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Excessive Weight Gain and Effects on Lipids With Intensive Therapy of Type 1 Diabetes—Reply

Jonathan Q. Purnell, MD; John D. Brunzell, MD
JAMA. 1998;280(23):1991-1992. doi:10-1001/pubs.JAMA-ISSN-0098-7484-280-23-jbk1216.
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In Reply.—Dr Wei suggests that final lipid levels in each treatment group in the DCCT represented an interaction between improved glycemic control and increased body weight. An important point we had hoped to make with our article was that 75% of the intensively treated group who did not gain an excessive amount of weight retained the benefits of improved glycemic control on lipids. Therefore, in the majority of subjects enrolled in the intensive treatment group of the DCCT, intensive therapy would be expected to improve risks for both microvascular and macrovascular complications. However, in the top quartile of subjects who gained excessive weight and became obese, the benefits of intensive therapy on lipid levels appeared to be lost. At follow-up, the top quartile for weight gain with intensive treatment had nearly identical lipid levels compared with the conventional therapy group and significantly higher levels than all 3 of the lower quartiles in the intensively treated group. Specifically, the top quartile of intensive therapy had higher levels of triglycerides and total and LDL cholesterol; increased cholesterol in intermediate-density lipoprotein and dense LDL fractions; and lower high-density lipoprotein (HDL) cholesterol compared with the lowest quartile of weight gain (who did not change weight on average over the duration of the study). The findings of higher triglycerides, an increase in dense LDL particles, lower HDL cholesterol, greater waist-to-hip ratio, and higher insulin requirements with excessive weight gain in the fourth quartile compared with the first quartile suggest the emergence of the insulin resistance syndrome in the former, which is associated with a greater risk for CAD in subjects without diabetes.1,2 Although we did not seek to minimize the risk of weight gain with conventional treatment on CAD risk factors, the constellation of lipid and blood pressure abnormalities in the subjects who experienced excessive weight gain with intensive therapy is particularly worrisome.


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