Diabetes is associated with a gre a t e r

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1 E p i d e m i o l o g y / H e a l t h S e r v i c e s / P s y c h o s o c i a l R e s e a r c h O R I G I N A L A R T I C L E The Patt e rn of Dyslipidemia Among Urban African-Americans With Type 2 Diabetes CURTISS B. COOK, MD DIANE M. ERDMAN, PHARMD GINA J. RYAN, PHARMD KURT J. GREENLUND, PHD WAYNE H. GILES, MD DANIEL L. GALLINA, MD IMAD M. EL-KEBBI, MD DAVID C. ZIEMER, MD KRIS L. ERNST, RN VIRGINIA G. DUNBAR, BS LAWRENCE S. PHILLIPS, MD O B J E C T I V E To analyze lipid profiles from a large sample of African-American patients with type 2 diabetes who receive care at an urban outpatient diabetes clinic. RESEARCH DESIGN AND METHODS Fasting serum lipid profiles of 4,014 African- Americans and 328 Caucasians with type 2 diabetes were retrieved from a computerized re g i s t ry. American Diabetes Association criteria were applied to classify LDL cholesterol, HDL cholestero l, and triglyceride (TG) levels into risk categories. The pro p o rtion of patients who had none, one, two, and three lipoprotein concentrations outside of recommended clinical targets was examined. Multiple logistical re g ression analyses were perf o rmed to determine the influence of sex and race on the probability of having a lipid level outside of the recommended targ e t. R E S U LT S The percentages of African-Americans with high-, borderline-, and low-risk LDL c h o l e s t e rol concentrations were 58, 26, and 16%, re s p e c t i v e l y, and the percentages for Caucasians w e re 54, 29, and 16%, respectively (P = 0.51). For HDL cholesterol, 41, 33, and 26% of African- Americans were in the high-, borderline-, and low-risk categories, re s p e c t i v e l y, compared with 73, 18, and 9% of Caucasians, respectively (P ). Nearly 81% of African-Americans had TG concentrations that were in the low-risk category compared with only 50% of Caucasians. M o re women than men had high-risk LDL and HDL cholesterol profiles. The most common patt e rn of dyslipidemia was an LDL cholesterol level above target combined with an HDL cholest e rol level below target, which was detected in nearly 50% of African-Americans and 42% of Caucasians. African-Americans had lower odds of having an HDL cholesterol or TG level outside of target. African-American women, compared to men, had greater probabilities of having a b n o rmal levels of LDL and HDL, but a lower likelihood of having a TG level above goal. C O N C L U S I O N S In a large sample of urban type 2 diabetic patients receiving care at a diabetes treatment program, race and sex diff e rences in serum lipid profiles were pre s e n t. Because hypertriglyceridemia was rare among African-American subjects, interventions will need to focus primarily on improving their LDL and HDL cholesterol levels. Further studies a re re q u i red re g a rding how to best adapt these observed diff e rences into more effective strategies to optimize lipid levels for this population of diabetic patients and to determine whether similar patterns of dyslipidemia occur in other clinical settings. Diabetes Care 2 3 : , 2000 F rom the Division of Endocrinology and Metabolism (C.B.C., D.L.G., I.E.-K., D.C.Z., L.S.P.), Department of Medicine, Emory University School of Medicine; the Diabetes Clinic of the Grady Health System (D.M.E., K.L.E., V.G.D.); the Department of Pharmacy Practice (G.J.R.), Mercer University; and the Division of Adult and Community Health (K.J.G., W.H.G.), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. A d d ress correspondence and reprint requests to Curtiss B. Cook, MD, Diabetes Unit, Emory University School of Medicine, 69 Butler St. S.E., Atlanta, GA cbcook@emory. e d u. Received for publication 27 September 1999 and accepted in revised form 6 December A b b re v i a t i o n s : ADA, American Diabetes Association; ANCOVA, analysis of covariance; ANOVA, analysis of variance; CVD, cardiovascular