We read with interest the findings of Sarah Lewington and colleagues from the Prospective Studies Collaboration and Asia Pacific Cohort Studies Collaboration on the sex-specific relevance of diabetes to vascular occlusive mortality in their meta-analysis of almost 1 million adults aged 35–89 years. Of particular interest was their observation that, among all age and sex groups, women aged 35–59 years comprised the group in which diabetes conferred the highest relative risk for occlusive vascular death, an increase of about six times even after adjustment for other major cardiovascular risk factors. This substantial risk increment is particularly alarming when considered alongside data showing that women aged 20–49 years were the segment of the Canadian population that had the largest increase in the prevalence of diabetes (an increase of 108·2%) between 1995 and 2005. Accordingly, we concur with the conclusion of the investigators that future research should consider which factors might account for the amplification of occlusive vascular risk in women with diabetes