This article has Open Peer Review reports available.
Diabetes, gender, and left ventricular structure in African-Americans: the atherosclerosis risk in communities study
© Foppa et al; licensee BioMed Central Ltd. 2006
Received: 14 September 2006
Accepted: 08 November 2006
Published: 08 November 2006
Cardiovascular risk associated with diabetes may be partially attributed to left ventricular structural abnormalities. However, the relations between left ventricular structure and diabetes have not been extensively studied in African-Americans.
We studied 514 male and 965 female African-Americans 51 to 70 years old, in whom echocardiographic left ventricular mass measurements were collected for the ARIC Study. In these, we investigated the independent association of diabetes with left ventricular structural abnormalities.
Diabetes, hypertension and obesity prevalences were 22%, 57% and 45%, respectively. Unindexed left ventricular mass was higher with diabetes in both men (238.3 ± 79.4 g vs. 213.7 ± 58.6 g; p < 0.001) and women (206.4 ± 61.5 g vs. 176.9 ± 50.1 g; p < 0.001), respectively. Prevalence of height-indexed left ventricular hypertrophy was higher in women while increased relative wall thickness was similar in men and women. Those with diabetes had higher prevalences of height-indexed left ventricular hypertrophy (52% vs. 32%; p < 0.001), and of increased relative wall thickness (73% vs. 64%; p = 0.002). Gender-adjusted associations of diabetes with left ventricular hypertrophy (OR = 2.29 95%CI:1.79–2.94) were attenuated after multiple adjustments in logistic regression (OR = 1.50 95%CI:1.12–2.00). Diabetes was associated with higher left ventricle diameter (OR = 2.13 95%CI:1.28–3.53) only in men and with higher wall thickness (OR = 1.89 95%CI:1.34–2.66) only in women. Attenuations in diabetes associations were frequently seen after adjustment for obesity indices.
In African-Americans, diabetes is associated with left ventricular hypertrophy and, with different patterns of left ventricular structural abnormalities between genders. Attenuation seen in adjusted associations suggests that the higher frequency of structural abnormalities seen in diabetes may be due to factors other than hyperglycemia.
Left ventricular hypertrophy (LVH) is frequent in diabetic patients [1, 2]. and has been identified as a powerful marker of impaired prognosis in cardiovascular disease , including in African-Americans .
Alterations in left ventricular (LV) structure have been linked to diabetes but also to a large number of related conditions such as aging, hypertension, obesity, central obesity, dyslipidemia, salt intake, and physical inactivity [5–7] Hence, the underlying processes common to the coexistent risk factors, as opposed to hyperinsulinemia or hyperglycemia, per se, may explain much of the association seen between diabetes and LV structural abnormalities.
African-Americans have a high prevalence of left ventricular structural abnormalities  and of its clinical correlates, frequently presented together [9, 10] However, few population-based studies have adequately studied the relations between diabetes and these structural adaptive responses in African-Americans , which may have distinct pathophysiologic mechanisms , and also may differ between genders .
This study evaluates the independent cross-sectional associations of diabetes with LV structural alterations in a community-based sample of African-Americans with a high prevalence of other known risk factors for LVH.
The ARIC Study is a prospective study designed to investigate the etiology and natural history of CVD in four U.S. communities. The study design and procedures, including the echocardiography protocol, have been previously reported [14, 15]. Between 1987 and 1989, ARIC enrolled individuals 45 to 64 years old, and requested participants to return for clinical visits every three years through 1998. The initial Jackson (MI) center cohort consisted of 3728 African-Americans. Of these, echocardiography studies were performed in 863 men and 1571 women between 1993 and 1996. We excluded those with one or more of the following criteria: inadequate M-mode measurements (n = 549), clinically (n = 62) or echocardiographically (n = 212) diagnosed prevalent cardiovascular disease, and missing covariates (n = 132), leaving 1479 participants for analysis.
