Obesity paradox: differential effects on cancer and noncancer mortality in patients with type 2 diabetes mellitus

OBJECTIVE

To investigate associations between body mass index (BMI) and cause-specific mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

Prospective follow-up of a nationally representative cohort of 89,056 Taiwanese patients with T2DM recruited since 1995. Vital status was matched with the National Death Certificate Database until the end of 2006. Self-reported body weight and height were used to calculate BMI, which was treated either as a continuous or categorical variable (underweight, <18.5; normal, 18.5-22.9; overweight, 23.0-24.9; obesity I, 25.0-29.9; and obesity II, ≥30.0 kg/m(2)). Causes of death were classified as all-cause, cancer, diabetes complications (macrovascular and microvascular), and other. Cox regression was used to estimate the hazard ratios.

RESULTS

A total of 26,951 patients (30.3% of the cohort) died during follow-up (cancer 5.4%, diabetes complications 17.4%, and other causes 7.5%). As a continuous variable, BMI was inversely associated with mortality from all-cause, cancer, diabetes complications, and other causes, with respective adjusted hazard ratios (95% confidence intervals) of 0.942 (0.939-0.946), 0.966 (0.958-0.975), 0.935 (0.930-0.939), and 0.942 (0.935-0.949). Compared to normal weight, underweight was significantly predictive for any of causes of death, while overweight, obesity I, and obesity II were all significantly associated with mortality in an inverse pattern. After excluding patients with a follow-up duration <2 years, most BMI categories were not significantly predictive of mortality from cancer, suggesting a potential bias of cancer-induced weight loss.

CONCLUSIONS

The obesity paradox, mainly observed in noncancer mortality, exists in patients with T2DM, suggesting a survival advantage in obese diabetic patients.

Diabetes, metformin use, and colon cancer: a population-based cohort study in Taiwan

OBJECTIVE

A retrospective cohort study, using a population-based reimbursement database, was conducted for investigating the relationship between diabetes and colon cancer and assessing whether metformin had a protective effect.

METHODS

Overall, 493,704 men and 502,139 women, covered by the National Health Insurance, without colon cancer were followed from 2003 to 2005. Cox regression evaluated the adjusted relative risk (RR), considering confounders and detection examinations.

RESULTS

Even though diabetes patients had a significantly higher probability of receiving examinations that could lead to the detection of colon cancer, they had a significantly higher risk (24%) of this cancer after adjustment. Metformin users had a significantly lower risk (27%) of colon cancer. While comparing patients with diabetes for <1, 1-3, and ≥ 3 years to nondiabetes individuals, the adjusted RR (95% confidence interval) was 1.308 (1.020-1.679), 1.087 (0.900-1.313), and 1.185 (1.055-1.330) respectively. The higher risk among those with diabetes for <1 year suggested a possible reverse causality or a link with prediabetes. However, diabetes still might play some role in the development of colon cancer in those with diabetes for ≥ 3 years. The duration of metformin use showed an inverse trend, with a significant RR of 0.643 (0.490-0.845) in users for ≥ 3 years, when compared with nonusers. In addition, metformin may reduce colon cancer risk associated with chronic obstructive pulmonary disease (a surrogate for smoking).

CONCLUSIONS

Following adjustment for potential detection bias and other covariates, diabetes remains a significant risk factor for colon cancer. Metformin may protect against colon cancer.

Diabetes but not insulin is associated with higher colon cancer mortality

AIM: To evaluate whether diabetic patients had a higher risk of colon cancer mortality and its associated risk factors.

METHODS: The sex-specific crude and age-standardized (to the 2000 World Health Organization population) mortality rates of colon cancer in the Taiwanese general population were first calculated from 1995 to 2006. The trends were evaluated by linear regression. A total of 113 347 diabetic men and 131 573 diabetic women aged ≥ 25 years at recruitment from 1995 to 1998 were followed up until the end of 2006. Age/sex-specific colon cancer mortality rate ratios were calculated comparing the mortality rates of the diabetic patients with the average mortality rates of the general population within 12 years (1995-2006). A sub-cohort of diabetic patients (42 260 men and 49 405 women) was interviewed using a baseline questionnaire and Cox’s regression was used to evaluate the risk factors for colon cancer mortality in these diabetic patients.

