CME Supplements

In the past 2 decades, the burden of care for psychiatric complaints in primary care—including bipolar depression—has increased considerably. The prevalence of bipolar disorder (BPD) in primary care has been recently estimated to range up to 4.3%, and in studies with broader definitions of the disorder or in populations with higher-than-usual psychiatric disorders, the prevalence has been reported to be up to 11.4%. Even though BPD is seen commonly in primary care, there are still profound disparities in the delivery of care, including underdiagnosis, misdiagnosis, and inappropriate treatments. There is abundant evidence that BPD can be successfully managed in the primary care setting when adequate physician education, collaborative care teams, and patient education are employed. Efficacious and well-tolerated pharmacologic treatments for BPD are available, and evidence-based pharmacotherapy can be optimally managed by the primary care provider. In this supplement, experts in BPD discuss the recognition and management of bipolar depression and associated comorbidities in the primary care setting.

Click here to read the supplement.

After reading the supplement, click here to access the posttest and evaluation form to receive CME credit.

In the past 2 decades, the burden of care for psychiatric complaints in primary care—including bipolar depression—has increased considerably. The prevalence of bipolar disorder (BPD) in primary care has been recently estimated to range up to 4.3%, and in studies with broader definitions of the disorder or in populations with higher-than-usual psychiatric disorders, the prevalence has been reported to be up to 11.4%. Even though BPD is seen commonly in primary care, there are still profound disparities in the delivery of care, including underdiagnosis, misdiagnosis, and inappropriate treatments. There is abundant evidence that BPD can be successfully managed in the primary care setting when adequate physician education, collaborative care teams, and patient education are employed. Efficacious and well-tolerated pharmacologic treatments for BPD are available, and evidence-based pharmacotherapy can be optimally managed by the primary care provider. In this supplement, experts in BPD discuss the recognition and management of bipolar depression and associated comorbidities in the primary care setting.

Click here to read the supplement.

After reading the supplement, click here to access the posttest and evaluation form to receive CME credit.

In the past 2 decades, the burden of care for psychiatric complaints in primary care—including bipolar depression—has increased considerably. The prevalence of bipolar disorder (BPD) in primary care has been recently estimated to range up to 4.3%, and in studies with broader definitions of the disorder or in populations with higher-than-usual psychiatric disorders, the prevalence has been reported to be up to 11.4%. Even though BPD is seen commonly in primary care, there are still profound disparities in the delivery of care, including underdiagnosis, misdiagnosis, and inappropriate treatments. There is abundant evidence that BPD can be successfully managed in the primary care setting when adequate physician education, collaborative care teams, and patient education are employed. Efficacious and well-tolerated pharmacologic treatments for BPD are available, and evidence-based pharmacotherapy can be optimally managed by the primary care provider. In this supplement, experts in BPD discuss the recognition and management of bipolar depression and associated comorbidities in the primary care setting.

Click here to read the supplement.

After reading the supplement, click here to access the posttest and evaluation form to receive CME credit.

While better appreciated than 2 decades ago, gender-related differences remain an important issue in clinical practice. This supplement includes 8 articles that focus on the needs and considerations in providing care to women. Four articles focus on cardiometabolic diseases: acute coronary syndrome, coronary heart disease, obesity, and diabetes mellitus. Additional topics include the early management of rheumatoid arthritis and the pharmacologic management of nausea and vomiting of pregnancy.

The last 2 articles each offer the opportunity to earn 1 free CME credit: The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care and Chronic Migraine in Women. Credit is awarded for successful completion of the quizzes at the links below; these links may also be found in the Women’s Health supplement on the first page of each article.

The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care www.pceconsortium.org/oab

Chronic Migraine in Women www.pceconsortium.org/migraine

Click here to view the supplement

While better appreciated than 2 decades ago, gender-related differences remain an important issue in clinical practice. This supplement includes 8 articles that focus on the needs and considerations in providing care to women. Four articles focus on cardiometabolic diseases: acute coronary syndrome, coronary heart disease, obesity, and diabetes mellitus. Additional topics include the early management of rheumatoid arthritis and the pharmacologic management of nausea and vomiting of pregnancy.

The last 2 articles each offer the opportunity to earn 1 free CME credit: The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care and Chronic Migraine in Women. Credit is awarded for successful completion of the quizzes at the links below; these links may also be found in the Women’s Health supplement on the first page of each article.

