Association of Cardiometabolic Multimorbidity With Mortality

6. Glycemic Targets: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Larger effect size in composite kidney outcomes than in major cardiovascular events associated with sodium-glucose cotransporter-2 (SGLT2) inhibitors compared with glucagon-like peptide-1 receptor agonists (GLP-1RAs): A pooled analysis of type 2 diabetes trials

AIM

To compare treatment effect sizes between a composite kidney outcome (CKO) and three-point major adverse cardiovascular event (MACE-3) outcomes with use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs), and to investigate the relationship between treatment effects on CKO and MACE-3 in patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

We performed a MEDLINE database search up to December 31, 2021 to identify all placebo-controlled Phase 3 trials which investigated the efficacy of glucose-lowering interventions, and selected those reporting results for CKO and MACE-3. Hazard ratios (HRs) with 95% confidence intervals (CIs) for both outcomes were extracted for each trial, and we evaluated differences in treatment effect sizes by using a ratio of HRs (rHR): the HR for CKO to the HR for MACE-3. A random-effects meta-analysis was used to obtain the overall rHR across trials and according to subgroup. We investigated the relationship between treatment effects on CKO and MACE-3 using the coefficient of determination (R² ) with weighted meta-regression. The study protocol was registered on PROSPERO (CRD42022299690).

RESULTS

A total of 12 studies fulfilled the prespecified criteria, and comprised a total of 104 987 patients with T2D. On average, treatment effect sizes were 17% greater for CKO than for MACE-3 (rHR 0.83, 95% CI 0.74 to 0.92; I²  = 50%; P = 0.03; τ²  = 0.0161), especially for trials of SGLT2 inhibitors compared with GLP-1RAs. For secondary outcomes, treatment effect size was 22%, 21%, 16% and 9% greater for CKO than for myocardial infarction, stroke, death from cardiovascular causes, and hospitalization for heart disease, respectively. MACE-3 and CKO were moderately correlated (ρ = 0.40; P = 0.21), and only 11% (95% CI 1% to 54%) of the variability in the MACE-3 effect could be explained by the variability in the CKO effect.

CONCLUSION

In T2D patients, treatment effect sizes were greater for kidney than for macrovascular (MACE-3) outcomes, with important differences according to the drugs considered. CKO and MACE-3 are independent. Caution must be taken when interpreting CKO in the absence of MACE-3 data.

The multiple roles of life stress in metabolic disorders

The activation of stress-related neuroendocrine systems helps to maintain homeostasis, but excessive stress can damage body functions. We review current evidence from basic sciences and epidemiology linking stress to the development and progression of metabolic disorders throughout life. Findings from rodents demonstrate that stress can affect features of metabolic dysfunction, such as insulin resistance, glucose and lipid homeostasis, as well as ageing processes such as cellular senescence and telomere length shortening. In human studies, stressors in the home, workplace and neighbourhood are associated with accelerated ageing and metabolic and immune alterations, both directly and indirectly via behavioural risks. The likelihood of developing clinical conditions, such as diabetes mellitus and hepatic steatosis is increased in individuals with adverse childhood experiences or long-term (years) or severe stress at work or in private life. The increased risk of metabolic disorders is often associated with other stress-related conditions, such as mental health disorders, cardiovascular disease and increased susceptibility to infections. Equally, stress can worsen prognosis in metabolic diseases. As favourable modifications in stressors are associated with reductions in incidence of metabolic disorders, further investigation of the therapeutic value of targeting stress in personalized medicine is warranted.

Cardiometabolic multimorbidity and incident dementia: the Swedish twin registry

AIMS

Cardiometabolic diseases (CMDs), including diabetes, heart disease, and stroke, are established risk factors for dementia, but their combined impact has been investigated only recently. This study aimed to examine the association between mid- and late-life cardiometabolic multimorbidity and dementia and explore the role of genetic background in this association.

METHODS AND RESULTS

Within the Swedish Twin Registry, 17 913 dementia-free individuals aged ≥60 were followed for 18 years. CMDs [including age of onset in mid (60) or late (≥60) life] and dementia were ascertained from medical records. Cardiometabolic multimorbidity was defined as having ≥2 CMDs. Cox regression was used to estimate the CMD-dementia association in (i) a classical cohort study design and (ii) a co-twin study design involving 356 monozygotic and dizygotic pairs. By comparing the strength of the association in the two designs, the contribution of genetic background was estimated. At baseline, 3,312 (18.5%) participants had 1 CMD and 839 (4.7%) had ≥2 CMDs. Over the follow-up period, 3,020 participants developed dementia. In the classic cohort design, the hazard ratio (95% confidence interval) of dementia was 1.42 (1.27-1.58) for 1 CMD and 2.10 (1.73-2.57) for ≥2 CMDs. Dementia risk was stronger with mid-life as opposed to late-life CMDs. In the co-twin design, the CMD-dementia association was attenuated among monozygotic [0.99 (0.50-1.98)] but not dizygotic [1.55 (1.15-2.09)] twins, suggesting that the association was in part due to genetic factors common to both CMDs and dementia.