RESULTS: The crude and age-standardized trends of colon cancer mortality from 1995 to 2006 increased significantly for both sexes in the general population. A total of 641 diabetic men and 573 diabetic women died of colon cancer, with a mortality rate of 74.4 and 54.3 per 100 000 person-years, respectively. Mortality rate ratios [95% confidence intervals (CIs)] showed a significantly higher risk of mortality from colon cancer for the diabetic patients compared to the general population, with the magnitude increasing with decreasing age: 1.65 (1.40-1.95), 2.01 (1.78-2.27), 2.75 (2.36-3.21) and 5.69 (4.65-6.96) for ≥ 75, 65-74, 55-64 and 25-54 years old, respectively, for men; and 1.46 (1.24-1.72), 2.09 (1.84-2.38), 2.67 (2.27-3.14) and 3.05 (2.29-4.06), respectively, for women. Among the sub-cohort of diabetic patients who had been interviewed with the baseline questionnaire, including information on age, sex, diabetes duration, diabetes type, body mass index, smoking, insulin use and area of residence, age and smoking were significantly predictive for colon cancer mortality, with respective adjusted hazard ratios (HRs) (95% CIs) of 1.077 (1.066-1.088) and 1.384 (1.068-1.792). Diabetes duration became a significant factor when those who died of colon cancer within 5 years of diabetes diagnosis were excluded to minimize the possible contamination of diabetes caused by incipient colon cancer, with an adjusted hazard ratio of 1.021 (1.007-1.034). Sex, diabetes type, insulin use, body mass index and area of residence were not significant predictors for colon cancer mortality in the diabetic patients. Although insulin use was categorized into subgroups of duration of use (non-users and users < 5 years, 5-9 years and ≥ 10 years), none of the HRs for colon cancer mortality was significant with regards to different durations of insulin use.

CONCLUSION: Colon cancer mortality is increasing in Taiwan. A higher risk is observed in diabetic patients. Smoking, but not insulin use, is a modifiable risk factor.

Diabetes, insulin use, and non-Hodgkin lymphoma mortality in Taiwan

The objective was to evaluate non-Hodgkin lymphoma (NHL) mortality trends and mortality rate ratios between diabetes patients and the general population, and to study NHL risk factors among diabetes patients in Taiwan. A cohort of 80 397 patients with type 2 diabetes mellitus older than 45 years was recruited in 1995-1998 and followed up until 2006. Age-standardized NHL mortality in 1995-2006 was calculated. Non-Hodgkin lymphoma risk factors in diabetes patients were evaluated using Cox regression. Age-standardized NHL mortality trend was steady. Eighty-two male and 69 female diabetes patients died of NHL (crude mortality rates, 35.1 and 23.0 per 100 000 person-years, respectively; corresponding overall mortality rate ratios comparing diabetes patients to the general population, 2.06 and 2.14). The mortality rate ratios were 1.47, 2.33, and 2.78 for men aged at least 65, 55 to 64, and 45 to 54 years, respectively; the corresponding ratios for women were 1.48, 2.22, and 2.79. Age and male sex were significant risk factors, whereas insulin use, diabetes duration, smoking, body mass index, and area of residence were not. Diabetes duration became a significant factor after excluding patients who died of NHL within 5 years of diabetes diagnosis. Patients with diabetes have a higher risk of mortality from NHL, but insulin use is not associated with NHL mortality. Future studies are needed to fully elucidate any association between increased mortality rate ratio and younger age as well as the lack of association between NHL and insulin use demonstrated herein.

Diabetes, insulin use and Helicobacter pylori eradication: a retrospective cohort study

Background

Diabetic patients may have a higher risk of gastric cancer. However, whether they have a higher incidence of Helicobacter pylori (HP) eradication is not known. Furthermore, whether insulin use in patients with type 2 diabetes may be associated with a higher incidence of HP eradication has not been investigated.

Methods

This is a retrospective cohort study. The reimbursement databases from 1996 to 2005 of 1 million insurants of the National Health Insurance in Taiwan were retrieved. After excluding those aged <25 years, cases of gastric cancer, cases receiving HP eradication before 2005, patients with type 1 diabetes mellitus and those with unknown living region, the reimbursement data of a total of 601,441 insurants were analyzed. Diabetes status and insulin use in patients with type 2 diabetes before 2005 were the main exposures of interest and the first event of HP eradication in 2005 was the main outcome evaluated. HP eradication was defined as a combination use of proton pump inhibitor or H2 receptor blockers, plus clarithromycin or metronidazole, plus amoxicillin or tetracycline, with or without bismuth, in the same prescription for 7-14 days. The association between type 2 diabetes/insulin use and HP eradication was evaluated by logistic regression, considering the confounding effect of diabetes duration, comorbidities, medications and panendoscopic examination.

