Effects of Weight Loss and Interaction with Physical Activity on Risks of Cardiovascular Outcomes in Individuals with Type 2 Diabetes

Background

This study investigated the effects of weight loss during follow-up on cardiovascular outcomes in a type 2 diabetes cohort and tested interactions with clinical and laboratory variables, particularly physical activity, that could impact the associations.

Methods

Relative weight changes were assessed in 651 individuals with type 2 diabetes and categorized as ≥5% loss, <5% loss, or gain. Associations between weight loss categories and incident cardiovascular outcomes (total cardiovascular events [CVEs], major adverse cardiovascular events [MACEs], and cardiovascular mortality) were assessed using multivariable Cox regression with interaction analyses.

Results

During the initial 2 years, 125 individuals (19.2%) lost ≥5% of their weight, 180 (27.6%) lost <5%, and 346 (53.1%) gained weight. Over a median additional follow-up of 9.3 years, 188 patients had CVEs (150 MACEs) and 106 patients died from cardiovascular causes. Patients with ≥5% weight loss had a significantly lower risk of total CVEs (hazard ratio [HR], 0.52; 95% confidence interval, 0.33 to 0.89; P=0.011) than those who gained weight, but non-significant lower risks of MACEs or cardiovascular deaths. Patients with <5% weight loss had risks similar to those with weight gain. There were interactions between weight loss and physical activity. In active individuals, ≥5% weight loss was associated with significantly lower risks for total CVEs (HR, 0.20; P=0.004) and MACEs (HR, 0.21; P=0.010), whereas in sedentary individuals, no cardiovascular protective effect of weight loss was evidenced. Conclusion: Weight loss ≥5% may be beneficial for cardiovascular disease prevention, particularly when achieved with regular physical activity, even in high-risk individuals with long-standing type 2 diabetes.

Prognostic importance of cardiovascular autonomic neuropathy on cardiovascular and mortality outcomes in individuals with type 2 diabetes: The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate whether tests for cardiovascular autonomic neuropathy (CAN) and 24-hour heart rate variability (HRV) could improve the prediction for outcomes in type 2 diabetes.

METHODS

541 type 2 diabetic individuals performed tests of CAN. A subsample (313) had 24-hour HRV (the standard deviation of all normal RR intervals [SDNN] and the standard deviation of the averaged normal RR intervals for all 5 min segments [SDANN]). Multivariate Cox regressions examined the associations between CAN/low HRV with cardiovascular events (CVEs) and all-cause mortality. The improvement in risk discrimination of adding CAN/HRV was tested by C-statistics and by the Integrated Discrimination Improvement (IDI) index.

RESULTS

25% had CAN, and 17-18% had low HRV, respectively by SDANN-SDNN. Over a median follow-up of 12 years, there were 177 CVEs and 236 all-cause deaths in the whole cohort, and 96 CVEs and 129 all-cause deaths in the subsample. CAN was associated with 40% excess risks of CVEs/all-cause mortality, low HRV was associated with 2-fold higher risks of outcomes. HRV improved risk discrimination for CVEs/mortality with increases in C-statistics up to 0.039 and IDIs up to 25%.

CONCLUSIONS

Low HRV was a better predictor of outcomes than tests of CAN, and it improved risk discrimination.

Differential effects of treatment targets on risks of adverse outcomes according to diabetes duration, age and complications: Can these characteristics be used to individualize diabetes treatment? The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate interactions between more/less strict treatment targets (HbA_1c, systolic blood pressure, LDL-cholesterol) and clinical characteristics (age, diabetes duration and presence of complications) for occurrence of cardiovascular/microvascular complications and mortality in type 2diabetes.

METHODS

690 individuals were followed-up for 10 years (median). Interactions between treatment targets, estimated as mean values during the first 2-years, and clinical characteristics were tested in multivariable Cox regressions adjusted for other risk factors. Hazard ratios (HRs) were estimated in stratified analyses for cardiovascular/microvascular outcomes and mortality.