CONCLUSION

Cardiometabolic multimorbidity, particularly in mid-life, is associated with an increased risk of dementia. Genetic background may underpin this association.

Metabolic Risk Factors for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease: A Prospective Study

Non-alcoholic fatty liver disease (NAFLD) is a fast-growing public health problem and predisposes to hepatocellular carcinoma (HCC) in a significant proportion of patients. Metabolic alterations might underlie the progression of NAFLD to HCC, but the magnitudes of risk and population-attributable risk fractions (PAFs) for various metabolic conditions that are associated with HCC risk in patients with NAFLD are unknown. We investigated the associations between metabolic conditions and HCC development in individuals with a prior history of NAFLD. The study included 11,245 participants in the SEER-Medicare database, comprising 1310 NAFLD-related HCC cases and 9835 NAFLD controls. We excluded individuals with competing liver diseases (e.g., alcoholic liver disease and chronic viral hepatitis). Baseline pre-existing diabetes mellitus, dyslipidemia, obesity, hypertension, hypothyroidism, and metabolic syndrome were assessed. Multivariable-adjusted logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). PAFs were also calculated for each metabolic condition. The results show that diabetes (OR = 2.39, 95% CI: 2.04-2.79), metabolic syndrome (OR = 1.73, 95% CI: 1.49-2.01), and obesity (OR = 1.62, 95% CI: 1.43-1.85) were associated with a higher HCC risk in individuals with NAFLD. The highest PAF for HCC was observed for pre-existing diabetes (42.1%, 95% CI: 35.7-48.5), followed by metabolic syndrome (28.8%, 95% CI: 21.7-35.9) and obesity (13.2%, 95% CI: 9.6-16.8). The major predisposing factors for HCC in individuals with NAFLD are diabetes mellitus, metabolic syndrome, and obesity, and their control would be critically important in mitigating the rising incidence of NAFLD-related HCC.

Role of depression in the development of cardiometabolic multimorbidity: Findings from the UK Biobank study

BACKGROUND

Depression has been acknowledged as a risk factor for cardiometabolic diseases, but its role in the development of cardiometabolic multimorbidity (CM) remains unclear. We aimed to prospectively investigate how depression affected the development of CM based on the UK Biobank study.

METHODS

We included 459,747 participants with none or one prior cardiometabolic disease. Depression was assessed by the clinical diagnosis and Patient Health Questionnaire (PHQ-2). CM was defined as the coexistence of two or more conditions of type 2 diabetes, stroke, and coronary heart disease (CHD). Multistate models were used to examine the role of depression in the transitions from baseline to single cardiometabolic diseases and subsequently to CM.

RESULTS

During a median follow-up of 12.07 years, we documented 3413 incident CM cases among initially disease-free participants and 7461 cases among participants with one prior cardiometabolic disease, respectively. The hazard of developing CM associated with depression was higher among disease-free individuals than that among individuals with one cardiometabolic disease (HR, 95 % CI: 1.68, 1.54-1.83 vs 1.28, 1.20-1.35). Moreover, depression was significantly associated with all transitions from baseline to diabetes (HR, 95 % CI: 1.43, 1.37-1.50), stroke (1.28, 1.20-1.38), and CHD (1.35, 1.31-1.40). After the onset of these cardiometabolic diseases, the HR values (95 % CIs) of progression to CM were 1.26 (1.09-1.46) for diabetes, 1.43 (1.16-1.76) for stroke, and 1.23 (1.08-1.40) for CHD.

CONCLUSIONS

Depression was an independent risk factor for CM, and adversely influenced the whole progression from disease-free status to CM.