Results

In 2005, there were 10,051 incident cases receiving HP eradication. HP eradication was significantly increased with age, male sex, diabetes status, insulin use, use of calcium channel blocker, panendoscopic examination, hypertension, dyslipidemia, chronic obstructive pulmonary disease, stroke, nephropathy, ischemic heart disease and peripheral arterial disease. Significant differences were also seen for occupation and living region. Medications including statin, fibrate, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and oral anti-diabetic agents were not associated with HP eradication. The adjusted odds ratios for diabetes, insulin use and use of calcium channel blocker was 1.133 (1.074, 1.195), 1.414 (1.228, 1.629) and 1.147 (1.074, 1.225), respectively.

Conclusions

Type 2 diabetes and insulin use in the diabetic patients are significantly associated with a higher incidence of HP eradication. Additionally, use of calcium channel blocker also shows a significant association with HP eradication.

Pioglitazone and bladder cancer in human studies: is it diabetes itself, diabetes drugs, flawed analyses or different ethnicities?

This article reviews human observations on pioglitazone and bladder cancer risk. The PROspective pioglitAzone Clinical Trial In macroVascular Events trial showed an imbalance in bladder cancer between users of pioglitazone and placebo (14 versus six cases, p = 0.069). However, after excluding bladder cancer probably ascribed to other etiology, a blind assessment concluded that the imbalance might not be related to pioglitazone. Epidemiologic studies conducted in the United States and France using insurance databases independently suggested that pioglitazone use for >2 years might confer a 20%-40% higher risk. Another study evaluating bladder cancer risk in diabetic patients using the National Health Insurance in Taiwan did not find any incident bladder cancer case among 422 pioglitazone users for a follow-up of up to 3 years. Because observational studies may suffer from selection and information bias, and inadequate adjustment for confounders may inflate the estimated risk, causal inference from these studies should be interpreted with caution. While investigating cancer risk associated with a medication, indication bias should also be attended, especially when the medication is used at a late stage of the disease. Because pioglitazone is usually a second or third line antidiabetic agent, the users are always characterized by older age, longer diabetes duration, poorer glycemic control, and higher rates of complications and comorbidities. Biased estimates will also result if these differences are not appropriately addressed in the analyses. Current evidence neither concludes nor excludes a causal role of pioglitazone on bladder cancer. Clinical trials aiming at evaluating the risk of cancer associated with a medication is not ethical and may not be expected to provide an answer on the issue of pioglitazone-related bladder cancer. However, a meta-analysis using all available clinical trials to compare the bladder cancer risk between pioglitazone and comparators will be helpful. Well-conducted epidemiologic observational studies are probably other options. Because bladder cancer incidence and their risk factors may differ significantly among different ethnicities, a clarification of such a link in different ethnicities is needed, better by using long-term databases with large and representative sample size and appropriate adjustment for confounders. Furthermore, the interactions with other comorbidities and concomitant medications should be addressed.

Insulin use is not significantly predictive for prostate cancer mortality in diabetic patients: a 12-year follow-up study

What's known on the subject? and What does the study add? Even though a lower risk of prostate cancer has been reported in patients with diabetes, they may have a higher risk of cancer development involving the liver, pancreas, endometrium, colorectum, breast and bladder. Insulin may have mitogenic properties besides its metabolic function. However, whether exogenous insulin use for glycaemic control in diabetic patients could increase the risk of prostate cancer has rarely been studied. This is the first prospective follow-up study for up to 12 years to show that exogenous insulin use for glycaemic control in the diabetic patients is not significantly predictive for prostate cancer mortality.

OBJECTIVE

To evaluate whether insulin use in diabetic patients could be predictive for prostate cancer mortality.

PATIENTS AND METHODS

A total of 39 135 diabetic men aged ≥40 years from a nationally representative cohort were followed prospectively from 1995 to 2006 for prostate cancer mortality. Cox proportional hazards models were used to estimate the hazard ratios for the following independent variables: age, diabetes type, diabetes duration, body mass index, smoking, insulin use and area of residence. The models were created for patients aged ≥40 years and ≥65 years, separately; and before and after excluding patients with a duration between onset of diabetes and prostate cancer mortality <5 years.

RESULTS

A total of 105 diabetic men died of prostate cancer during follow-up. Age was the only significant risk factor. Insulin use was associated with an insignificantly higher risk of prostate cancer mortality ranging from 24% to 49%. When stratified by the duration of insulin use <5 and ≥5 years, a lack of significant association was also observed.

CONCLUSIONS

Insulin use in diabetic patients does not significantly predict the mortality from prostate cancer. Further confirmation in other ethnicities is needed.