RESULTS

During follow-up, 214 patients had a cardiovascular event (175 MACEs); and 265 died (132 cardiovascular deaths); there were 206 renal, 161 retinopathy and 181 peripheral neuropathy events. There were interactions between treatment parameters and clinical characteristics, in most of them the HRs were higher in older individuals, in those with longer diabetes durations and with complications, particularly for the cardiovascular outcomes and mortality. For microvascular outcomes the opposite was observed. For cardiovascular mortality, the HRs of higher HbA_1c were 1.31 (1.08-1.58) and 1.09 (0.88-1.34), respectively with longer/shorter diabetes duration (p-for-interaction 0.11); and 1.43 (1.14-1.79) and 1.02 (0.85-1.23) in older/younger individuals (p-for-interaction 0.019).

CONCLUSIONS

Our findings do not support less strict treatment targets for older individuals, with longer diabetes duration or with complications, particularly for cardiovascular and mortality prevention.

Importance of hematological parameters for micro- and macrovascular outcomes in patients with type 2 diabetes: the Rio de Janeiro type 2 diabetes cohort study

Background

The prognostic importance of several hematological parameters has been scarcely investigated in type 2 diabetes. So, we aimed to evaluate their prognostic importance for development of complications in a cohort of type 2 diabetes.

Methods

In a prospective study, 689 individuals with type 2 diabetes had blood red cell, platelet and leukocyte parameters obtained at baseline. Multivariate Cox analyses examined the associations between several hematological parameters (including neutrophyl-to-lymphocyte, lymphocyte-to-monocyte, platelet-to-lymphocyte, and monocyte-to-HDL ratios) and the occurrence of microvascular (retina, renal and peripheral neuropathy) and cardiovascular complications (total cardiovascular events [CVEs], and major adverse CVEs [MACEs]), and all-cause and cardiovascular mortality. Improvements in risk discrimination were assessed by C-statistics and Integrated Discrimination Improvement (IDI) index.

Results

During a median follow-up of 10.5 years, 212 patients had a CVE (174 MACEs), 264 patients died (131 cardiovascular deaths); 206 had a renal, 161 a retinopathy and 179 patients had a neuropathy outcome. In multivariate-adjusted analyses, the lymphocytes count and lymphocyte-to-monocyte ratio were protective (hazard ratios [HRs]: 0.77 and 0.72, respectively), whereas the neutrophyl-to-lymphocyte and platelet-to-lymphocyte ratios were associated with increased risks (HRs: 1.19 and 1.17) for all-cause mortality. For cardiovascular mortality, the monocytes count, the neutrophyl-to-lymphocyte and monocyte-to-HDL ratios were associated with increased risks and the lymphocyte-to-monocyte ratio was protective. Higher lymphocyte-to-monocyte ratio was protective for renal failure outcome. However, none of them improved risk discrimination.

Conclusions

Low lymphocytes count and leukocyte ratios that mainly included lymphocytes were predictors of macrovascular complications and mortality in individuals with type 2 diabetes. However, they did not improve risk prediction over traditional risk factors.

Importance of non-invasive liver fibrosis scores for mortality and complications development in individuals with type 2 diabetes

AIMS

To evaluate the non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) and Fibrosis-4 score (FIB4) as predictors of complications development and mortality in a cohort of type 2 diabetes.

METHODS

554 type 2 diabetic subjects had NFS and FIB4 calculated at baseline. Multivariate Cox and Poisson analyses evaluated the associations between fibrosis scores and the occurrence of microvascular and cardiovascular complications, and all-cause mortality.

RESULTS

According to recommended cut-offs of NFS, 12.8% had advanced fibrosis and 45.9% had absence of advanced fibrosis and of FIB4, 3.8% and 86.1%, respectively. During a median follow-up of 11 years, 217subjects died, 172 had cardiovascular events (CVEs), 184 had renal events, and 139 had retinopathy and 185 neuropathy events. As continuous variables, both scores predicted all-cause mortality: NFS, HR: 1.30 (p = 0.032) and FIB4, HR: 1.24 (p = 0.021); an increased NFS implied in a significant 90% excess risk of mortality, whereas a higher FIB4 in a borderline 69% higher risk. The scores were mainly predictors of mortality in women and for non-cardiovascular deaths. The NFS was a predictor of renal events, mainly for renal function deterioration.

CONCLUSIONS

The NFS and FIB4 predicted all-cause mortality, particularly in women and for non-cardiovascular causes. The NFS predicted adverse renal outcomes. These liver fibrosis scores may improve stratification risk in individuals with diabetes and NAFLD.

