The need for multifactorial cardiovascular risk control in order to minimize type 2 diabetes mellitus (T2DM) complications has long been emphasized and more recently confirmed by the STENO-2 extension study [1] . Furthermore, as a chronic condition, it is the duration of risk factor exposure which will determine more accurately the likelihood of complications.

As a developing country in the Middle-East North Africa (MENA) region, the prevalence of T2DM is moderately elevated in Lebanon [2] . We have previously shown that the risk factors and presence of complications were frequent in an adult diabetic population surveyed in a tertiary health care center [3] . It is not known what happens to these risk factors over time in the Lebanese population. One epidemiologic report from 4 countries of the MENA region suggests that risk factors such as smoking, obesity, and hypertension tend to worsen over a 15-year period [4] . However, these risk factors were assessed in a population study design, which would not include the same study subjects over time. The current study aims to assess the change over time in cardiovascular risk in the same cohort, under real life conditions. The primary objective of the study is to compare cardiovascular risk factors after a 2-year follow-up to baseline in adults with T2DM presenting to an outpatient clinic in a tertiary care center. The secondary objective is to compare these risk factors to other populations with T2DM, namely the National Health Assessment and Nutrition Examination Survey (NHANES) population [5] .

At baseline, 220 patients out of the 300 screened with T2DM were included in the analysis. Out of these, 200 completed their visit at two years. Twenty patients were lost to follow up, including three death reports: first death due to a complicated stroke, second death due to a complicated coronary artery bypass graft and the cause of the third death could not be collected from the family.

The current study compared in a longitudinal manner a cohort of patients with T2DM presenting for their usual care. It showed either similar risk or improvement in some of the cardiovascular risk factors, namely BP control and LDL-C level. Overall, the absolute values remain far from target recommendations and the cardiovascular risk remains high. Variables which are largely affected by lifestyle did not show improvement, namely HbA1C, BMI, HDL-C level, and smoking rates.

The improved BP and LDL-C control can be explained at least partially on the basis of increased use of statins and ACEI/ARB class. The relative “ease” in achieving target control with cholesterol and BP is largely medication-dependent, although lifestyle factors such as smoking and salt intake remain crucial for optimal control. Nonetheless, the rate of medication use remains very low and is lower in comparison to other observed cohorts namely STENO-2 [1] , NHANES [5] , and the population-based KORA cohort study [12] . Our study also reported a 10-year CHD risk similar to the 10-year CHD risk of 19% reported in Germany by Laxy et al. [12] . Although the outcome is not alarming in itself, the baseline existing CAD affecting nearly one quarter of the sample is an important indicator of the high morbidity in this population. Therefore, the risk for complications and the need for vigilance in prevention still stand.

^a [10] Saaddine, J., Cadwell, B., Gregg, E., Engelgau, M., Vinicor, F., Imperatore, G. and Narayan, K. (2006) Improvements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988-2002. Annals of Internal Medicine, 144, 465-474; ^b [3] Taleb, N., Salti, H., Al-Mokaddam, M., Merheb, M., Salti, I. and Nasrallah, M. (2008) Vascular complications of diabetes in Lebanon: Experience at the American University of Beirut. British Journal of Diabetes and Vascular Medicine, 8, 80-83; ^cBL = Baseline; ^dSignificant at the 5% level.

Possible explanations for the lack of improvement in HbA1C, smoking and obesity rates are the difficulty in implementing significant lifestyle changes, especially in chronic disease. In support of this, The KORA study which is a national survey on the quality of diabetes care in Germany revealed similar trends in terms of poor patient self-management and physician-delivered care [12] . The difficulty in sustaining care, even in countries with socialized medicine, speaks for the nature of T2DM and its silent chronicity, which present a challenge to both the patient and the physician to sustain implementation of guidelines.