The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care www.pceconsortium.org/oab

Chronic Migraine in Women www.pceconsortium.org/migraine

Click here to view the supplement

While better appreciated than 2 decades ago, gender-related differences remain an important issue in clinical practice. This supplement includes 8 articles that focus on the needs and considerations in providing care to women. Four articles focus on cardiometabolic diseases: acute coronary syndrome, coronary heart disease, obesity, and diabetes mellitus. Additional topics include the early management of rheumatoid arthritis and the pharmacologic management of nausea and vomiting of pregnancy.

The last 2 articles each offer the opportunity to earn 1 free CME credit: The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care and Chronic Migraine in Women. Credit is awarded for successful completion of the quizzes at the links below; these links may also be found in the Women’s Health supplement on the first page of each article.

The Pharmacologic Management of Idiopathic Overactive Bladder in Primary Care www.pceconsortium.org/oab

Chronic Migraine in Women www.pceconsortium.org/migraine

Click here to view the supplement

Bipolar disorder is characterized by the cyclical occurrence of elevated (manic or hypomanic) and depressed mood states. The illness, which includes the bipolar I and bipolar II subtypes, exacts a heavy toll in terms of quality of life, functioning, morbidity, comorbidity, and mortality.¹ Depressive episodes and symptoms deserve particular attention: Not only do they dominate the long-term course of the illness; they are associated with similar or greater psychosocial impairment than corresponding levels of manic or hypomanic symptoms.¹

Bipolar disorder is characterized by the cyclical occurrence of elevated (manic or hypomanic) and depressed mood states. The illness, which includes the bipolar I and bipolar II subtypes, exacts a heavy toll in terms of quality of life, functioning, morbidity, comorbidity, and mortality.¹ Depressive episodes and symptoms deserve particular attention: Not only do they dominate the long-term course of the illness; they are associated with similar or greater psychosocial impairment than corresponding levels of manic or hypomanic symptoms.¹

Bipolar disorder is characterized by the cyclical occurrence of elevated (manic or hypomanic) and depressed mood states. The illness, which includes the bipolar I and bipolar II subtypes, exacts a heavy toll in terms of quality of life, functioning, morbidity, comorbidity, and mortality.¹ Depressive episodes and symptoms deserve particular attention: Not only do they dominate the long-term course of the illness; they are associated with similar or greater psychosocial impairment than corresponding levels of manic or hypomanic symptoms.¹

The glucagon-like peptide-1 receptor (GLP-1R) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors have quickly become important treatment options for persons with type 2 diabetes. This article reviews the differences among the 3 GLP-1R agonists and 4 DPP-4 inhibitors currently available and how these differences impact treatment individualization. Emphasis is placed on strategies to improve patient self-management with the GLP-1R agonists, particularly those related to nausea and vomiting and medication adherence.

Physicians and Physician Assistants – Click Here to Take the Test

The glucagon-like peptide-1 receptor (GLP-1R) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors have quickly become important treatment options for persons with type 2 diabetes. This article reviews the differences among the 3 GLP-1R agonists and 4 DPP-4 inhibitors currently available and how these differences impact treatment individualization. Emphasis is placed on strategies to improve patient self-management with the GLP-1R agonists, particularly those related to nausea and vomiting and medication adherence.

Physicians and Physician Assistants – Click Here to Take the Test

The glucagon-like peptide-1 receptor (GLP-1R) agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors have quickly become important treatment options for persons with type 2 diabetes. This article reviews the differences among the 3 GLP-1R agonists and 4 DPP-4 inhibitors currently available and how these differences impact treatment individualization. Emphasis is placed on strategies to improve patient self-management with the GLP-1R agonists, particularly those related to nausea and vomiting and medication adherence.

Physicians and Physician Assistants – Click Here to Take the Test

An estimated 1 of every 3 Americans has hypertension, putting them at an increased risk for cardiovascular disease, heart failure, stroke, and kidney disease. Despite the availability of effective medications to control high blood pressure, only half of the patients with hypertension under treatment are meeting their blood pressure goals. To address these gaps in the quality of care patients receive, this supplement will focus on the following topics in hypertension management: key clinical trials and their influence on sequencing algorithms; the differences between thiazide-type diuretics; the use of thiazide-type diuretics in African American patients; and strategies to improve patient adherence to hypertensive therapy.