disease; TG, triglyceride. A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Diabetes is associated with a gre a t e r risk of morbidity and mort a l i t y f rom cardiovascular disease (CVD), and heart disease is the leading cause of death among people with diabetes (1). Although heart disease mortality in the nondiabetic U.S. population has declined substantially, similar pro g ress has not been made in those with diabetes (2). There f o re, eff o rts to reduce the risk of heart disease through evaluation of risk factors and the introduction of preventive and therapeutic measures into a t reatment program must be a primary focus when caring for the diabetic p a t i e n t. The pathogenesis of heart disease in diabetes is complex, but serum lipids are f requently abnormal and likely contribute to the risk of coro n a ry art e ry disease (3 7). Although concentrations of total and LDL cholesterol in diabetic individuals are reportedly comparable with levels found in people without diabetes, low levels of HDL cholesterol and elevated triglyceride (TG) levels, both pro b a b l e contributors to CVD, have been reported in type 2 diabetes (3 7). Because detection and treatment of dyslipidemia is one means of reducing CVD risk, determination of serum lipid levels in people with diabetes is now considered a standard of care (8 10). Race and sex diff e rences in pattern s of serum lipids have been noted in diabetes (11 13). African-Americans with type 2 diabetes re p o rtedly have lower TG and higher HDL cholesterol concentrations than Caucasians, and women with diabetes have higher LDL and HDL c h o l e s t e rol concentrations than their male counterparts (11 13). Howe v e r, no studies have profiled seru m lipids in a large population of African- Americans with type 2 diabetes. To guide therapeutic decisions geared toward o p t i m i zing management of diabetic dysl i p i d e m i a, we analyzed fasting seru m lipids in more than 4,000 African-Americans with type 2 diabetes who had i n itial visits to our clinic between 1992 and DIABETES CARE, VOLUME 23, NUMBER 3, MARCH

2 Dyslipidemia in urban African-Americans Table 1 Characteristics and fasting lipid profiles of African-American and Caucasian patients with type 2 diabetes RESEARCH DESIGN AND M E T H O D S Selection criteria Patients were selected for analysis from an on-site re g i s t ry maintained in the clinic a c c o rding to whether they had a diagnosis of type 2 diabetes and had initial visits between 1 January 1992 and 31 December 1997 (14,15). Patients were classified at the time of their first visit as having type 2 diabetes according to traditional clinical characteristics, such as a prior history of use of oral agents to control hyperglycemia, the p resence of obesity, no history of ketosis, or family history of diabetes. Because of the small number of patients belonging to Hispanic (n = 78) and other ethnic groups (n = 83), only African-Americans (n = 4,014) and Caucasians (n = 328) with type 2 diabetes were included in the analyses. Laboratory studies Lipid, HbA 1 c, and fasting plasma glucose d e t e rminations were perf o rmed with fasting blood samples obtained at the time of the initial visit by using standard techniques as previously described (16). LDL c h o l e s t e rol was calculated with the Friedewald formula and was not available when A f r i c a n - A m e r i c a n s C a u c a s i a n s B o t h M e n Wo m e n B o t h M e n Wo m e n n 4, 014 1, 427 2, Age (years) 53 ± ± ± 0.3* 54 ± ± ± 0.9 Diabetes duration (years) 5.2 ± ± ± 0.2* 5.9 ± ± ± 0.6 BMI (kg/m 2 ) 33 ± ± ± 0.2* 33 ± ± ± 0.6* H b A 1 c (%) 9.3 ± ± ± ± ± ± 0.2 Fasting plasma glucose 191 ± ± ± 1.6* 204 ± ± ± 5.8* ( m g / d l ) P e rcentage on each therapy D i e t S u l f o n y l u re a S u l f o n y l u rea and insulin I n s u l i n L i p i d s Total cholestero l 210 ± ± ± ± ± ± 4.5 LDL cholestero l 140 ± ± ± ± ± ± 3.2 HDL cholestero l 46 ± ± ± ± ± ± 0.9 Tr i g l y c e r i d e s 159 ± ± ± ± ± ± 24 Data are n, means ± SEM, or %. LDL cholesterol values are data from 3,846 African-Americans and 278 Caucasians. *P 0.01, comparison of women vs. men within each race group (ANOVA); P 0.01, African-American vs. Caucasian (ANOVA); P 0.01, women vs. men (ANCOVA, adjusted for age, duration of disease, fasting plasma glucose, HbA 1 c, and BMI); P 0.001, African-American vs. Caucasian (ANCOVA, adjusted for patient age, duration of disease, fasting plasma glucose, HbA 1 c, and BMI). TG levels were 400 mg/dl (16,17). Thus, LDL cholesterol concentrations were available for 3,846 African-Americans and 278 Caucasians. BMI (kg/m 2 ) was calculated f rom weight and height measure m e n t s taken at the initial visit. No changes were implemented in labo r a t o ry methodologies or pro c e d u res between 1992 and Data analyses C u rrent American Diabetes Association (ADA) guidelines were used to classify l i p o p rotein concentrations into CVD risk categories (10). The values used to define low-, borderline-, and high-risk LDL chol e s t e rol levels were 100, , and 130 mg/dl, re s p e c t i v e l y. For TG, the cuto ff points were 200, , and 400 mg/dl. High-, borderline-, and low-risk categories for HDL cholesterol concentrations w e re defined according to sex. For men, the cutoff points were 35, 35 45, and 45 mg/dl, re s p e c t i v e l y. For women, the c u t o ff points were 45, 45 55, and 55 mg/dl, respectively (10). Because ADA guidelines recommend an LDL cholestero l level of 100, a TG level of 200 mg/dl, and an HDL cholesterol level of 45 mg/dl in men and 55 mg/dl in women as clinical targets (11), the percentages of patients who had none, one, two, or all three of these lipoproteins not at goal level were also determined. This latter analysis was conducted among the 3,846 African-Americans and 278 Caucasians for whom LDL m e a s u rements were available (i.e., among those with TG levels of 400 mg/dl). Statistical analyses were perf o rm e d with the StatView software program (SAS Institute, Cary, NC). Analysis of variance ( A N O VA) was used to determine diff e r- ences in patient characteristics, and analysis of covariance (ANCOVA) was used to test for diff e rences in mean lipid levels. The 2 test was used to test for diff e re n c e s in pro p o rtions. Multiple logistical re g re s- sions adjusted for patient characteristics and method of treatment for hyperg l y c e m i a (e.g., diet, oral agent, or insulin) were used to determine the influence of race and sex on the risk of having an LDL cholestero l, HDL cholesterol, or TG level outside of the desirable clinical targ e t. R E S U LT S Patient characteristics and mean serum lipid levels Small but statistically significant diff e r- ences were detected in some patient characteristics at the first visit (Table 1). African-Americans had higher average H b A 1 c levels than Caucasians. During the period of this analysis, insulin and sulf o n y l u reas were the only agents available t h rough our health system to treat hyperglycemia. Overall, African-Americans had significantly higher mean HDL cholestero l and lower TG levels than Caucasians ( Table 1). African-American women had significantly higher total cholesterol, LDL c h o l e s t e rol, and HDL cholesterol levels but lower average TG levels than African- American men. A similar pattern was evident among Caucasians except that women had significantly higher TG levels than their male counterparts (Table 1). Patterns of serum lipids by risk category The percentages of African-Americans with a high-, borderline-, or low-risk LDL chol e s t e rol level were 58, 26, and 16%, re s p e ctively (Fig. 1). For Caucasians, the p rop o rtions were 54, 29, and 16%, re s p e c- tively (P = 0.51, 2 race comparison). More African-American women (61%) than men (51%) had LDL cholesterol levels in the high-risk category, and the distributions a c c o rding to risk category were signifi- 320 DIABETES CARE, VOLUME 23, NUMBER 3, MARCH 2000