Usefulness of the vibration perception thresholds measurement as a diagnostic method for diabetic peripheral neuropathy: Results from the Rio de Janeiro type 2 diabetes cohort study

AIMS

To investigate the associated factors with the vibration threshold perception (VPT) in patients with type 2 diabetes and to assess whether it is useful for detection of diabetic peripheral neuropathy (DPN).

METHODS

VPTs were measured with Vibration Sensory Analyzer (VSA-3000) in 426 diabetic patients. The diagnosis of DPN was based on Neuropathy Symptom Score and Neuropathy Disability Score (NDS). ROC curve analysis and multiple linear and logistic regressions were performed to investigate the associations between VPT and DPN.

RESULTS

Values of VPT were progressively higher according to NDS stages. Age, height, diabetes duration, and mean cumulative HbA_1c exposure (partial correlation coefficients: 0.34; 0.27; 0.10; and 0.13; respectively) were the variables independently associated with VPT. Area under ROC curve of VPT for detection of DPN was 0.71 (95% CI: 0.66-0.75) and >8.9 μm was its best cut-off value. VPT, age, female sex, height, diabetes duration and mean HbA_1c levels were the independent correlates of the presence of DPN. An increased VPT triplicate the likelihood of having DPN (OR: 3.24; 95% CI: 2.05-5.11).

CONCLUSIONS

VPT, measured by an automatic device, shares common correlates with DPN and is strongly associated with its presence. VPT testing may be useful as a screening tool for DPN assessment.

Treatment Adherence and Its Associated Factors in Patients with Type 2 Diabetes: Results from the Rio de Janeiro Type 2 Diabetes Cohort Study

OBJECTIVES

To investigate treatment adherence in patients with type 2 diabetes and to evaluate its associated factors.

METHODS

The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire was used to assess treatment adherence. Good adherence was defined as ≥5 days a week in each SDSCA item. Pain, emotional, and physical domains of the SF-36 quality of life questionnaire and the Canadian Occupational Performance Measure (COPM) were also evaluated. Multivariable logistic regressions explored the independent correlates of good general adherence and of specific items of the SDSCA (diet, exercise, and medications).

RESULTS

Good adherence was 93.5% for medication use, 59.3% for foot care, 56.1% for blood glucose monitoring, 29.2% for diet, and 22.5% for exercise. Patients with general good adherence had lower BMI, better serum lipid profile, higher values of functional capacity, emotional and pain domains of SF-36, better occupational performance, and lower prevalence of pain or limitation in the upper and lower limbs than patients with worse adherence. The variables associated with good adherence were younger age, lower BMI, presence of macrovascular complications, better occupational performance and emotional domain of SF-36, and higher HDL cholesterol levels. The presence of pain/limitation in the upper limbs was associated with worse adherence. Good medication adherence was associated with longer diabetes duration, lower BMI, and lower HbA_1c levels. Higher values of pain and emotional domains of the SF-36 and lower BMI were related to better exercise and diet adherence, while the presence of peripheral neuropathy and joint pain/limitation were associated with worse exercise adherence.

CONCLUSIONS

Emotional and physical performances are important determinants of good diabetic treatment adherence. Good adherence has beneficial impact on BMI, lipid, and glycemic control.

Aortic Stiffness as a Surrogate Endpoint to Micro- and Macrovascular Complications in Patients with Type 2 Diabetes

Increased aortic stiffness has been recognized as a predictor of adverse cardiovascular outcomes in some clinical conditions, such as in patients with arterial hypertension and end-stage renal disease, in population-based samples and, more recently, in type 2 diabetic patients. Patients with type 2 diabetes have higher aortic stiffness than non-diabetic individuals, and increased aortic stiffness has been correlated to the presence of micro- and macrovascular chronic diabetic complications. We aimed to review the current knowledge on the relationships between aortic stiffness and diabetic complications, their possible underlying physiopathological mechanisms, and their potential applications to clinical type 2 diabetes management.