Diabetes was defined as a participant report of physician diagnosis or diabetic medication use, fasting glucose ≥ 126 mg/dL, or casual glucose ≥ 200 mg/dL. Hypertension was defined as a mean of two separate measures greater than 140/90 mmHg or antihypertensive drug use. Obesity was defined as a body mass index ≥ 30 kg/m2. Body surface area (BSA) was calculated as BSA = 0.007184 * weight [kg]0.425 * height [cm]0.725, according to the Dubois formula . Waist-hip ratio was calculated from measurements of waist (measured at the umbilicus) and hip (measured at maximum gluteal protrusion) circumferences.
The two-dimensional guided M-mode echocardiographic tracings were acquired with an Acuson 128XP/10c System. Images were digitized and analyzed off-line with a commercially available program. Only frames with optimal visualization of interfaces that simultaneously showed the interventricular septum, LV internal diameter, and posterior wall were used for readings. Tracings were read by one of two cardiologists, unaware of subject's clinical data, and the average value from 3 measurements was computed. LV mass was calculated using M-mode tracings according to American Society of Echocardiography conventions  and Devereux modified cubed formula . To account for gender and body size variations we indexed LV mass employing height2.7, with a boundary of 51 g/m2.7 to define LVH in both genders . The intra- and intersonographer correlations for LV mass between the first and second scan, examined in a subsample, were 0.94 and 0.82, respectively. The intrareader correlation for LV mass was 0.98 .
Alterations in LV geometry were assessed by several approaches. Relative wall thickness (RWT) was calculated as the sum of wall thicknesses (septum + diastolic posterior wall thickness) divided by LV diastolic diameter, with elevated RWT defined as greater or equal to 0.45 ; In multivariate analysis increased LV diameter was defined as the upper quartile of gender specific left ventricular diameter. To define increased wall thickness for modeling, we used the median as cut-off point for the sum of wall thicknesses, as about two-thirds of both men and women in the sample had a RWT above 0.45.
We investigated the differences in crude prevalences between groups in stratified analyses with Chi-square statistics. We used logistic regression analysis (SAS 8.0 Software, Cary, NC) to study the independent association of variables with pre-defined echocardiographic features. Associations were adjusted for adiposity by including obesity, defined by BMI, and waist-hip ratio in models. For further, in multiple adjustment, we added the covariates age, systolic blood pressure, antihypertensive medication use, total cholesterol, activity level, smoking and education level. Height was also included as a covariate in analyses of increased LV diameter and increased wall thickness. In these multivariable models, we used clinically defined cut-points, when present, for continuous exposure variables. In order to produce exposure frequencies similar to that of diabetes, we modeled variables without pre-defined cut-points comparing the upper quartile to the lower three. Gender interactions were tested using the Wald statistic of the gender interaction term. We employed the variance inflation factor to identify collinearity among variables measuring potentially similar biological effects. The variance inflation factor was never greater than 3.0, suggesting that important collinearity was absent .
The 1479 individuals included in the study differed somewhat from the 955 subjects undergoing the exam but excluded from these analyses. The included participants had a similar gender distribution, somewhat lower prevalences of diabetes (22% vs. 25%; P = 0.22) and obesity (45% vs. 49%; P = 0.07), and less hypertension (57% vs. 64%; P = 0.02) than those excluded.
Participant characteristics by gender
Men (N = 514)
Women (N = 965)
Age – years
Height – m
Body Mass Index – kg/m2
Systolic Blood Pressure – mmHg
Glucose – mg/dL
Metabolic Syndrome|| (%)
Echocardiographic measurements and prevalences of structural abnormalities in men and women*
Men (N = 514)
Women (N = 965)
Left Ventricular Diameter Diastole – mm
Septum Thickness – mm
Posterior Wall Thickness – mm
Relative Wall Thickness (RWT)
Fractional Shortening (%)
Left Ventricular Mass Estimates||
LV mass – g
LV mass/BSA – g/m2
LV mass/Height2.7 – g/m2.7
Unindexed LVH (38)
Height2.7 – Indexed LVH
Relative Wall Thickness >= 0.45
Crude and adjusted associations of diabetes with height-indexed left ventricular hypertrophy (LVH2.7)
Multiply Adjusted †
The unadjusted association of diabetes with relative wall thickness differed notably between men (OR = 0.84 95%CI 0.53–1.32) and women (OR = 2.06 95%CI 1.46–2.91; interaction P = 0.002). Multiply-adjusted gender-specific analyses revealed that diabetes was associated with increased RWT in women (OR = 1.63 95%CI 1.12–2.37) but not in men (OR = 0.64 95%CI 0.39–1.04).