Revised Protein Sparing Diet in Obesity and Type 2 Diabetes Mellitus

Effective nutrition therapy is a pressing issue in obesity and type 2 diabetes mellitus (T2DM) management. As such, this research aimed to determine the performance of a revised dietary strategy built on the protein-sparing diet in obesity and type 2 diabetes mellitus with regard to obtaining a rapid and stable improvement in glucometabolic control, body weight, body composition, and energy metabolism when applying the strategy in just twenty-one days. The revised protein-sparing diet differs from the traditional protein-sparing modified fast (PSMF) because it does not include foods. The daily calorie intake of this diet is exclusively derived from Isolate whey protein in addition to a formulation of Isolate whey protein enriched with essential amino acids in free form, with the addition of lipids such as extra virgin olive oil and coconut oil as a source of medium chain fatty acids, where the latter is taken for only the first four days of the diet, together with the use, for the same duration, of extended-release metformin, as the only antihyperglycemic allowed. Anthropometric measurements, bioimpedance analysis, indirect calorimetry, and blood chemistry assessments were conducted at the beginning of the study, time 0 (T0), and at the end, time 1 (T1), i.e., on the 21st day. The main outcomes of the revised protein-sparing diet after only twenty-one days were a reduction in body weight with the predominant loss of visceral atherogenic abdominal fat and, therefore, a possible contextual reduction in ectopic fat deposits together with a simultaneous reduction in insulin resistance and normalization of insulin levels, maintenance of free fat mass and basal metabolism, restoration of metabolic flexibility, and improvement of the glucometabolic and lipidic parameters. These results demonstrate the promising potential of the revised protein-sparing diet as an "etiologic tool" in the integrated nutritional treatment of metabolic diseases such as obesity and type 2 diabetes mellitus.

Disease patterns of coronary heart disease and type 2 diabetes harbored distinct and shared genetic architecture

BACKGROUND

Coronary heart disease (CHD) and type 2 diabetes (T2D) are two complex diseases with complex interrelationships. However, the genetic architecture of the two diseases is often studied independently by the individual single-nucleotide polymorphism (SNP) approach. Here, we presented a genotypic-phenotypic framework for deciphering the genetic architecture underlying the disease patterns of CHD and T2D.

METHOD

A data-driven SNP-set approach was performed in a genome-wide association study consisting of subpopulations with different disease patterns of CHD and T2D (comorbidity, CHD without T2D, T2D without CHD and all none). We applied nonsmooth nonnegative matrix factorization (nsNMF) clustering to generate SNP sets interacting the information of SNP and subject. Relationships between SNP sets and phenotype sets harboring different disease patterns were then assessed, and we further co-clustered the SNP sets into a genetic network to topologically elucidate the genetic architecture composed of SNP sets.

RESULTS

We identified 23 non-identical SNP sets with significant association with CHD or T2D (SNP-set based association test, P < 3.70 × [Formula: see text]). Among them, disease patterns involving CHD and T2D were related to distinct SNP sets (Hypergeometric test, P < 2.17 × [Formula: see text]). Accordingly, numerous genes (e.g., KLKs, GRM8, SHANK2) and pathways (e.g., fatty acid metabolism) were diversely implicated in different subtypes and related pathophysiological processes. Finally, we showed that the genetic architecture for disease patterns of CHD and T2D was composed of disjoint genetic networks (heterogeneity), with common genes contributing to it (pleiotropy).

CONCLUSION

The SNP-set approach deciphered the complexity of both genotype and phenotype as well as their complex relationships. Different disease patterns of CHD and T2D share distinct genetic architectures, for which lipid metabolism related to fibrosis may be an atherogenic pathway that is specifically activated by diabetes. Our findings provide new insights for exploring new biological pathways.

Protective effect of ischaemic postconditioning combined with nicorandil on myocardial ischaemia‒reperfusion injury in diabetic rats

BACKGROUND

The diabetic heart exhibits a high sensitivity to ischaemia/reperfusion (I/R) injury. Diabetes mellitus (DM) can affect the efficacy of cardioprotective interventions and reduce the therapeutic potential of existing treatment options. This study aimed to investigate the feasibility of shifting from monotherapy to combination therapy in diabetic myocardial I/R injury.

METHODS

6-8 week rats were randomized into 10 groups: sham, I/R, ischaemia postconditioning (I-Post), nicorandil (Nic), combination therapy (I-Post + Nic), DM sham, DM I/R, DM I-Post, DM Nic and DM I-Post + Nic. The extent of myocardial injury was clarified by measuring CK-MB and NO levels in plasma, ROS content in myocardial tissues, and TTC/Evans Blue staining to assess the area of myocardial infarction. Pathological staining of cardiac tissue sections were performed to clarify the structural changes in myocardial histopathology. Finally, Western blotting was performed to detect the phosphorylation levels of some key proteins in the PI3K/Akt signalling pathway in myocardial tissues.