Prevalence of subclinical hypercortisolism in type 2 diabetic patients from the Rio de Janeiro Type 2 Diabetes Cohort Study

AIMS

Subclinical hypercortisolism was reported to be more prevalent among diabetic, obese and hypertensive patients. Our primary aim was to investigate the prevalence of subclinical hypercortisolism in patients from the Rio de Janeiro Type 2 Diabetes (RIO-T2D) Cohort; and secondarily to assess its associated factors.

METHODS

From May 2013 to August 2014, 393 diabetic outpatients underwent overnight 1mg dexamethasone suppression test (DST). Patients with non-suppressive morning cortisol (≥1.8μg/dl) were further evaluated with nocturnal salivary cortisol, two readings >0.35μg/dl were considered confirmatory for subclinical hypercortisolism.

RESULTS

One-hundred twenty-eight patients (32.6%) failed to suppress morning cortisol, and in 33 patients (8.6%) subclinical hypercortisolism was confirmed. Independent correlates of a positive DST were older age (OR: 1.04; 95% CI: 1.01-1.07; p=0.007), number of anti-hypertensive drugs in use (OR: 1.26; 95% CI: 1.05-1.50; p=0.012), longer diabetes duration (OR: 1.03; 95% CI: 1.004-1.06; p=0.023), and presence of diabetic nephropathy (OR: 1.70; 95% CI: 1.01-2.87; p=0.047). Independent correlates of confirmed subclinical hypercortisolism were a greater number of anti-hypertensive medications (OR: 1.54; 95% CI: 1.14-2.06; p=0.004), shorter diabetes duration (OR: 0.92; 95% CI: 0.87-0.98; p=0.006), and increased aortic stiffness (OR: 2.81; 95% CI: 1.20-6.57; p=0.017); metformin use was protective (OR: 0.27; 95% CI: 0.10-0.73; p=0.010).

CONCLUSION

Patients with type 2 diabetes had a high prevalence of subclinical hypercortisolism, and its presence was associated with more severe hypertension and increased aortic stiffness.

QT-interval parameters are increased in systemic lupus erythematosus patients

Systemic lupus erythematosus (SLE) patients have increased cardiovascular morbidity and mortality. QT-interval parameters are presumed markers of cardiovascular risk and have not been previously evaluated in SLE. Standard 12-lead ECGs were obtained from 140 female SLE outpatients and 37 age and body mass index-matched controls. QT interval was measured in each lead and heart rate-corrected maximum QT-interval duration (QTcmax) and QT-interval dispersion (QTd) were calculated. Risk factors for cardiovascular disease and lupus clinical features, disease treatment, disease activity and damage index were recorded. SLE patients have increased QT-interval parameters when compared to controls (QTcmax: 427.91 31.53 ms1/2 versus 410.05 15.45 ms1/2, P 0.001; QTd: 52.38 22.21 ms versus 37.12 12.88 ms, P 0.001). These differences persisted after excluding those patients with arterial hypertension, diabetes and with ECG abnormalities (QTcmax: 419.90 28.78 ms1/2 versus 409.15 15.85 ms1/2, P 0.041; QTd: 54.74 26.00 ms versus 37.96 13.05 ms, P 0.001). Multivariate linear regression for factors associated with QTcmaxselected the presence of electrocardiographic left ventricular hypertrophy (ECG-LVH) ( P 0.003), nonspecific ST-T-wave abnormalities ( P 0.022) and left atrial enlargement ( P 0.044). Multivariate associates with QTd were age ( P 0.018), ECG-LVH ( P 0.022) and ST-T abnormalities ( P 0.031). In conclusion, SLE patients have increased QT interval parameters when compared to controls. This prolongation may lead to an increased cardiovascular risk. This finding might be due to subclinical atherosclerotic cardiovascular disease.

NAFLD and Increased Aortic Stiffness: Parallel or Common Physiopathological Mechanisms?

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver diseases worldwide. Liver inflammation and fibrosis related to NAFLD contribute to disease progression and increasing liver-related mortality and morbidity. Increasing data suggest that NAFLD may be linked to atherosclerotic vascular disease independent of other established cardiovascular risk factors. Central arterial stiffness has been recognized as a measure of cumulative cardiovascular risk marker load, and the measure of carotid-femoral pulse wave velocity (cf-PWV) is regarded as the gold standard assessment of aortic stiffness. It has been shown that increased aortic stiffness predicts cardiovascular morbidity and mortality in several clinical settings, including type 2 diabetes mellitus, a well-known condition associated with advanced stages of NAFLD. Furthermore, recently-published studies reported a strong association between NAFLD and increased arterial stiffness, suggesting a possible link in the pathogenesis of atherosclerosis and NAFLD. We sought to review the published data on the associations between NAFLD and aortic stiffness, in order to better understand the interplay between these two conditions and identify possible common physiopathological mechanisms.