Pioglitazone and bladder cancer: a population-based study of Taiwanese

OBJECTIVE

The association between pioglitazone and bladder cancer has not been investigated in Asians. We aimed to investigate this association.

RESEARCH DESIGN AND METHODS

A total of 1,000,000 individuals were randomly sampled from the National Health Insurance database, and incident cases of bladder cancer during the period from 1 January 2006 to 31 December 2009 were analyzed among 54,928 patients with type 2 diabetes and without previous bladder cancer.

RESULTS

Among 165 incident case subjects, 10 (0.39%) were ever users and 155 (0.30%) were never users of pioglitazone (adjusted hazard ratio in full model 1.305 [95% CI 0.661-2.576]). All bladder cancer in ever users occurred within a duration of therapy <24 months, suggesting an early effect of pioglitazone on bladder cancer or late use of pioglitazone in high-risk patients.

CONCLUSIONS

The association between pioglitazone and bladder cancer was not significant. However, confirmation of this finding is required because of the possible lack of statistical power owing to the small number of events.

Peroxisome proliferator-activated receptor agonists and bladder cancer: lessons from animal studies

This article reviews available animal studies on the possible link between the use of peroxisome proliferator-activated receptor (PPAR) agonists and bladder cancer, with further discussion on the possible implications to humans. Carcinogenicity studies suggest that the PPARγ agonist pioglitazone and dual PPARα/γ agonists such as ragaglitazar, muraglitazar, and naveglitazar may increase the risk of bladder cancer in a dose-responsive pattern in rats. It is interesting that bladder cancer related to PPAR agonists shows remarkable species- and sex-specificity and has a predilection to occur in the ventral dome of bladder in rodents. While male rats treated with pioglitazone or muraglitazar have a higher propensity to develop bladder cancer than female rats, mice of both sexes do not develop bladder cancer even when exposed to very high doses. Direct genotoxicity or cytotoxicity of PPAR agonists is unlikely to be the mode of action because most of the parent compounds or their metabolites of the PPAR agonists are neither mutagenic nor genotoxic, and they are rarely excreted in the urine; but a receptor-mediated PPAR effect cannot be excluded. Some suggest a "urolithiasis hypothesis" referring to the formation of urinary solids and calculi, which subsequently causes bladder necrosis, regenerative proliferation, hypertrophy, and cancer. However, whether these animal findings could have human relevance is not yet fully understood. Some argue that the urolithiasis-induced bladder cancer might be rat-specific and would probably not be applicable to humans. An effect of increased urinary growth factors induced by PPAR agonists has also been proposed, but this requires more investigations. Before fully clarified, a balance between the risks and benefits of the use of pioglitazone, an approved oral antidiabetic agent that has recently been linked to an increased but not yet confirmed risk of bladder cancer in humans, should be justified for individual use.

Diabetes conveys a higher risk of gastric cancer mortality despite an age-standardised decreasing trend in the general population in Taiwan

BACKGROUND

The association between diabetes and gastric cancer has been rarely studied.

OBJECTIVE

To investigate gastric cancer mortality trends, the mortality rate ratios between patients with diabetes and the general population, and the risk factors for gastric cancer mortality in diabetic patients.

METHODS

In the Taiwanese general population from 1995 to 2006, age-standardised trends of gastric cancer mortality were evaluated, followed by calculation of age-sex-specific mortality rates. A total of 113,347 men with diabetes and 131,573 women with diabetes, aged ≥ 25 years and recruited in 1995-1998, were followed to 2006 for gastric cancer mortality. Age-sex-specific mortality rate ratios for diabetic patients versus the general population were calculated. Cox's regression was used to evaluate the risk factors among diabetic patients.

RESULTS

A decreasing trend of age-standardised gastric cancer mortality in the general population (p < 0.0001) was observed from 1995 to 2006 for both sexes. A total of 627 diabetic men and 422 diabetic women died of gastric cancer, with a calculated mortality rate of 72.8 and 40.0 per 100,000 person-years, respectively. Mortality rate ratios showed a significantly higher risk in diabetic patients with a magnitude most remarkable at the youngest age: 1.52 (1.31-1.77), 1.58 (1.40-1.78) and 4.49 (3.93-5.12) for ≥ 75, 65-74 and 25-64 years old, respectively, for men; and 1.58 (1.32-1.90), 1.95 (1.67-2.27) and 3.65 (3.11-4.28), respectively, for women. In the diabetic patients, age and male sex were associated with gastric cancer mortality, but diabetes type, insulin use, and smoking were not. Body mass index and area of residence did not show consistent association. Diabetes duration was significantly predictive when those who died of gastric cancer within 5 years of diabetes diagnosis were excluded from analysis.