RESULTS

We confirms that myocardial injury in diabetic I/R rats remained at a high level after treatment with I-Post or nicorandil alone. I-Post combined with nicorandil showed better therapeutic effects in diabetic I/R rats, and the combined treatment further reduced the area of myocardial injury in diabetic I/R rats compared with I-Post or nicorandil treatment alone (P < 0.001), as well as the levels of the myocardial injury markers CK-MB and ROS (P < 0.001); it also significantly increased plasma NO levels. Pathological staining also showed that diabetic rats benefited significantly from the combination therapy. Further mechanistic studies confirmed this finding. The protein phosphorylation levels of PI3K/Akt signalling pathway in the heart tissue of diabetic I/R rats were significantly higher after the combination treatment than after one treatment alone (all P < 0.05).

CONCLUSION

I-Post combined with nicorandil treatment maintains effective cardioprotection against diabetic myocardial I/R injury by activating the PI3K/Akt signalling pathway.

Assessment of the Safety, Efficacy, and Benefit of Empagliflozin in Patients With Type 2 Diabetes Mellitus (T2DM) and Heart Failure With Reduced Ejection Fraction (HFrEF) at High Risk for Cardiovascular Events

Background Since the increasing prevalence of type 2 diabetes mellitus (T2DM), heart failure coexisting with it has had a significant impact on clinical management and prognosis. Patients with T2DM and heart failure with reduced ejection fraction (HFrEF) have increased mortality and morbidity. Empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, is widely acknowledged to reduce cardiovascular risk in T2DM patients. We wanted to assess the composite outcomes of heart failure, cardiovascular death, and hospitalization following the start of empagliflozin therapy in the Saudi population. Methods This is a retrospective observational study conducted at King Fahad Armed Forces Hospital-Jeddah. We included patients aged 18 or older, male or female, with T2DM with HFrEF <40% and with a risk of cardiovascular events who were treated with empagliflozin 25 mg once daily as combination therapy and patients using other diabetic agents without empagliflozin as the comparative group. Results A total of 195 patients with T2DM and HFrEF who were at high risk for cardiovascular (CV) events were included in the study. Regarding gender, most of the patients (82.1%) were male with an average age of 61.28 ± 9.92. The patients were divided into 71 individuals who received empagliflozin and 124 who did not. When comparing the surgical procedure and comorbid status of the patients, coronary artery bypass graft (1.4%), coronary artery disease (5.6%), dyslipidemia (5.6%), and ischemic cardiomyopathy (0%) were found compared to the non-empagliflozin group. Meanwhile, hypertension was found to be 71.8% and ischemic heart disease was 50.7% in empagliflozin patients. Furthermore, only dyslipidemia differed significantly (p <0.001) between the empagliflozin and non-empagliflozin groups of patients. However, no significant differences were observed between the average low-density lipoprotein (p = 0.990) and high-density lipoprotein (p = 0.399). There was no significant difference observed in the primary outcome of CV deaths or hospital admission of patients between empagliflozin and non-empagliflozin. No deaths were reported in either of the comparative groups in our study. Conclusion In this study, there was no significant difference observed in hospital admission of the patients between the empagliflozin and non-empagliflozin groups. No cardiovascular mortality was reported in the study population. Further matched group comparative studies or placebo-controlled studies are required to compare the existing evidence of the impact of empagliflozin on T2DM patients with HFrEF and at high risk for CV deaths or hospital admission.

The impact of sodium-glucose cotransporter inhibitors on blood pressure: a meta-analysis and metaregression of 111 randomized-controlled trials

OBJECTIVE

Multiple trials on sodium-glucose cotransporter (SGLT) inhibitors have been performed recently demonstrating blood pressure (BP) reduction benefits in both diabetic and nondiabetic patients. Hence, we conducted a systematic review and meta-analysis to determine the effect of different SGLT inhibitors on BP in both patients with and without diabetes mellitus.

METHODS

Four electronic databases (PubMed, Embase, Cochrane, and SCOPUS) were searched on 4 November 2021 for articles published from 1 January 2000 up to 21 November 2021, for studies evaluating the BP effects of SGLT inhibitors. Pair-wise meta-analysis and random effects metaregression models were utilized.

RESULTS

In total, 111 studies examining SBP (108 studies, 104 304 patients) and/or DBP (82 studies, 74 719 patients) were included. In patients with diabetes, the random effects model demonstrated SGLT inhibitor produced a mean reduction in SBPs of -3.46 mmHg (95% confidence interval: -3.83, -3.09) compared with placebo. There were no statistically significant changes in BP among patients without diabetes. Drug response relationship was not observed in SGLT inhibitors and BP, except for Canagliflozin and DBP.