Initial and accrued damage as predictors of mortality in Brazilian patients with systemic lupus erythematosus: a cohort study

The aim of this study was to investigate whether initial and accrued organ damage measured by Systemic Lupus International Collaborating Clinics (SLICC) Damage Index (SDI) predicts mortality in cohort of Brazilian patients with systemic lupus erythematosus (SLE). One hundred and five outpatients with SLE were enrolled from July 2000 to March 2001; their demographics, disease manifestations, interventions and quantified disease activity (SLEDAI) were obtained. SDI was measured at baseline and at the end of follow-up. Initial and accrued SDI prognostic values for mortality were investigated by multivariate Cox survival analysis and Kaplan-Meyer survival curves. After a median follow-up of 6.3 years, 19 patients died due to disease activity, end-organ failure, cardiovascular events, cancer and infection. Deceased patients had longer disease duration and greater initial and final SDI than survivors had. After adjustment for age, sex and disease duration, both initial and final SDI >/= 3 points were independent predictors of mortality, with hazard ratios (HRs) of 3.0 (1.1-8.2) and 4.7 (1.6-14.5), respectively. Damage accrual during follow-up was the strongest predictor of death (HR: 5.1, 2.0-13.0). Renal and pulmonary damages were the main predictors of increased mortality risk. In conclusion, baseline and accrued damage increase mortality risk in Brazilian patients with SLE. Measures to prevent damage development and progression are urgent to reduce the mortality of patients with SLE.

Prevalence and associated factors of non-alcoholic fatty liver disease in patients with type-2 diabetes mellitus

BACKGROUND/AIMS

Diabetic patients have an increased prevalence and severity of non-alcoholic fatty liver disease (NAFLD). We aimed to investigate the prevalence and the factors associated with the presence of ultrasonographic NAFLD in type-2 diabetic individuals.

METHODS

In a cross-sectional design study, 180 type-2 diabetic patients were submitted to a complete clinical and laboratory evaluation and abdominal ultrasonography for NAFLD detection and grading. Statistical analysis included bivariate tests, analysis of variance (anova, for increasing severity of steatosis) and multivariate logistic regression.

RESULTS

The prevalence of ultrasonographic NAFLD was 69.4% [95% confidence interval (CI): 58.3-82.7%]. Patients with NAFLD were more obese, had a higher waist circumference and serum triglyceride and alanine aminotransferase (ALT) levels than those without steatosis. Neither diabetic degenerative complication, nor glycaemic control was associated with liver steatosis. On multivariate analysis, a high serum triglycerides level [>2.82 mmol/L, odds ratio (OR): 3.7-4.1, 95% CI: 1.2-13.3] and a high-normal ALT level (> or =40 U/L, OR: 2.5-2.7, 95% CI: 1.2-5.9) were independently associated with hepatic steatosis, together with either the presence of obesity (OR: 7.1, 95% CI: 3.0-17.0) or of increased waist circumference (OR: 4.8, 95% CI: 1.9-12.2).

CONCLUSIONS

Type-2 diabetic patients have a high prevalence of ultrasonographic NAFLD and its presence is associated with obesity, mainly abdominal, hypertriglyceridaemia and high-normal ALT levels. Non-alcoholic fatty liver disease in diabetic patients may develop and progress independent of the diabetes progression itself.

Predictors of development and progression of microvascular complications in a cohort of Brazilian type 2 diabetic patients

AIMS

Microvascular complications are associated with increased mortality in diabetes. The objective of this study was to investigate the predictors of microvascular complication development and progression in a prospective study of Brazilian type 2 diabetic patients.