Studies which reflected a multidisciplinary and intensive approach in the treatment of T2DM have been typically more successful in the control of the condition. In the Diabetes Prevention Program (DPP), “the lifestyle intervention group” who received supervised intensive training in diet, physical activity of 150 minutes a week, and behavior modification showed a significant delay or prevention in development of diabetes, more than the group on metformin without intensive lifestyle modification [13] . The multidisciplinary approach success was well-illustrated in a retrospective within-group comparison study, in a clinic with previously poorly controlled subjects with T2DM. In this clinic, a cohort of diabetic patients was followed-up for at least one year by a Multidisciplinary Diabetes Care (MDC) team which consisted of endocrinologists, clinical pharmacists, clinical dieticians and certified diabetes nurse educators. When comparing the results to the pre-enrollment phase, considered as the “standard care phase”, it was shown that the MDC approach was effective in improving glycemic and blood pressure control among diabetic patients [14] . The multidisciplinary approach in diabetes has been endorsed by the National Institute of Health [15] .

Ideally, diabetes complications prevention should happen at the primary level, with preventing or delaying the condition itself the longest possible. However, given the size of the epidemic, the need for complications prevention remains imminent at the secondary and tertiary levels. The prevalence of T2DM is described to be around 16.7 % using self-report, in a population study of Lebanese adults above 40 years of age [2] . In the current study, we have shown that the complications rate of these subjects is high, be it in microvascular or macrovascular rate, and the risk factors persist, and remain either equal or higher than other populations. We suggest that the reasons behind the high morbidity are possibly delay in diagnosis of T2DM, insufficient use of medical therapy (in a country where medical care is not socialized), and extremely poor lifestyle as reflected by high smoking and obesity rates. Measures to address all three are vitally needed. In support of the delay in diagnosis, it was estimated that about one quarter of subjects screened for T2DM in Beirut in 2005 did not know they had the condition [16] . One may argue that since study completion, new classes of hypoglycemic therapies have emerged such as glucagon like receptor agonists and sodium-glucose transport-2 inhibitors, with unprecedented demonstration of cardiovascular risk reduction [17] [18] [19] . However, the cost of such therapy in the population surveyed in our study would have been prohibitive and unlikely to have affected their use as they are not covered nor reimbursed by the Lebanese Ministry of Public Health dispensaries.

Ultimately, our study strength is in data homogeneity as the information was collected by the same investigators, examined by the same ophthalmologist and run in the same laboratory. Also, this study is unique in Lebanon as it prospectively provides a follow-up on a cohort of patients with T2DM over a two-year period. In parallel, one limitation of the study is that our results cannot be likely generalized to the whole Lebanese population, as AUBMC remains a referral center, and the population attending the outpatient department is in general of lower socioeconomic status. Another limitation to the interpretation of results is that attitude and behavior regarding diabetes knowledge and lifestyle implementation was not formally assessed in this study [20] . It is therefore difficult to make any assertions as to the nature of lack of improving lifestyle measures. Finally, the duration of two years is too short to assess actual change in macrovascular outcomes, but reliable in assessing risk factor change.

This observational study evaluates the effectiveness of the current management of T2DM and reveals a high rate of suboptimal target delivery in about two-third of patients presenting to endocrine clinic. At baseline, there was a high rate of complications, and upon two-year follow-up there was persistence of complications risk factors. There is a call for an intense and multidisciplinary approach in awareness raising, effective lifestyle improvement measures and more medication accessibility to be implemented as a priority.

We are thankful for all patients who participated in the study.

The authors declare that there is no conflict of interest regarding the publication of this paper.

Zreik, R.S., Salti, H.I., Salti, I.S., Boukhalil, R., Haddad, T. and Nasrallah, M.P. (2016) What Happens to Modifiable Cardiovascular Risk Factors over Time in Type 2 Diabetes? Experience from a Developing Country under Standard of Care Conditions. Journal of Diabetes Mellitus, 6, 307-317. http://dx.doi.org/10.4236/jdm.2016.64032