CONCLUSION

Sodium-glucose cotransporter 2 inhibitors and combined sodium-glucose cotransporter 1/2 inhibitors produced small reductions in BP in patients with diabetes.

Glyceraldehyde-derived advanced glycation end-products are associated with left ventricular ejection fraction and brain natriuretic peptide in patients with diabetic adverse cardiac remodeling

Objectives: Glyceraldehyde-derived advanced glycation end-products (Glycer-AGEs) have a strong binding affinity for their cognate receptor and elicit oxidative stress and inflammation. However, it remains unknown whether the levels of Glycer-AGEs correlate with the severity of cardiac function and heart failure in patients with diabetic adverse cardiac remodeling (DbCR). Fourteen heart failure patients with type 2 diabetes mellitus (DM) without other cardiac disorders (DbCR group) were enrolled. Another 14 patients with idiopathic dilated cardiomyopathy (DCM) without DM were served as a control (DCM group). All patients were assessed for serum Glycer-AGEs, nitrotyrosine (NT), and tumor necrosis factor alpha (TNFα) and for plasma brain natriuretic peptide (BNP). The left ventricular ejection fraction (LVEF) was evaluated by echocardiography. Results: The mean serum levels of Glycer-AGEs, NT, and TNFα in the DbCR group were significantly higher than those in the DCM group (for Glycer-AGEs, p = .0073; for NT, p = .005; for TNFα, p < .0001, respectively). In the patients with DbCR, the levels of serum Glycer-AGEs and TNFα were closely associated with LVEF and BNP values. Conclusions: Both Glycer-AGEs and TNFα showed close associations with LVEF and the levels of BNP in patients with DbCR. Glycer-AGEs and TNFα may play a pathological role in the development of DbCR.

Pharmacotherapy of type 2 diabetes: An update and future directions

Type 2 diabetes (T2D) is a widely prevalent disease with substantial economic and social impact for which multiple conventional and novel pharmacotherapies are currently available; however, the landscape of T2D treatment is constantly changing as new therapies emerge and the understanding of currently available agents deepens. This review aims to provide an updated summary of the pharmacotherapeutic approach to T2D. Each class of agents is presented by mechanism of action, details of administration, side effect profile, cost, and use in certain populations including heart failure, non-alcoholic fatty liver disease, obesity, chronic kidney disease, and older individuals. We also review targets of novel therapeutic T2D agent development. Finally, we outline an up-to-date treatment approach that starts with identification of an individualized goal for glycemic control then selection, initiation, and further intensification of a personalized therapeutic plan for T2D.

The effect of almond intake on cardiometabolic risk factors, inflammatory markers, and liver enzymes: A systematic review and meta-analysis

Almond intake may be correlated with improvements in several cardiometabolic parameters, but its effects are controversial in the published literature, and it needs to be comprehensively summarized. We conducted a systematic search in several international electronic databases, including MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov until April 2021 to identify randomized controlled trials that examined the effects of almond consumption on cardiometabolic risk factors, inflammatory markers, and liver enzymes. Data were pooled using the random-effects model method and presented as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Twenty-six eligible trials were analyzed (n = 1750 participants). Almond intake significantly decreased diastolic blood pressure, total cholesterol, triglyceride, low-density lipoprotein (LDL), non-high-density lipoprotein (HDL), and very LDL (p < 0.05). The effects of almond intake on systolic blood pressure, fasting blood glucose, insulin, hemoglobin A1c, homeostatic model assessment of insulin resistance, C-peptide, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, C-reactive protein (CRP), hs-CRP (high sensitivity C-reactive protein), interleukin 6, tumor necrosis factor-α, ICAM (Intercellular Adhesion Molecule), VCAM (Vascular Cell Adhesion Molecule), homocysteine, HDL, ox-LDL, ApoA1, ApoB, and lipoprotien-a were not statistically significant (p > .05). The current body of evidence supports the ingestion of almonds for their beneficial lipid-lowering and antihypertensive effects. However, the effects of almonds on antiinflammatory markers, glycemic control, and hepatic enzymes should be further evaluated via performing more extensive randomized trials.

Healthy lifestyle and life expectancy at age 30 years in the Chinese population: an observational study

BACKGROUND

The improvement of life expectancy is one of the aims of the Healthy China 2030 blueprint. We aimed to investigate the extent to which healthy lifestyles are associated with life expectancy in Chinese adults.