Crude and adjusted gender-specific associations of diabetes with increased left ventricular diameter and wall thickness
Left Ventricular Diameter
Multiply Adjusted †
Consistent with previous reports [8, 9], LV structural abnormalities were frequent in this community sample of African-Americans. The prevalence of left ventricular hypertrophy was particularly high in women, even after body size adjustments. Within this context, we found an association of diabetes with LVH which, though diminishing with adjustment for obesity indices, was independent of body size. The association of LV structural abnormalities with diabetes , as well as with impaired glucose tolerance  in our African American cohort, is consistent with previous studies in predominantly or exclusively white cohorts.
Employment of relative wall thickness to evaluate geometric remodeling resulted in an unanticipated finding. Whereas RWT prevalences were similar between men and women, diabetes was associated with increased RWT in women; in men, if anything, with the reverse. Separate evaluation of the components of relative wall thickness – ventricular chamber size and wall thickness – produced a possible explanation for the apparent paradox: In women diabetes was associated with increased wall thickness, but not with increased left ventricular diameter. In men, on the contrary, diabetes was more strongly associated with increased left ventricular diameter than with increased wall thickness. This finding demonstrates a potential limitation of using the ratio of these two measures to identify the structural changes related to diabetes.
Differences in correlates of left ventricular structure may indicate that the pathophysiologic mechanisms leading to heart maladaptive response differ somewhat between genders. Females have been found to have an increased wall thickness response to pressure overload compared with males in clinical  and in animal studies . These gender-specific differences in the impact of carbohydrate metabolism has also been identified in patients with the metabolic syndrome , but has been scarcely investigated in African-Americans. In non-diabetic American Indians of the Strong Heart Study  fasting insulin levels were associated with LV mass in men and with wall thickness in women. In the Framingham Study cohorts , increased LV mass and RWT were seen in diabetic women but not diabetic men. More recent analysis from the Framingham Heart Study , showed an increase in RWT parallel to diabetes severity and to insulin resistance (homeostasis model, HOMA-IR) only in women, although most of this association appeared to be explained by obesity. It is important to note that adjustment for indices of adiposity appeared to account for most of the reduction in the magnitude of diabetes associations seen in multiply-adjusted models. This finding was suggested by Galvan et al., and is consistent with a recent review that concluded that associations of insulin and glucose metabolism with LV mass were mostly explained by adiposity . In fact, one of the largest studies to date, the HyperGEN Study, with adequate representation of African-Americans, found inverse associations with fasting insulin levels and adaptive LV responses, once adjustment for several elements of the insulin resistance syndrome was performed . Moreover, another analysis from the ARIC African-American participants showed greater interventricular and septal wall thicknesses in the obese, independent of blood pressure levels and diabetes .
The traditional explanation for the important association of obesity with abnormal LV responses is that obesity produces a hemodynamic stress, with increased heart rate, blood volume, and blood pressure . However, recent recognition of the inflammatory state present in obesity, believed to be in large part mediated by adipocyte secretory products and which may underlie insulin resistance , has changed our understanding of the pathophysiologic links of obesity with diabetes and cardiovascular diseases . Moreover, many of these immune-inflammatory mediators may have important roles in ventricular remodeling  and heart failure . The frequently large associations seen here with adiposity indices and the important reduction in diabetes associations seen with adjustment for these indices provides epidemiologic evidence supporting the hypothesis that these processes are indeed active in the pathophysiology of ventricular dysfunction.
There are, however, additional specific mechanisms by which diabetes might be related to LV geometry and hypertrophy. Diabetes may contribute to ventricular adaptive changes through an increase in pro-inflammatory immune mediators resulting from the oxidative stress caused by hyperglycemia [32, 35]. The association may also be mediated through the production of advanced glycation end products (AGE), which may, by leading to a reduced degradation of collagen, impair ventricular compliance .