CONCLUSIONS

Despite a decreasing age-standardised mortality trend in the general population, diabetic patients have a higher risk of gastric cancer mortality and this was most remarkable in the youngest age group of 25-64 years.

Clinical features of heart failure hospitalization in younger and elderly patients in Taiwan

BACKGROUND

  This study compared the comorbidities, drugs, expenses and in-hospital mortality between younger and elderly patients hospitalized with heart failure.

METHODS

A random sample of 1,000.000 insurants of the National Health Insurance program of Taiwan in 2005 was used. Comparisons were made between younger (20-64years) and elderly (≥65years) patients.

RESULTS

Heart failure hospitalization was identified in 2692 patients. Ageing, female sex, diabetes, hypertension, chronic obstructive pulmonary disease, nephropathy, infection and ischaemic heart disease were significantly associated with heart failure hospitalization. The incidence was 88 and 2181 per 100,000 population, in younger and elderly people, respectively. The most common comorbidity in the elderly was hypertension (38·3%), followed by infection (32·0%) and ischaemic heart disease (31·9%). In younger patients, hypertension (41·3%), diabetes (35·5%) and ischaemic heart disease (29·8%) were the most common comorbidity. Diuretics were the most common drugs for both the younger (74·4%) and the elderly (76·9%) patients, followed by angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers and aspirin. The length of stay was longer (17·1 vs. 11·0days, P<0·0001), total expense higher (105,290·5 vs. 85,473·6 New Taiwan Dollars, P<0·05) and in-hospital mortality higher (4·2% vs. 2·7%, P=0·0823) in the elderly. Length of stay, nephropathy, infection, ischaemic heart disease and peripheral arterial disease were associated with expenses. In-hospital mortality was associated with age, length of stay, cancer, infection and peripheral arterial disease.

CONCLUSIONS

The elderly have a 25-fold higher risk of heart failure hospitalization, longer length of in-hospital stay, higher total medical expense and higher in-hospital mortality.

Diabetes and risk of prostate cancer: a study using the National Health Insurance

OBJECTIVE

The link between diabetes and prostate cancer is rarely studied in Asians.

RESEARCH DESIGN AND METHODS

The trend of age-standardized prostate cancer incidence in 1995-2006 in the Taiwanese general population was calculated. A random sample of 1,000,000 subjects covered by the National Health Insurance in 2005 was recruited. A total of 494,630 men for all ages and 204,741 men ≥ 40 years old and without prostate cancer at the beginning of 2003 were followed to the end of 2005. Cumulative incidence and risk ratio between diabetic and nondiabetic men were calculated. Logistic regression estimated the adjusted odds ratios for risk factors.

RESULTS

The trend of prostate cancer incidence increased significantly (P < 0.0001). The cumulative incidence markedly increased with age in either the diabetic or nondiabetic men. The respective risk ratio (95% CI) for all ages and age 40-64, 65-74, and ≥ 75 years was 5.83 (5.10-6.66), 2.09 (1.60-2.74), 1.35 (1.07-1.71), and 1.39 (1.12-1.71). In logistic regression for all ages or for age ≥ 40 years, age, diabetes, nephropathy, ischemic heart disease, dyslipidemia, living region, and occupation were significantly associated with increased risk, but medications including insulin and oral antidiabetic agents were not.

CONCLUSIONS

Prostate cancer incidence is increasing in Taiwan. A positive link between diabetes and prostate cancer is observed, which is more remarkable in the youngest age of 40-64 years. The association between prostate cancer and comorbidities commonly seen in diabetic patients suggests a more complicated scenario in the link between prostate cancer and diabetes at different disease stages.

Prostate cancer mortality in Taiwanese men: increasing age-standardized trend in general population and increased risk in diabetic men

BACKGROUND

To evaluate the trend of prostate cancer mortality in Taiwanese general population and the association between diabetes and prostate cancer mortality.

MATERIALS AND METHODS

In the general population during 1995-2006, the trends of prostate cancer mortality were evaluated, followed by calculation of age-specific mortality rates for age 40-64, 65-74, and ≥ 75 years. A cohort of 102,651 diabetic men aged ≥ 40 years recruited in 1995-1998 was followed prospectively.