3 Cook and Associates cantly diff e rent between sexes (P , 2 sex comparison). More Caucasian women (61%) than men (46%) had LDL c h o l e s t e rol levels in the high-risk category, and a significant diff e rence in the distribution by risk class was also detected between Caucasian men and women (P 0.026, 2 sex comparison). D i ff e rences in the pro p o rtion of patients in each HDL cholesterol risk category were evident between African-Americans and Caucasians. For African-Americans, 41% were in the high-risk HDL cholesterol group, 33% w e re in the borderline-risk group, and 26% w e re in the low-risk group (Fig. 1). For Caucasians, the percentages were 73, 18, and 9%, respectively (P , 2 race comparison). In either racial group, the distribution of HDL cholesterol level by risk category was less favorable among women than men, but this sex diff e rence was significant only among African-Americans (P , 2 sex comparison). Among African-Americans, 46% of women and 31% of men had highrisk HDL cholesterol profiles, whereas 76 and 69% of Caucasian men and women, re s p e c t i v e l y, were in the high-risk HDL gro u p (Fig. 1). Only 4 and 15% of African-Americans had a TG concentration in the high- and b o rderline-risk categories, re s p e c t i v e l y, but 81% had a low-risk TG level (Fig. 1). In comparison, 16 and 34% of Caucasians had a high- or borderline-risk TG level, re s p e c t i v e l y, whereas 50% had a low-risk TG level (P , 2 race comparison). Among African-American men, 6, 17, and 78% had TG levels in the high-, bord e r l i n e -, and low-risk groups, re s p e c t i v e l y, and 3, 15, and 83% of African-American women had levels in these categories, re s p e c t i v e l y (P , 2 sex comparison). In Caucasian men, 13, 32, and 55% had high-, b o rderline-, and low-risk TG levels, re s p e c- t i v e l y, whereas the distribution in Caucasian women was 17, 36, and 47%, respectively (P = 0.17, 2 sex comparison). P ro p o rtion with none, one, two, or t h ree values outside of the clinical t a rg e t For subjects with a TG level of 400 mg/dl (because higher values did not permit valid LDL cholesterol calculation), the pro p o r- tions of patients who had none, one, two, or three lipid (LDL cholesterol, HDL chol e s t e rol, TG) values outside of the clinical t a rgets were determined. There f o re, this analysis considered those patients who had an LDL cholesterol level of 100 mg/dl Figure 1 Percentage of patients with high- ( ), borderline- ( ), and low-risk ( ) LDL cholesterol, HDL cholesterol, and TG profiles according to race and sex. LDL cholesterol data were derived from 3,846 African-Americans and 278 Caucasians, whereas HDL cholesterol and TG data were derived from 4,014 African-Americans and 328 Caucasians. (patients in the borderline- and high-risk LDL cholesterol categories), those with HDL cholesterol levels 45 mg/dl in men and 55 in women (patients in the borderline- and high-risk HDL cholesterol categories), and TG levels of mg/dl ( Table 2). The percentages of African- Americans who had none, one, two, or all t h ree lipid values outside of target were nearly 5, 30, 54, and 12%, re s p e c t i v e l y ( Table 2); for Caucasians, the perc e n t a g e s w e re 2, 16, 48, and 34%, respectively (P , 2 race comparison). A combination of an LDL cholesterol level above goal with an HDL cholesterol level below targ e t was observed in almost 50% of African- Americans and in 42% of Caucasians, which made this the most fre q u e n t o b s e rved pattern of dyslipidemia in both g roups. The second most prevalent dyslipidemia pattern among African-Americans was an isolated LDL cholestero l i n c rease, which was observed in 20% of the patients. In Caucasians, the second most common pattern was a dyslipidemia consisting of all three (LDL cholesterol, HDL c h o l e s t e rol, TG) lipoproteins, which was o b s e rved in 34% of the patients (Table 2). Influence of race and sex Multiple logistical re g ression analyses were p e rf o rmed to examine race and sex influences on the probabilities of having seru m lipids that were outside of re c o m m e n d e d clinical targets after adjusting for other variables (Table 3). The likelihood of having an DIABETES CARE, VOLUME 23, NUMBER 3, MARCH

