In high-income countries, rates of atherosclerotic complications in type 2 diabetes have declined markedly over time due to better management of traditional risk factors including lipids, blood pressure and glycemia levels. Population-wide reductions in smoking have also helped lower atherosclerotic complications and so reduce premature mortality in type 2 diabetes. However, as excess adiposity is a stronger driver for heart failure (HF), and obesity levels have remained largely unchanged, HF risks have not declined as much and may even be rising in the increasing number of people developing type 2 diabetes at younger ages. Excess weight is also an underrecognized risk factor for chronic kidney disease (CKD). Based on evidence from a range of sources, we explain how excess adiposity must be influencing most risks well before diabetes develops, particularly in younger-onset diabetes, which is linked to greater excess adiposity. We also review potential mechanisms linking excess adiposity to HF and CKD and speculate on how some of the responsible pathways—e.g., hemodynamic, cellular overnutrition, and inflammatory—could be favorably influenced by intentional weight loss (via lifestyle or drugs). On the basis of available evidence, we suggest that the cardiorenal outcome benefits seen with sodium–glucose cotransporter 2 inhibitors may partially derive from their interference of some of these same pathways. We also note that many other complications common in diabetes (e.g., hepatic, joint disease, perhaps mental health) are also variably linked to excess adiposity, the aggregated exposure to which has now increased in type 2 diabetes. All such observations suggest a greater need to tackle excess adiposity earlier in type 2 diabetes.

中文翻译：

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2 型糖尿病患者的心血管和肾脏风险：当代对过度肥胖的认识

在高收入国家，由于对血脂、血压和血糖水平等传统危险因素的更好管理，2型糖尿病动脉粥样硬化并发症的发生率随着时间的推移显着下降。全民吸烟量的减少也有助于降低动脉粥样硬化并发症，从而降低 2 型糖尿病的过早死亡率。然而，由于过度肥胖是心力衰竭 (HF) 的一个更强有力的驱动因素，而且肥胖水平基本保持不变，因此，心力衰竭的风险并没有下降那么多，甚至在越来越多的年轻时患上 2 型糖尿病的人中，心力衰竭的风险甚至可能上升。体重过重也是慢性肾脏病 (CKD) 的一个未被充分认识的危险因素。基于来自多种来源的证据，我们解释了过度肥胖如何在糖尿病发生之前就影响大多数风险，特别是在年轻发病的糖尿病中，这与更大的过度肥胖有关。我们还回顾了过度肥胖与心力衰竭和慢性肾病之间的潜在机制，并推测一些相关途径（例如血流动力学、细胞营养过剩和炎症）如何受到有意减肥（通过生活方式或药物）的有利影响。根据现有证据，我们认为钠-葡萄糖协同转运蛋白 2 抑制剂对心肾结果的益处可能部分源于它们对某些相同途径的干扰。我们还注意到，糖尿病中常见的许多其他并发症（例如肝脏、关节疾病，或许还有心理健康）也与过度肥胖存在不同程度的相关性，目前 2 型糖尿病中肥胖的总暴露量有所增加。所有这些观察结果表明，更需要在 2 型糖尿病早期解决过度肥胖问题。