Type 2 diabetes and cardiovascular disease: Have all risk factors the same strength?

Table 1 Cardiovascular risk factors in diabetes mellitus

Traditional	Nontraditional
Dyslipidaemia	Insulin resistance and Hyperinsulinemia
Hypertension	Postprandial Hyperglycaemia
Obesity	Glucose variability
Abdominal obesity	Microalbuminuria
Physical exercise	Haematological factors
Cigarette smoking	Thrombogenic factors
	Inflammation C-reactive protein
	Homocysteine and vitamins
	Erectile dysfunction
	Genetics and Epigenetics

Table 2 Recommendations for blood pressure control in diabetes

Recommendations	Class	Level
Blood pressure control is recommended in patients with diabetes mellitus and hypertension to lower the risk of cardiovascular events	I	A
It is recommended that a patient with hypertension and diabetes mellitus is treated in an individualized manner, targeting a blood pressure of < 140/85 mmHg	I	A
It is recommended that a combination of blood pressure lowering agents is used to achieve blood pressure control	I	A
A RAAS blocker (ACE-I or ARB) is recommended in the treatment of hypertension in diabetes mellitus, particularly in the presence of proteinuria or microalbuminuria	I	A
Simultaneous administration of two RAAS blockers should be avoided in patients with diabetes mellitus	III	B

ACE-I: Angiotensin converting enzyme-inhibitors; ARB: Angiotensin receptor blockers; RAAS: Renin angiotensin aldosterone system; Class: Class of recommendation; Level: Level of evidence.

Table 3 Suggested mechanisms for the influence of smoking on risk of type 2 diabetes

Direct effects due to inhalation of smoke from tobacco products

Impaired insulin sensitivity based on influence of haemodynamic dysregulation in capillary vascular bed

Impaired insulin sensitivity due to increase in inflammatory markers secondary to bronchitis and pulmonary infections caused by smoking

Impaired beta-cell function due to toxic effects of tobacco smoke

Lipotoxicity due to influence of increased triglyceride levels

Hypercortisolaemia and increase in abdominal fat tissue

Elevated sympathetic nervous activation

Indirect effects on glucose metabolism

Unhealthy lifestyle in smokers (poor diet, lack of physical activity)

Increased alcohol consumption (toxic effects on beta cells)

Psychosocial stress and impaired sleep associated with smoking

Impaired fetal growth in smoking pregnant women, associated with increased diabetes risk in offspring in adult life

Table 4 The strategic “five As” for smoking cessation

A-ASK:	Systematically inquire about smoking status at every opportunity
A-ADVISE:	Unequivocally urge all smokers to quit
A-ASSESS:	Determine the person’s degree of addiction and readiness to quit
A-ASSIST	Agree on a smoking cessation strategy, including setting a quit date, behavioral counseling, and pharmacological support
A-ARRANGE	Arrange a schedule for follow-up