METHODS

We used the prospective China Kadoorie Biobank (CKB) study to examine the relative risk of mortality associated with individual and combined lifestyle factors (never smoking or quitting not for illness, no excessive alcohol use, being physically active, healthy eating habits, and healthy body shape). Participants with coronary heart disease, stroke, cancer, or missing values for body-mass index were excluded. For analysis of chronic respiratory diseases, participants with chronic obstructive pulmonary disease or asthma were excluded. We estimated the national prevalence of lifestyle factors using data from the China Nutrition and Health Surveillance (CNHS; 2015) and derived mortality rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (2015). All three data sources were combined to estimate the life expectancy of individuals at age 30 years following different levels of lifestyle factors by using the life table method. The cause-specific decomposition of the life expectancy differences was analysed using Arriaga's method.

FINDINGS

After the exclusion of CKB participants with coronary heart disease, stroke, cancer, or missing BMI data at baseline, 487 209 were included in the primary analysis. Participants with COPD or asthma at baseline were additionally excluded for chronic respiratory disease-related analysis, leaving 451 233 participants with data available for analysis. Data from 171 127 adults aged 30-84 years from the CNHS 2015 were used to estimate the sex-specific and age-specific prevalence of lifestyle-related factors. There were 42 496 deaths documented over a median follow-up of 11·1 years (IQR 10·2-12·1) in CKB. The adjusted hazard ratios (aHRs) of participants adopting five versus 0-1 low-risk factors was 0·38 (95% CI 0·34-0·43) for all-cause mortality, aHR 0·37 (0·30-0·46) for cardiovascular disease mortality, aHR 0·47 (0·39-0·56) for cancer mortality, and aHR 0·30 (0·14-0·64) for chronic respiratory disease mortality. The life expectancy at age 30 years for individuals with 0-1 low-risk factors was on average 41·7 years (95% CI 41·5-42·0) for men and 47·3 years (46·6-48·0) for women. For individuals with all five low-risk factors, the life expectancy at age 30 was 50·5 years (95% CI 48·5-52·4) for men and 55·4 years (53·5-57·4) for women; meaning a difference of 8·8 years (95% CI 6·8-10·7) for men and 8·1 years (6·5-9·9) for women. The estimated extended life expectancy for men and women was mainly attributable to reduced death from cardiovascular disease (2·4 years [27% of the total extended life expectancy] for men and 3·7 years [46%] for women), cancer (2·6 years [30%] for men and 0·9 years [11%] for women), and chronic respiratory disease (0·6 years [7%] for men and 1·2 years [15%] for women).

INTERPRETATION

Our findings suggest that increasing the adoption of these five healthy lifestyle factors through public health interventions could be associated with substantial gains in life expectancy in the Chinese population.

FUNDING

National Natural Science Foundation of China, National Key Research and Development Program of China, Kadoorie Charitable Foundation, UK Wellcome Trust.

Use of fish oil and mortality of patients with cardiometabolic multimorbidity: A prospective study of UK biobank

BACKGROUND AND AIMS

Cardiometabolic multimorbidity (CMM) has risen as a global issue of public health, with an in-creasing prevalence and more severe clinical prognosis. This study aimed to estimate the association between use of fish oil and mortality among patients with CMM.

METHODS AND RESULTS

In this prospective study based on UK Biobank, participants with ≥2 of cardiometabolic diseases (CMDs, including coronary heart disease [CHD], diabetes, hypertension, and stroke in this study) at recruitment were included. Use of fish oil was derived from touchscreen questionnaires at baseline. All-cause and cardiovascular mortality were accessed via electronic health-related records. Kaplan-Meier curves and flexible parametric Royston-Parmar proportion-hazard models were fitted to assess the as-sociations of fish-oil use with all-cause, cardiovascular mortality, and related life expectancy alterations. Among 30 068 participants from UK Biobank (67.9% men; mean age 61.75 years), 5357 deaths were reported during 12.03 years of follow-up. For patients with CMM, use of fish oil was associated with a 17% lower risk of all-cause mortality (95% confidence interval [95% CI] 0.78-0.88, P < 0.001), and 19% lower risk of cardiovascular mortality (95% CI 0.72-0.90, P < 0.001) in multivariable-adjusted models. At 45 years old, using fish oil was associated with 1.66 years of life expectancy gained.

CONCLUSION

Among patients with CMM, use of fish oil was associated with a significantly reduced risk of all-cause, cardiovascular mortality, and prolonged life expectancy.