4 Dyslipidemia in urban African-Americans Table 2 Patients with none, one, two, and three lipid values not at clinical targets according to race and sex* African-American (n = 3,846) Caucasian (n = 278) Number not at targ e t B o t h M e n Wo m e n B o t h M e n Wo m e n None out of targ e t 185 (4.8) 92 (2.4) 93 (2.4) 5 (1.8) 3 (1.1) 2 (0.7) One out of targ e t 1,139 (29.6) 452 (11.8) 687 (17.8) 45 (16.2) 26 (9.4) 19 (6.8) LDL cholesterol 100 mg/dl 783 (20.3) 298 (7.7) 485 (12.6) 21 (7.6) 13 (4.7) 8 (2.9) HDL cholesterol below target (mg/dl) 348 (9.0) 147 (3.8) 201 (5.2) 22 (7.9) 13 (4.7) 9 (3.2) TG mg/dl 8 (0.2) 7 (0.18) 1 (0.02) 2 (0.7) 2 (0.7) Two out of targ e t 2,061 (53.6) 642 (16.7) 1,419 (36.9) 134 (48.2) 59 (21.2) 75 (27.0) LDL cholesterol 100 mg/dl + HDL cholesterol below targ e t 1,919 (49.9) 578 (15.0) 1,341 (34.9) 117 (42.1) 49 (17.6) 68 (24.5) LDL cholesterol 100 mg/dl + TG mg/dl 67 (1.7) 31 (0.8) 36 (0.9) HDL cholesterol below target + TG mg/dl 75 (2.0) 33 (0.9) 42 (1.1) 17 (6.1) 10 (3.6) 7 (2.5) T h ree out of targ e t 461 (12.0) 164 (4.3) 297 (7.7) 94 (33.8) 35 (12.6) 59 (21.2) Data are n (%). *Data only for those patients for whom LDL cholesterol could be calculated (i.e., TG 400 mg/dl); patients in borderline- and high-risk LDL cholest e rol categories; HDL cholesterol 45 mg/dl in men and 55 mg/dl in women (patients in borderline- and high-risk HDL cholesterol categories). LDL cholesterol level above target was similar between African-American and Caucasian men and between African-American and Caucasian women. African-American men and women both had significantly lower probabilities of having an HDL chol e s t e rol level below target and a TG level above target compared with their Caucasian counterpart s. R e g a rding sex (Table 3), African-American women had greater odds of having an LDL above target, an HDL cholesterol level below clinical goal, and a significantly lower likelihood of having a TG level 200 mg/dl when compared with African-American men. Among Caucasians, women had significantly greater odds of having an LDL c h o l e s t e rol level of 100 mg/dl compare d with men but comparable probabilities of having HDL cholesterol and TG levels outside of clinical targ e t s. C O N C L U S I O N S Detection and t reatment of dyslipidemia is one means of reducing the risk of CVD disease associated with diabetes (8,18). Patients in our larg e urban outpatient diabetes clinic are primarily African-Americans with type 2 diabetes and re p resent a group at high risk for CVD (19 22). There f o re, the information re g a rding the lipoprotein profiles in this population is important in planning eff e c t i v e i n t e rventions. To our knowledge, this is the l a rgest group of African-Americans with type 2 diabetes whose lipid profiles have been analyzed. When applying current ADA guidelines to classify lipoprotein concentrations, the pro p o rtion of patients who had an LDL c h o l e s t e rol level that was within low-, borderline-, and high-risk categories was similar for African-Americans and Caucasians. H o w e v e r, more women than men in either race group were in the high-risk LDL chol e s t e rol category. Although the optimal goal for LDL cholesterol is controversial, limited data suggest that a concentration of mg/dl (the recommended level for people with known coro n a ry art e ry disease) should also be the target for people with diabetes (10,23 25). When using this clinical end point, a substantial perc e n t a g e ( 80%) of both African-Americans and Caucasians in this study population would re q u i re intervention and ongoing monitoring to ensure that the recommended LDL c h o l e s t e rol goal is reached and maintained. Table 