Webcast—October 2012

An estimated 1 of every 3 Americans has hypertension, putting them at an increased risk for cardiovascular disease, heart failure, stroke, and kidney disease. Despite the availability of effective medications to control high blood pressure, only half of the patients with hypertension under treatment are meeting their blood pressure goals. To address these gaps in the quality of care patients receive, this supplement will focus on the following topics in hypertension management: key clinical trials and their influence on sequencing algorithms; the differences between thiazide-type diuretics; the use of thiazide-type diuretics in African American patients; and strategies to improve patient adherence to hypertensive therapy.

Webcast—October 2012

An estimated 1 of every 3 Americans has hypertension, putting them at an increased risk for cardiovascular disease, heart failure, stroke, and kidney disease. Despite the availability of effective medications to control high blood pressure, only half of the patients with hypertension under treatment are meeting their blood pressure goals. To address these gaps in the quality of care patients receive, this supplement will focus on the following topics in hypertension management: key clinical trials and their influence on sequencing algorithms; the differences between thiazide-type diuretics; the use of thiazide-type diuretics in African American patients; and strategies to improve patient adherence to hypertensive therapy.

Webcast—October 2012

Since chronic diseases are largely self-managed, the family physician must work collaboratively with each patient to individualize therapy. One key consideration in individualizing therapy is patient gender, since men and women often manifest, deal with, and manage diseases differently. This supplement highlights these gender-related differences by focusing on the management of 6 diseases in men, including benign prostatic hyperplasia, gout, diabetes, acute coronary syndrome, coronary heart disease, and dyslipidemia.

Since chronic diseases are largely self-managed, the family physician must work collaboratively with each patient to individualize therapy. One key consideration in individualizing therapy is patient gender, since men and women often manifest, deal with, and manage diseases differently. This supplement highlights these gender-related differences by focusing on the management of 6 diseases in men, including benign prostatic hyperplasia, gout, diabetes, acute coronary syndrome, coronary heart disease, and dyslipidemia.

Since chronic diseases are largely self-managed, the family physician must work collaboratively with each patient to individualize therapy. One key consideration in individualizing therapy is patient gender, since men and women often manifest, deal with, and manage diseases differently. This supplement highlights these gender-related differences by focusing on the management of 6 diseases in men, including benign prostatic hyperplasia, gout, diabetes, acute coronary syndrome, coronary heart disease, and dyslipidemia.

The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.¹ This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.

Men at Risk for Type 2 Diabetes Mellitus

Key Risk Factors for Type 2 Diabetes Mellitus in Men

This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.² Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).³ While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.

With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.^2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8

Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.⁹ The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.

Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).¹⁰ Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).¹¹ Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.¹²

TABLE 1

Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*

Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).

Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.

Risk of Complications in Men With Type 2 Diabetes Mellitus

In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.

Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus

A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.¹⁵ Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.¹⁵ These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.¹⁶ Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.¹⁷ Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.¹⁷

Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.¹⁸ After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.

Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.¹⁹ Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.^20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.²⁰ The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).

Other Chronic Complications

Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.²²

While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.

Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies

Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.²³ There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .^24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.

TABLE 2

Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)^24-32

Summary

The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.

Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.

Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.

The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.¹ This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.

Men at Risk for Type 2 Diabetes Mellitus

Key Risk Factors for Type 2 Diabetes Mellitus in Men

This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.² Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).³ While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.

With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.^2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8

Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.⁹ The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.

Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).¹⁰ Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).¹¹ Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.¹²

TABLE 1

Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*

Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).

Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.

Risk of Complications in Men With Type 2 Diabetes Mellitus

In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.

Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus

A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.¹⁵ Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.¹⁵ These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.¹⁶ Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.¹⁷ Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.¹⁷

Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.¹⁸ After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.

Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.¹⁹ Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.^20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.²⁰ The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).

Other Chronic Complications

Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.²²

While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.

Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies

Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.²³ There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .^24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.

TABLE 2

Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)^24-32

Summary

The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.

Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.

Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.

The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.¹ This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.

Men at Risk for Type 2 Diabetes Mellitus

Key Risk Factors for Type 2 Diabetes Mellitus in Men

This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.² Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).³ While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.

With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.^2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8

Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.⁹ The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.

Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).¹⁰ Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).¹¹ Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.¹²

TABLE 1

Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*

Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).

Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.

Risk of Complications in Men With Type 2 Diabetes Mellitus

In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.

Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus

A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.¹⁵ Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.¹⁵ These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.¹⁶ Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.¹⁷ Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.¹⁷

Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.¹⁸ After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.

Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.¹⁹ Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.^20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.²⁰ The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).

Other Chronic Complications

Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.²²

While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.

Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies

Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.²³ There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .^24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.

TABLE 2

Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)^24-32

Summary

The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.

Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.

Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.