Quantifying differences in packaged food and drink purchases among households with diet-related cardiometabolic multi-morbidity: a cross-sectional analysis

BACKGROUND

Diet is important for chronic disease management, with limited research understanding dietary choices among those with multi-morbidity, the state of having 2 or more chronic conditions. The objective of this study was to identify associations between packaged food and drink purchases and diet-related cardiometabolic multi-morbidity (DRCMM).

METHODS

Cross-sectional associations between packaged food and drink purchases and household DRCMM were investigated using a national sample of U.S. households participating in a research marketing study. DRCMM households were defined as household head(s) self-reporting 2 or more diet-related chronic conditions. Separate multivariable logistic regression models were used to model the associations between household DRCMM status and total servings of, and total calories and nutrients from, packaged food and drinks purchased per month, as well as the nutrient density (protein, carbohydrates, and fat per serving) of packaged food and drinks purchased per month, adjusted for household size.

RESULTS

Among eligible households, 3795 (16.8%) had DRCMM. On average, households with DRCMM versus without purchased 14.8 more servings per capita, per month, from packaged foods and drinks (p < 0.001). DRCMM households were 1.01 times more likely to purchase fat and carbohydrates in lieu of protein across all packaged food and drinks (p = 0.002, p = 0.000, respectively). DRCMM households averaged fewer grams per serving of protein, carbohydrates, and fat per month across all food and drink purchases (all p < 0.001). When carbonated soft drinks and juices were excluded, the same associations for grams of protein and carbohydrates per serving per month were seen (both p < 0.001) but the association for grams of fat per serving per month attenuated.

CONCLUSIONS

DRCMM households purchased greater quantities of packaged food and drinks per capita than non-DRCMM households, which contributed to more fat, carbohydrates, and sodium in the home. However, food and drinks in DRCMM homes on average were lower in nutrient-density. Future studies are needed to understand the motivations for packaged food and drink choices among households with DRCMM to inform interventions targeting the home food environment.

Medication non-adherence and therapeutic inertia independently contribute to poor disease control for cardiometabolic diseases

Poorly controlled cardiometabolic biometric health gap measures [e.g.,uncontrolled blood pressure (BP), HbA1c, and low-density lipoprotein cholesterol (LDL-C)] are mediated by medication adherence and clinician-level therapeutic inertia (TI). The study of comparing relative contribution of these two factors to disease control is lacking. We conducted a retrospective cohort study using 7 years of longitudinal electronic health records (EHR) from primary care cardiometabolic patients who were 35 years or older. Cox-regression modeling was applied to estimate how baseline proportion of days covered (PDC) and TI were associated with cardiometabolic related health gap closure. 92,766 patients were included in the analysis, among which 89.9%, 85.8%, and 73.3% closed a BP, HbA1c, or LDL-C gap, respectively, with median days to gap closure ranging from 223 to 408 days. Patients who did not retrieve a medication were the least likely to achieve biometric control, particularly for LDL-C (HR = 0.58, 95% CI: 0.55-0.60). TI or uncertainty of TI was associated with a high risk of health gap persistence, particularly for LDL-C (HR ranges 0.46-0.48). Both poor medication adherence and TI are independently associated with persistent health gaps, and TI has a much higher impact on disease control compared to medication adherence, implying disease management strategies should prioritize reducing TI.

Association of metabolic comorbidity with myocardial infarction in individuals with a family history of cardiovascular disease: a prospective cohort study

Background

The association between metabolic comorbidity and myocardial infarction (MI) among individuals with a family history of cardiovascular disease (CVD) is yet to be elucidated. We aimed to examine the combined effects of metabolic comorbidities, including diabetes mellitus, hypertension, and dyslipidemia, with a family history of CVD in first-degree on the risk of incident MI.

Methods

This cohort study consisted of 81,803 participants aged 40–89 years without a previous history of MI at baseline from the Korean Genome and Epidemiology Study. We performed Cox proportional hazard regression analysis to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for MI and early-onset MI risk associated with metabolic comorbidity in individuals with a family history of CVD.

Results

During a median follow-up of 5 years, 1,075 and 479 cases of total and early-onset MI were reported, respectively. According to the disease score, among individuals who had a positive family history of CVD, the HRs for MI were 1.92 (95% CI: 1.47–2.51) in individuals with one disease, 2.75 (95% CI: 2.09–3.61) in those with two diseases, and 3.74 (95% CI: 2.45–5.71) in those with three diseases at baseline compared to individuals without a family history of CVD and metabolic diseases. Similarly, an increase of the disease score among individuals with a positive family history of CVD was associated with an increase in early-onset MI risk.