3 Multiple logistical re g ression analyses examining the influence of race and sex on the p robability of having LDL cholesterol, HDL cholesterol, and TG levels outside of re c o m m e n d e d t a rg e t s P robability of LDL cholesterol 100 mg/dl African-American vs. Caucasian* 1.01 ( ) African-American men vs. Caucasian men 1.16 ( ) African-American women vs. Caucasian women 0.90 ( ) Women vs. men 1.50 ( ) African-American women vs. African-American men 1.46 ( ) Caucasian women vs. Caucasian men 2.31 ( ) P robability of HDL cholesterol level below targ e t African-American vs. Caucasian* 0.28 ( ) African-American men vs. Caucasian men 0.33 ( ) African-American women vs. Caucasian women 0.23 ( ) Women vs. men 1.23 ( ) African-American women vs. African-American men 1.31 ( ) Caucasian women vs. Caucasian men 1.56 ( ) P robability of TG 200 mg/dl African-American vs. Caucasian* 0.24 ( ) African-American men vs. Caucasian men 0.33 ( ) African-American women vs. Caucasian women 0.19 ( ) Women vs. men 0.69 ( ) African-American women vs. African-American men 0.65 ( ) Caucasian women vs. Caucasian men 1.10 ( ) Data are odds ratios (95% CIs). *Adjusted for sex, mode of hyperglycemic therapy at presentation, patient age, duration of disease, HbA 1 c, fasting plasma glucose, BMI, and systolic and diastolic blood pre s s u re; adjusted for race, mode of hyperglycemic therapy at presentation, patient age, duration of disease, HbA 1 c, fasting plasma glucose, BMI, and systolic and diastolic blood pre s s u re; defined as a value of 45 mg/dl in men and 55 mg/dl in women. P 322 DIABETES CARE, VOLUME 23, NUMBER 3, MARCH 2000

5 Cook and Associates Although the distribution of HDL chol e s t e rol level by risk category is significantly d i ff e rent for African-Americans and Caucasians (with African-Americans having a slightly better profile), the percentage of patients with an unfavorable concentration was nonetheless high in both gro u p s. Although sex comparisons for HDL chol e s t e rol risk categories were statistically significant only for African-Americans, more women than men in both race groups had high-risk HDL profiles. The greater prop o rtion of women with high LDL and low HDL cholesterol may explain in part why the protective effect of sex against heart disease is not evident in diabetic women (26). Given the recent findings of the beneficial effect of increasing HDL cholestero l levels, our data indicate that increasing this l i p o p rotein, along with lowering LDL chol e s t e rol, should be an important target for i n t e rvention in this population (27). Most African-Americans and Caucasians with a TG level of 400 mg/dl had a combination of a high LDL and a low HDL cholesterol level. An isolated incre a s e in LDL cholesterol was the second most common pattern of dyslipidemia in African-Americans; in Caucasians, the second most common pattern was unfavorable levels of all three lipoproteins (LDL c h o l e s t e rol, HDL cholesterol, and TG) combined. More o v e r, only 19% of African- Americans overall, compared with 50% of Caucasians, had a TG level of 200 mg/dl. The data suggest that, at least in this gro u p of urban type 2 diabetic patients, TG level will be an infrequent target for therapy in A f r i c a n - A m e r i c a n s. Although African-American women had a greater BMI and similar severity of h y p e rglycemia (as assessed through HbA 1 c ) as compared with their male counterpart s, their degree of hypertriglyceridemia was less. On average, African-American women had the lowest average TG level, and, when adjusted for other variables, a significantly lower probability of having a TG level above clinical target ( 200 mg/dl). Caucasian women also had a greater BMI and comparable HbA 1 c levels compared with Caucasian men, but Caucasian women had the highest mean TG levels. Although the sample of Caucasian women was small re l- ative to that of African-American women, the data suggest that African-American