METHODS

A prospective follow-up study was carried out with 471 type 2 diabetic outpatients. Primary end points were the development or progression of retinopathy, peripheral neuropathy, and clinical nephropathy. Predictors were assessed for each individual microvascular complication and also as a composite outcome by Kaplan-Meier estimation of survival curves and by uni- and multivariate Cox analysis.

RESULTS

During a median follow-up of 57 months (range 2-84 months), 196 patients (41.6%) developed or had a progression in microvascular disease. Retinopathy occurred in 22.5%, nephropathy in 19.1%, and neuropathy in 15.5% of the patients. In Cox multivariate analysis, increased echocardiographic left ventricular mass (LVM) and longer diabetes duration were selected as predictors for all end points. Higher mean fasting glycemia was a predictor for retinopathy and neuropathy, lower serum high-density lipoprotein (HDL) cholesterol for neuropathy, and higher total cholesterol for nephropathy. Increased LVM [hazard ratio (HR): 1.39, 95% CI: 1.23-1.56], higher fasting glycemia (HR: 1.19, 95% CI: 1.04-1.36), and longer diabetes duration (HR: 1.28, 95% CI: 1.11-1.47) were the predictors of the composite end point.

CONCLUSIONS

Development and progression of microvascular complications in Brazilian type 2 diabetic patients are associated with worse hypertension and metabolic control. Additional studies are necessary to show if modification of these risk factors can reduce the burden of morbidity and mortality related to microvascular disease in type 2 diabetes.

Prevalence and factors associated with dyslipoproteinemias in Brazilian systemic lupus erythematosus patients

To determine the prevalence of dyslipoproteinemias and their related factors in a Brazilian systemic lupus erythematosus (SLE) population, fasting lipids were measured in 185 female SLE outpatients. Age, BMI, smoking, post-menopausal status, presence of diabetes and hypertension, SLE duration, number of ARA criteria, drug treatment and disease activity (by SLEDAI) were registered. Statistics included uni and multivariate logistic regression. Eighty-nine patients (48.1%) had hypercholesterolemia, 55 (29.7%) had hypertriglyceridemia and 109 (58.9%) had either. On multivariate analysis, 24-h proteinuria (OR = 2.08, 95% CI: 1.11-3.88), BMI (OR = 1.08, 95% CI: 1.01-1.16) and post-menopausal status (OR = 2.48, 95% CI: 1.25-4.92) were associated with hypercholesterolemia. Disease activity was related to low HDL-cholesterol (OR = 2.59, 95% CI: 1.20-5.58) and, in pre-menopausal patients, also to hypertriglyceridemia (OR = 1.16, 95% CI: 1.03-1.30). Antimalarial use was protective for hypertriglyceridemia (OR = 0.44, 95% CI: 0.22-0.90). In conclusion, the increased prevalence of dyslipoproteinemias is due to proteinuria, obesity and SLE activity. Antimalarials have beneficial effect on lipid profile that may be due to reduction in disease activity.

QTc interval prolongation is a predictor of future strokes in patients with type 2 diabetes mellitus

BACKGROUND AND PURPOSE

QTc interval prolongation is a predictor of cardiovascular morbidity and mortality in general populations and in patients with diabetes. The aim of this study was to investigate the predictors of stroke in patients with type 2 diabetes, with particular emphasis on the independent role of QT interval parameters.

METHODS

We carried out a long-term follow-up study with 471 type 2 diabetics. Several clinical, laboratory, ECG, and echocardiographic variables were recorded at baseline. Predictive factors for stroke were evaluated by Kaplan-Meier estimation of survival curves and by univariate and multivariate Cox survival analyses.

RESULTS

After a median follow-up of 57 months (range, 2 to 84 months), 40 incident strokes were observed. QTc interval prolongation (>or=470 ms1/2) was an independent predictor of stroke, with adjusted hazard ratios ranging from 2.2 to 2.9 (95% confidence intervals, 1.1 to 6.0). Other independent factors associated with stroke were older age; the presence of cerebrovascular disease at baseline; increased 24-hour proteinuria, serum triglycerides, and left ventricular mass; and decreased high-density lipoprotein cholesterol. Excluding patients with previous cerebrovascular disease from the analysis did not change the results significantly.

CONCLUSIONS

QTc interval prolongation is a predictor of future stroke in patients with type 2 diabetes. Intervention studies are needed to assess whether this factor could be modified.