A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

A decade ago, the World Health Organization suggested that “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹ A recent survey found that medication adherence rates over the course of 1 year were 24% for patients with depression, 36% with diabetes, 54% with epilepsy, 32% with dyslipidemia, and 42% with hypertension.² Poor adherence rates such as these contribute to the low rates of disease control in patients with diabetes, dyslipidemia, hypertension, and other chronic diseases.^3,4 Since chronic diseases are largely self-managed, effective patient self-management is critical to good health-related outcomes. To help patients self-manage their diseases, the family physician must work collaboratively with each patient to select, initiate, and modify therapy based upon the patient’s needs, interests, and capabilities. Just as there are important differences between children and adults, men and women often manifest diseases differently. In addition, men and women often deal with and manage their diseases in different ways. While “Men’s Health” is often considered to be a focus on the urogenital tract, we have sought to also focus on diseases that have a high prevalence in men, or where treatment in men may be different compared with women.

The first 2 articles in this supplement on men’s health concern 2 diseases increasingly encountered by men as they age. Dr. Martin Miner provides his thoughts about screening for and diagnosing benign prostatic hyperplasia, including strategies to promote patient report of symptoms and the role of the prostate specific antigen test. A case study is utilized to illustrate key considerations when selecting therapy and promoting patient self-management of benign prostatic hyperplasia. Dr. Gary Ruoff follows a patient from initial diagnosis of gout through selection of treatment for the acute flare and chronic treatment with urate-lowering therapy. A treatment plan is presented at each management step. In the next article, Dr. Richard Aguilar takes a case study approach to describe key risk factors for type 2 diabetes mellitus in men. He also discusses how men self-manage type 2 diabetes differently than women and provides insight as to how to address common psychosocial issues in men. Drs. Louis Kuritzky and José Díez review clinical experience with the two newest antiplatelet agents, prasugrel and ticagrelor. Answers are also provided to common questions and problems encountered with the use of antiplatelet agents in primary care. The next 2 articles focus on major modifiable risk factors contributing to cardiovascular disease. In the first, Dr. Michael Cobble focuses on patient assessment and treatment strategies to help men modify abnormal lipid levels and blood pressure for primary prevention of coronary heart disease. Finally, a more in-depth discussion of dyslipidemia is provided by Dr. Peter Toth, who begins by providing a brief overview of the current evidence regarding the long-term benefits of statin therapy, as well as his clinical perspective on the newest statin, pitavastatin. Dr. Toth also provides answers to many problems frequently encountered in the primary care management of patients with dyslipidemia using statin therapy.

It is my hope that the insights provided by these authors will be helpful to family physicians in managing their male patients with these common chronic diseases.

Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability worldwide. In the United States alone, it is believed that approximately 27 million people are affected by this degenerative condition. Many factors are known to increase the risk of developing OA, including heredity, obesity, joint or nerve injury, repeated overuse of certain joints, lack of physical activity, and aging. Treatment for OA needs to be individualized according to the stage of the disease, patient tolerability, comorbidities involved, and response to therapies to meet the goals of reducing pain, improving joint mobility and quality of life, and limiting functional impairment while avoiding drug toxicity. This supplement will review the latest advances in the pathogenesis, underlying phenotypes, and current therapeutic options of OA.
Click here to read Supplement.

Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability worldwide. In the United States alone, it is believed that approximately 27 million people are affected by this degenerative condition. Many factors are known to increase the risk of developing OA, including heredity, obesity, joint or nerve injury, repeated overuse of certain joints, lack of physical activity, and aging. Treatment for OA needs to be individualized according to the stage of the disease, patient tolerability, comorbidities involved, and response to therapies to meet the goals of reducing pain, improving joint mobility and quality of life, and limiting functional impairment while avoiding drug toxicity. This supplement will review the latest advances in the pathogenesis, underlying phenotypes, and current therapeutic options of OA.
Click here to read Supplement.

Osteoarthritis (OA) is the most common form of arthritis and a leading cause of disability worldwide. In the United States alone, it is believed that approximately 27 million people are affected by this degenerative condition. Many factors are known to increase the risk of developing OA, including heredity, obesity, joint or nerve injury, repeated overuse of certain joints, lack of physical activity, and aging. Treatment for OA needs to be individualized according to the stage of the disease, patient tolerability, comorbidities involved, and response to therapies to meet the goals of reducing pain, improving joint mobility and quality of life, and limiting functional impairment while avoiding drug toxicity. This supplement will review the latest advances in the pathogenesis, underlying phenotypes, and current therapeutic options of OA.
Click here to read Supplement.