women with type 2 diabetes may be re l a- tively resistant to hypert r i g l y c e r i d e m i a. Additional studies are re q u i red to confirm these observ a t i o n s. This study has several potential limitations. Because this analysis was based on a clinic population, data from other centers a re re q u i red to determine whether our findings can be generalized to other diabetes care settings. Medications that can affect lipid levels (e.g., antilipemic agents, - b l o c k e r s, and diuretics) that patients may have been taking at the time of their initial visit were not captured in our re g i s t ry. Variables such as tobacco use, use of hormone re p l a c e m e n t therapy among postmenopausal women, and data on physical activity were likewise not available. There f o re, a complete pro f i l e of CVD risk could not be obtained; however, such data will be necessary for the development of a future comprehensive CVD risk reduction program. Finally, a similar gro u p of patients from our health system without diabetes was not available to allow comparison with subjects in this study. Data on socioeconomic status was not available for this analysis, but socioeconomic status would not likely account for the observed race and sex diff e rences in lipid profiles. First, previous studies indicate that a substantial pro p o rtion of patients in our public hospital setting are u n i n s u red and are below the federal p o v e rty line (14). Second, a prior study suggested no effect of socioeconomic status on CVD risk factors among African-Americans at risk for type 2 diabetes (28). Despite its limitations, this analysis has provided insight into the pattern of dyslipidemia for a large sample of urban African-Americans with type 2 diabetes. At the time of the first visit, an LDL chol e s t e rol level above target in combination with an HDL cholesterol level below t a rget, followed by dyslipidemia charact e rized by an isolated elevated LDL c h o l e s- t e rol level, will be the most pre v alent lipid p rofile encountered by p roviders, where a s h y p e rtriglyceridemia will be infre q u e n t. T h e re f o re, interventions during the course of diabetes treatment will need to be d i rected primarily toward optimizing levels of LDL and HDL cholesterol rather than TG among the African-American patients in this setting. In Caucasians, on the other hand, strategies to lower TG concentrations, in conjunction with optimizing levels of LDL and HDL cholest e rol, will need to be more gre a t l y e m p h a s i z e d. Finally, given the greater prop o rtion of women with high-risk LDL and HDL cholesterol profiles, interv e n t i o n s designed to move serum lipids into more desirable ranges will need to target women e s p e c i a l l y. The amount of morbidity and m o rtality in type 2 diabetes attributable to CVD warrants further investigation to adapt knowledge of these race and sex influences on serum lipids into more e ffective strategies to reduce CVD in these e x t remely high-risk patients. A c k n o w l e d g m e n t s This work was supp o rted in part by awards from the Agency for Health Care Policy and Research (HS-09722) ( L. S. P., C.B.C., I.E.K., D.C.Z., D.L.G.) and the National Institutes of Health (DK-33475, DK (L.S.P. ). This work was presented in part at the National Meeting of the American Diabetes Association, San Diego, CA, R e f e re n c e s 1. American Diabetes Association: D i a b e t e s 1996 Vital Statistics. Alexandria, VA, American Diabetes Association, Gu K, Cowie CC, Harris MI: Diabetes and decline in heart disease mortality in US adults. J A M A 281: , B a rrett-connor E, Grundy SM, Holdbro o k MJ: Plasma lipids and diabetes mellitus in an adult community. Am J Epidemiol : , Sowers JR, Lester MA: Diabetes and card i o- vascular disease. Diabetes Care 2 2 : , Steiner G: Risk factors for macrovascular disease in type 2 diabetes: classic lipid abnormalities. 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