RESULTS

The trends of crude and age-standardized mortality from prostate cancer in the general population increased significantly (P < 0.0001). In the general population, 7,966 men aged ≥ 40 years died of prostate cancer, and aging was associated with increased risk. Age-specific prostate cancer mortality suggested significantly increasing trend for ages 65-74 and ≥ 75 years. A total of 321 diabetic men died of prostate cancer (crude mortality rate 41.9/100,000 person-years). Mortality rate ratios (95% confidence interval) showed higher risk of prostate cancer mortality in the diabetic patients, with magnitude increased with decreasing age: 1.55 (1.29-1.86), 2.68 (2.29-3.13), and 6.84 (5.34-8.75) for age ≥ 75, 65-74, and 40-64 years, respectively.

CONCLUSIONS

Prostate cancer mortality in the Taiwanese general population is increasing. Diabetic patients have a higher risk of prostate cancer mortality, which is more remarkable with decreasing age.

Furano-1,2-naphthoquinone inhibits EGFR signaling associated with G2/M cell cycle arrest and apoptosis in A549 cells

Furano-1,2-naphthoquinone (FNQ), prepared from 2-hydroxy-1,4-naphthoquinone and chloroacetaldehyde in an efficient one-pot reaction, exhibits an anti-carcinogenic effect. FNQ exerted anti-proliferative activity with the G(2)/M cell cycle arrest and apoptosis in A549 cells. FNQ-induced G(2)/M arrest was correlated with a marked decrease in the expression levels of cyclin A and cyclin B, and their activating partner cyclin-dependent kinases (Cdk) 1 and 2 with concomitant induction of p53, p21, and p27. FNQ-induced apoptosis was accompanied with Bax up-regulation and the down-regulation of Bcl-2, X-linked inhibitor of apoptosis (XIAP), and survivin, resulting in cytochrome c release and sequential activation of caspase-9 and caspase-3. Western blot analysis revealed that FNQ suppressed EGFR phosphorylation and JAK2, STAT3, and STAT5 activation, but increased in activation of p38 MAPK and c-Jun NH2-terminal kinase (JNK) stress signal. The combined treatment of FNQ with AG1478 (a specific EGFR inhibitor) significantly enhanced the G(2)/M arrest and apoptosis, and also led to up-regulation in Bax, p53, p21, p27, release of mitochondrial cytochrome c, and down-regulation of Bcl-2, XIAP, survivin, cyclin A, cyclin B, Cdk1, and Cdk2 in A549 cells. These findings suggest that FNQ-mediated cytotoxicity of A549 cell related with the G(2)/M cell cycle arrest and apoptosis via inactivation of EGFR-mediated signaling pathway.

Gender differences in trends in diabetes prevalence from 1993 to 2008 in Taiwan

We examined time trends in the prevalence of diabetes using nationally representative samples, with a focus on gender differences. Data were from the Nutrition and Health Survey in Taiwan (NAHSIT), 1993-1996 (n = 2700), and NAHSIT 2004-2008 (n = 2258). Participants aged 19 years or older with adequate fasting glucose data were included. When needed, rates were standardized to the year 2000 WHO 5-year interval population for comparisons. The prevalence increased significantly in men, whose standardized rate increased from 4.6% to 9.3%. In women, the age standardized prevalence decreased slightly from 7.9% to 6.4%. High triglycerides (≥ 150 mg/dL) was associated with diabetes with odds ratios (OR) of 2.14, and 2.69 (all with p<0.05) in the two surveys. High waist circumference (men ≥ 90 cm; women ≥ 80 cm) was also associated with diabetes with ORs of 2.52, and 1.93 (all with p < 0.05). We recommend the development of innovative health promotion programs targeting not only the general population, but also high risk groups such as men, to further reduce diabetes.

Betel nut chewing and subclinical ischemic heart disease in diabetic patients

Background. This study investigated the association between betel nut chewing and subclinical ischemic heart disease (IHD) in Taiwanese type 2 diabetic patients. Methods. A total of 394 male patients aging ≥45 years and without previous heart disease were studied. Among them 349 had no habit of chewing betel nut and 45 possessed the habit for ≥5 years. Subclinical IHD was diagnosed by a Minnesota-coded resting electrocardiogram and was present in 71 cases. Statistical analyses were performed considering confounding effects of age, diabetic duration, smoking, body mass index, blood pressure, dyslipidemia, and metabolic control status. Results. Betel nut chewers were younger and had higher prevalence of smoking (86.7% versus 60.5%), higher body mass index, poorer glycemic control, and higher prevalence of subclinical IHD (28.9% versus 16.6%). Patients with subclinical IHD were older and had higher prevalence of betel nut chewing (18.0% versus 9.9%). The multivariate-adjusted odds ratio for subclinical IHD for chewers versus nonchewers was 4.640 (1.958–10.999). The adjusted odds ratios in younger or older patients divided by the median age of 63 years were similar: 4.724 (1.346–16.581) and 4.666 (1.278–17.028), respectively. Conclusions. Betel nut chewing is significantly associated with increased risk of subclinical IHD.