Some limitations to our study merit mention. Forty percent of the initially enrolled participants could not be analyzed, creating the possibility of selection bias influencing our results. In this regard, as those included were generally healthier than those excluded, and the associations we have demonstrated may underestimate the true association between diabetes and LVH. The high prevalence of obesity makes these results of questionable generalizability to leaner populations. Finally, the high prevalence of examined echocardiographic features results in the reported odds ratios being overestimates of relative risk.
In conclusion, diabetes is associated with increased LVH in middle-aged and elderly African-American men and women. Most of this increase appears to be more closely associated with obesity, especially central obesity, than to diabetes per se. Diabetes associated altered ventricular structure appears to differ by gender. This may be due to gender difference in the cardiac response to the pathophysiologic factors underlying LV morphology – in men the process of increased mass being more coupled with chamber dilation whereas in women expressed mostly as wall thickening. The gender difference in LV structure complicates the use of common geometric patterns definitions when comparing ventricular remodeling in response to diabetes.
The authors thank the staff and participants in the ARIC study for their important contributions, and Alvaro Vigo and Mariana Carballo for statistical assistance. Support for this study was provided by National Heart, Lung, and Blood Institute Contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021 and N01-HC-55022. Dr. Duncan and Dr. Foppa received support from a Centers of Excellence Grant of CNPq (the Brazilian National Council for Scientific and Technological Development).
- Galderisi M, Anderson KM, Wilson PWF, Levy D: Echocardiographic evidence for a existence of a distinct cardiomyopathy (The Framingham Heart Study). Am J Cardiol. 1991, 68: 85-89.View ArticlePubMedGoogle Scholar
- Lee M, Gardin JM, Lynch JC, Smith V-E, Tracy RP, Savage PJ, Szklo M, Ward BJ: Diabetes mellitus and echocardiographic left ventricular function in free-living elderly men and women: The Cardiovascular Health Study. Am Heart J. 1997, 133: 36-43.View ArticlePubMedGoogle Scholar
- Vakili BA, Okin PM, Devereux RB: Prognostic implications of left ventricular hypertrophy. Am Heart J. 2001, 141: 334-341.View ArticlePubMedGoogle Scholar
- Liao Y, McGee DL, Cao G, Cooper RS: Black-white differences in disability and morbidity in the last years of life. Am J Epidemiol. 1999, 149: 1097-1103.View ArticlePubMedGoogle Scholar
- Levy D: Echocardiographically detected left ventricular hypertrophy: prevalence and risk factors. The Framingham Heart Study. Ann Intern Med. 1988, 108: 7-13.View ArticlePubMedGoogle Scholar
- Gardin JM, Arnold A, Gottdiener JS, Wong ND, Fried LP, Klopfenstein HS, O'Leary DH, Tracy R, Kronmal R: Left ventricular mass in the elderly. The Cardiovascular Health Study. Hypertension. 1997, 29: 1095-1103.View ArticlePubMedGoogle Scholar
- Devereux RB, Roman MJ, De Simone G, O'Grady MJ, Paranicas M, Yeh JL, Fabsitz RR, Howard BV: Relations of left ventricular mass to demographic and hemodynamic variables in American Indians: the Strong Heart Study. Circulation. 1997, 96: 1416-1423.View ArticlePubMedGoogle Scholar
- Liebson PR, Grandits G, Prineas R, Dianzumba S, Flack JM, Cutler JA, Grimm R, Stamler J: Echocardiographic correlates of left ventricular structure among 844 mildly hypertensive men and women in the Treatment of Mild Hypertension Study (TOMHS). Circulation. 1993, 87: 476-486.View ArticlePubMedGoogle Scholar
