoms of bu-
limia and higher levels of diabetes-specific distress.
“These data suggest that mortality associated with in-
sulin restriction occurred in the context of eating disor-
der symptoms, rather than other psychological distress,”
the authors said. They added that these patients require
careful monitoring and would benefit from in-depth
evaluations by a mental health professional, ideally one
with specialized training in diabetes. “Unfortunately,
such specialty services are rarely available to individuals
with type 1 diabetes,” they said.
The researchers recommended that clinicians screen
their type 1 diabetes patients by routinely asking them if
they follow their insulin prescriptions. ■