Betel nut chewing and incidence of newly diagnosed type 2 diabetes mellitus in Taiwan

Background

Betel nut chewing is associated with type 2 diabetes mellitus (T2DM) in a recent prevalence study in Taiwan. The present study further investigated its link with the incidence of newly diagnosed T2DM during the years 1992-1996.

Methods

Population-based datasets of a sample of 93,484 out of 256,036 diabetic patients from 66 medical settings using the National Health Insurance scheme covering > 96% of the population, published population prevalence of betel nut chewing and the governmental census of national population were used for calculation of odds ratios, incidence rates and incidence rate ratios between chewers and never-chewers in the male population for the year 1992 to 1996.

Results

Ever chewers among the diabetic patients were younger, more obese and had higher prevalence of parental diabetes than never-chewers (all p values < 0.001). Odds ratios for T2DM for ever chewers vs. never-chewers in the age of < 40, 40-49, 50-59, 60-69 and ≥70 years were 1.06 (0.92-1.23), 1.60 (1.45-1.76), 2.12 (1.88-2.39), 3.58 (3.10-4.13) and 7.14 (5.47-9.31), respectively. In 1996, incidence rates (per 100,000 population) in the respective age groups were 19.1, 251.5, 567.3, 721.7 and 971.4 for never-chewers; and were 30.2, 520.9, 2566.9, 11672.8 and 630.3 for ever chewers. The respective incidence rate ratios were 1.58, 2.07, 4.52, 16.17 and 0.65. The age-specific incidence rates and rate ratios were relatively consistent from 1992 to 1996. The differences in obesity and parental diabetes between ever chewers and never-chewers were mostly not statistically significant after age stratification, suggesting the link could not be attributed to these two factors.

Conclusions

Chewing betel nut is associated with newly diagnosed T2DM, supporting the suggestion that the habit is diabetogenic.

A population study on the association between leisure time physical activity and self-rated health among diabetics in Taiwan

Background

There is strong evidence for the beneficial effects of physical activity in diabetes. There has been little research demonstrating a dose-response relationship between physical activity and self-rated health in diabetics. The aim of this study was to explore the dose-response association between leisure time physical activity and self-rated health among diabetics in Taiwan.

Methods

Data came from the 2001 Taiwan National Health Interview Survey (NHIS). Inclusion criteria were a physician confirmed diagnosis of diabetes mellitus and age 18 years and above (n = 797). Self-rated health was assessed by the question "In general, would you say that your health is excellent, very good, good, fair, or poor?" Individuals with a self perceived health status of good, very good, or excellent were considered to have positive health status.

Results

In the full model, the odds ratio (OR) for positive health was 2.51(95% CI = 1.53-4.13), 1.62(95% CI = 0.93-2.84), and 1.35(95% CI = 0.77-2.37), for those with a total weekly energy expenditure of ≥ 1000 kcal, between 500 and 999 kcal, and between 1 and 499 kcal, respectively, compared to inactive individuals. Those with duration over 10 years (OR = 0.53, 95%CI = 0.30-0.94), heart disease (OR = 0.50, 95%CI = 0.30-0.85), and dyslipidemia (OR = 0.65, 95% CI = 0.43-0.98) were less likely to have positive health than their counterparts. After stratified participants by duration, those with a duration of diabetes < 6 years, the adjusted OR for positive health was 1.95(95% CI = 1.02-3.72), 1.22(95% CI = 0.59-2.52), and 1.19(95% CI = 0.58-2.41) for those with a total weekly energy expenditure of ≥ 1000 kcal, between 500 and 999 kcal, and between 1 and 499 kcal, respectively, compared to inactive individuals. In participants with a duration of diabetes ≥ 6 years, total energy expenditure showed a gradient effect on self-perceived positive health. The adjusted OR for positive health was 3.45(95% CI = 1.53-7.79), 2.77(95% CI = 1.11-6.92), and 1.90(95% CI = 0.73-4.94) for those with a total weekly energy expenditure of ≥ 1000 kcal, between 500 and 999 kcal, and between 1 and 499 kcal, respectively, compared to inactive individuals.

Conclusions

Our results highlight that regular leisure activity with an energy expenditure ≧ 500 kcal per week is associated with better self-rated health for those with longstanding diabetes.

Metabolic syndrome components worsen lower urinary tract symptoms in women with type 2 diabetes

CONTEXT

Diabetic women are more susceptible to develop lower urinary tract symptoms (LUTS), especially overactive bladder (OAB). However, data regarding the effect of components of metabolic syndrome (MS) on this association are conflicting.