- Zabalgoitia M, Ur Rahman SN, Haley WE, Oneschuk L, Yunis C, Lucas C, Yarows S, Krause L, Amerena J: Impact of ethnicity on left ventricular mass and relative wall thickness in essential hypertension. Am J Cardiol. 1998, 81: 412-417.View ArticlePubMedGoogle Scholar
- Fox E, Taylor H, Andrew M, Han H, Mohamed E, Garrison R, Skelton T: Body mass index and blood pressure influences on left ventricular mass and geometry in African Americans: The Atherosclerotic Risk In Communities (ARIC) Study. Hypertension. 2004, 44: 55-60.View ArticlePubMedGoogle Scholar
- Palmieri V, Bella JN, Arnett DK, Liu JE, Oberman A, Schuck MY, Kitzman DW, Hopkins PN, Morgan D, Rao DC, et al.: Effect of type 2 diabetes mellitus on left ventricular geometry and systolic function in hypertensive subjects: Hypertension Genetic Epidemiology Network (HyperGEN) study. Circulation. 2001, 103: 102-107.View ArticlePubMedGoogle Scholar
- Duncan BB, Schmidt MI, Pankow JS, Ballantyne CM, Couper D, Vigo A, Hoogeveen R, Folsom AR, Heiss G: Low-grade systemic inflammation and the development of type 2 diabetes: the atherosclerosis risk in communities study. Diabetes. 2003, 52: 1799-1805.View ArticlePubMedGoogle Scholar
- Rohde LE, Zhi G, Aranki SF, Beckel NE, Lee RT, Reimold SC: Gender-associated differences in left ventricular geometry in patients with aortic valve disease and effect of distinct overload subsets. Am J Cardiol. 1997, 80: 475-480.View ArticlePubMedGoogle Scholar
- , : The Atherosclerosis Risk in Communities (ARIC) Study: Design and objectives. Am J Epidemiol. 1989, 129: 687-702.Google Scholar
- Collaborative Studies Coordinating Center, University of North Carolina: ARIC study documents: manuals, visit 3. http://www.cscc.unc.edu/aric/visit/index.phtml?visit=3
- Dubois D, Dubois EF: A formula to estimate the aproximate surface area if height and weight be known. Arch Intern Med. 1916, 17: 863-871.View ArticleGoogle Scholar
- Sahn DJ, DeMaria A, Kisslo J, Weyman A: The committee on M-mode Standardization of the American Society of Echocardiography: recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic methods. Circulation. 1978, 58: 1072-1083.View ArticlePubMedGoogle Scholar
- Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, Reichek N: Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. Am J Cardiol. 1986, 57: 450-458.View ArticlePubMedGoogle Scholar
- De Simone G, Devereux RB, Daniels SR, Koren MJ, Meyer RA, Laragh JH: Effect of growth on variability of left ventricular mass: assessment of allometric signals in adults and children and their capacity to predict cardiovascular risk. J Am Coll Cardiol. 1995, 25: 1056-1062.View ArticlePubMedGoogle Scholar
- Skelton TN, Andrew ME, Arnett DK, Burchfiel CM, Garrison RJ, Samdarshi TE, Taylor HA, Hutchinson RG: Echocardiographic left ventricular mass in African-Americans: the Jackson cohort of the Atherosclerosis Risk in Communities Study. Echocardiography. 2003, 20: 111-120.View ArticlePubMedGoogle Scholar
- Ganau A, Devereux RB, Roman MJ, De Simone G, Pickering TG, Saba PS, Vargiu P, Simongini I, Laragh JH: Patterns of left ventricular hypertrophy and geometric remodeling in essential hypertension. J Am Coll Cardiol. 1992, 19: 1550-1558.View ArticlePubMedGoogle Scholar
- Kleinbaun DG, Kupper LL, Muller KE: Applied regression analysis and mulitvariable methods. Boston: PWS-Kent Publishing Company, 1988.Google Scholar
- Ilercil A, Devereux RB, Roman MJ, Paranicas M, O'Grady MJ, Welty TK, Robbins DC, Fabsitz RR, Howard BV, Lee ET: Relationship of impaired glucose tolerance to left ventricular structure and function: The Strong Heart Study. Am Heart J. 2001, 141: 992-998.View ArticlePubMedGoogle Scholar
- Weinberg EO, Thienelt CD, Katz SE, Bartunek J, Tajima M, Rohrbach S, Douglas PS, Lorell BH: Gender differences in molecular remodeling in pressure overload hypertrophy. J Am Coll Cardiol. 1999, 34: 264-273.View ArticlePubMedGoogle Scholar
- Schillaci G, Pirro M, Pucci G, Mannarino MR, Gemelli F, Siepi D, Vaudo G, Mannarino E: Different impact of the metabolic syndrome on left ventricular structure and function in hypertensive men and women. Hypertension. 2006, 47 (5): 881-6.View ArticlePubMedGoogle Scholar
- Ilercil A, Devereux RB, Roman MJ, Paranicas M, O'Grady MJ, Lee ET, Welty TK, Fabsitz RR, Howard BV: Associations of insulin levels with left ventricular structure and function in American Indians: the strong heart study. Diabetes. 2002, 51: 1543-1547.View ArticlePubMedGoogle Scholar
- Rutter MK, Parise H, Benjamin EJ, Levy D, Larson MG, Meigs JB, Nesto RW, Wilson PW, Vasan RS: Impact of glucose intolerance and insulin resistance on cardiac structure and function: sex-related differences in the Framingham Heart Study. Circulation. 2003, 107: 448-454.View ArticlePubMedGoogle Scholar
- Galvan AQ, Galetta F, Natali A, Muscelli E, Sironi AM, Cini G, Camastra S, Ferrannini E: Insulin resistance and hyperinsulinemia: No independent relation to left ventricular mass in humans. Circulation. 2000, 102: 2233-2238.View ArticlePubMedGoogle Scholar
- Lee KW, Lip GY: Insulin resistance and vascular remodelling, in relation to left ventricular mass, geometry and function: an answer to LIFE?. J Hum Hypertens. 2003, 17: 299-304.View ArticlePubMedGoogle Scholar
- Devereux RB, De Simone G, Palmieri V, Oberman A, Hopkins P, Kitzman DW, Rao DC, Arnett DK: Relation of insulin to left ventricular geometry and function in African American and white hypertensive adults: the HyperGEN study. Am J Hypertens. 2002, 15: 1029-1035.View ArticlePubMedGoogle Scholar
- Alpert MA, Terry BE, Kelly DL: Effect of weight loss on cardiac chamber size, wall thickness and left ventricular function in morbid obesity. Am J Cardiol. 1985, 55: 783-786.View ArticlePubMedGoogle Scholar
- Schmidt MI, Duncan BB: Diabesity: an inflammatory metabolic condition. Clin Chem Lab Med. 2003, 41: 1120-1130.View ArticlePubMedGoogle Scholar
- Lips DJ, deWindt LJ, van Kraaij DJ, Doevendans PA: Molecular determinants of myocardial hypertrophy and failure: alternative pathways for beneficial and maladaptive hypertrophy. Eur Heart J. 2003, 24: 883-896.View ArticlePubMedGoogle Scholar
- Vasan RS, Sullivan LM, Roubenoff R, Dinarello CA, Harris T, Benjamin EJ, Sawyer DB, Levy D, Wilson PW, D'Agostino RB: Inflammatory markers and risk of heart failure in elderly subjects without prior myocardial infarction: the Framingham Heart Study. Circulation. 2003, 107: 1486-1491.View ArticlePubMedGoogle Scholar
- Brownlee M: Biochemistry and molecular cell biology of diabetic complications. Nature. 2001, 414: 813-820.View ArticlePubMedGoogle Scholar
- Avendano GF, Agarwal RK, Bashey RI, Lyons MM, Soni BJ, Jyothirmayi GN, Regan TJ: Effects of glucose intolerance on myocardial function and collagen-linked glycation. Diabetes. 1999, 48: 1443-1447.View ArticlePubMedGoogle Scholar
- Grundy SM, Brewer HB, Cleeman JI, Smith SC, Lenfant C: Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation. 2004, 109: 433-438.View ArticlePubMedGoogle Scholar
- Levy D, Savage DD, Garrison RJ, Anderson KM, Kannel WB, Castelli WP: Echocardiographic criteria for left ventricular hypertrophy: the Framingham Heart Study. Am J Cardiol. 1987, 59: 956-960.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.