OBJECTIVE

The objective of the study was to examine the potential role of MS in the development of LUTS in diabetic women.

DESIGN

The study was a prevalence study conducted between 2005 and 2007.

SETTING

The study was conducted in a university hospital.

PARTICIPANTS

A total of 518 women with type 2 diabetes aged 50-75 yr were included. They were subgrouped as MS (47.5%) and non-MS (52.5%) groups according to whether they fulfilled the criteria of MS.

MAIN OUTCOME MEASURE

We used American Urological Association Symptom Index (AUA-SI) to evaluate LUTS and Indevus Urgency Severity Scale to evaluate OAB, respectively.

RESULTS

Women in the MS group had significantly higher storage and total AUA-SI scores as well as a higher prevalence of LUTS and OAB. Most intriguingly, the number of MS components was strongly associated with the LUTS severity because the AUA-SI scores increased in parallel to the number of components were present. Similar results were found between MS and OAB. Multivariate analysis revealed that peripheral neuropathy, but not MS, significantly predicted LUTS in diabetic women after age adjustment. However, MS remained significantly predictive for LUTS and OAB after additional adjustment for neuropathy.

CONCLUSIONS

Our results suggest that MS may especially influence LUTS and OAB in diabetic women, probably by compounding the effect of peripheral neuropathy.

Hypertension is the most important component of metabolic syndrome in the association with ischemic heart disease in Taiwanese type 2 diabetic patients

BACKGROUND

To evaluate the association between components of metabolic syndrome (MS) and ischemic heart disease (IHD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A total of 1,296 (604 men and 692 women) subjects with T2DM aged 62.5+/-11.7 (14-87) years were studied. MS was defined using the World Health Organization modified criteria and included more than 2 of hypertension, obesity, dyslipidemia and microalbuminuria. IHD was diagnosed through history or ischemic electrocardiogram according to the Minnesota codes. Results showed that MS was present in 76.2% and IHD in 36.3% of the patients, respectively. MS increased with age for both sexes, but there was no difference between men and women in the age groups of <45, 45-54 and 55-64 years. However, the prevalence of MS was significantly higher in women (87.7% vs 78.0%) in the age group>or=65 years. IHD prevalence was significantly higher in patients with MS, hypertension, dyslipidemia and obesity (p<0.01), and was higher with borderline significance for microalbuminuria (0.05<p<0.1). The respective age-adjusted odds ratios were 3.61 (2.57-5.08), 7.10 (5.38-9.38), 1.70 (1.32-2.18), 1.75 (1.33-2.28), and 1.11 (0.88-1.41).

CONCLUSIONS

The prevalence of MS in subjects with T2DM is high and increases with age. The impact of different risk factors on IHD is diverse, with hypertension being the most important.

Association of C-reactive protein and hyperuricemia with diabetic nephropathy in Chinese type 2 diabetic patients

To investigate the relationship of micro-albuminuria with C-reactive protein (CRP) and hyperuricemia in Chinese patients with type 2 diabetes. All patients with type 2 diabetes, 40 years old and over were recruited consecutively from diabetic clinics at a medical center. Serum lipid, creatinine, uric acid, CRP, HbA(1C) and urinary albumin concentration were measured. A total of 515 patients, aged 60.3 +/- 10.7 years were recruited and the number (rate) of micro- and macro-albuminuria were 109 (21.2%) and 55 (10.7%). The prevalence of micro-albuminuria for the quartiles of CRP levels demonstrated a meaningful trend of increases between groups from 17.4, 21.1, 30.3, and 31.2% (P trend = 0.002). Besides, the median CRP concentrations was significantly higher in the patients with micro- and macro-albuminuria than those with non-albuminuria. Stepwise logistic regression analysis revealed that CRP was significantly associated with abnormal albuminuria (OR = 1.36, 95% CI = 1.12-1.64, P = 0.002). After excluding those subjects with angiotensin-converting enzyme inhibitors/angiotension II receptor blockers or/and statin usage, the observed relationship between serum CRP levels and albuminuria was still persistent (OR = 1.61, 95% CI = 1.24-2.08, P < 0.001). In addition, hyperuricemia were significantly associated with abnormal albuminuria in the patients without diuretics, uricosuric agents or alcohol usage. Both serum CRP levels and hyperuricemia were significantly related to the presence of albuminuria in patients with diabetes. In addition, Chinese type 2 diabetic patients with serum CRP levels in the lower range as other ethnic groups can lead to the development of micro-albuminuria.