Conclusion

Metabolic comorbidity was significantly associated with an increased risk of MI among individuals with a family history of CVD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14330-2.

Were US Asian Indian decedents with atherosclerosis more likely to have concurrent diabetes mellitus? Analysis of national multiple cause of mortality data (2012-2019)

BACKGROUND

Asian Indians (AI) are at high risk for both atherosclerotic diseases (ATH) and diabetes mellitus (DM). We analyze the clustering of these two comorbidities as contributing causes of death in AI versus Non-AI populations in the US.

METHODS

Using Mortality Multiple Cause-of-Death Files (2012-2019) from the National Center for Health Statistics, we included deaths at age ≥ 45 years among US residents where AI versus Non-AI status could be ascertained (n = 55,461 AI; n = 20,090,038 Non-AI) and identsified ATH (ICD10: I20-I25, I63, I70) and DM (ICD10: E10-E14) as contributing causes of death. We calculated the tetrachoric correlation (Rho) between these contributing causes and the difference in the fraction of deaths involving DM in those with versus without ATH.

RESULTS

Among AI decedents, 29.9% of deaths included ATH as a contributing cause, 16.4% included DM as a contributing cause with 8.3% deaths being included in the overlap (Rho = 0.36, SE = 0.007) whereas, among Non-AI, 22.4% of deaths included ATH as a contributing cause, 10.0% included DM as a contributing cause with 4.1% deaths being included in the overlap (Rho = 0.31, SE = 0.001). Thus, DM and ATH as co-occurring causes correlated more strongly in AI versus Non-AI (p < 0.001). Further, this difference in clustering of DM with ATH was highest for younger AI women (age < 60 years) compared to comparable Non-AI women.

CONCLUSIONS

The more frequent co-occurrence of DM and ATH as causes of death among AI compared to Non-AI suggest that the increased burden of these diseases among AI during life has vicious synergistic consequences in terms of mortality. Public health strategies targeted to AI should focus on prevention and clinical treatment of both conditions jointly, in all adults, and especially in women < 60 years.

Change of serum uric acid and progression of cardiometabolic multimorbidity among middle aged and older adults: A prospective cohort study

Background

Hyperuricemia is prevalent and associated with individual cardiometabolic diseases, highlighting the potential role of serum uric acid (SUA) in the development and progression of cardiometabolic multimorbidity (CMM, the coexistence of diabetes, heart disease, or stroke). This study aimed to examine the role of SUA change in the progression of CMM.

Methods

This prospective cohort study used data from the China Health and Retirement Longitudinal Study, included 4,820 participants aged 45 years or above with three complete surveys at 2011 (baseline), 2015, and 2018. SUA level at survey 2011 and 2015 was used to measure SUA change as keeping or rising to hyperuricemia, and keeping or declining to non-hyperuricemia. CMM progression was defined as the first report of CMM or additional report of cardiometabolic diseases during survey 2015 and 2018. We used logistic regression models to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) of SUA change on CMM progression.

Results

During the follow-up of around 7 years, 519 (10.8%) of the participants kept or rose to hyperuricemia from survey 2011 to 2015, and 311 (6.5%) experienced CMM progression from survey 2015 to 2018. Participants who kept or rose to hyperuricemia had 1.86 (95% CI, 1.29, 2.68) increased odds of CMM progression compared with those who kept or declined to non-hyperuricemia. Specifically, keeping or rising to hyperuricemia (vs. keeping or declining to non-hyperuricemia) was associated with 2.01 times higher odds (95% CI, 1.18, 3.43) of incident diabetes and 1.67 times higher odds (OR:1.67; 95% CI, 1.15, 2.43) of incident cardiovascular diseases following diabetes.

Conclusion

Keeping or rising to hyperuricemia was associated with CMM progression, particularly with incident cardiovascular diseases following diabetes. These findings suggest that monitoring SUA change may provide innovative insights into the prevention of CMM, especially in the secondary prevention of CMM (i.e., preventing further progression to cardiovascular diseases among patients with diabetes).

Real-world characteristics, modern antidiabetic treatment patterns, and comorbidities of patients with type 2 diabetes in central and Eastern Europe: retrospective cross-sectional and longitudinal evaluations in the CORDIALLY® study

Background

Guidelines from 2016 onwards recommend early use of SGLT2i or GLP-1 RA for patients with type 2 diabetes (T2D) and cardiovascular disease (CVD), to reduce CV events and mortality. Many eligible patients are not treated accordingly, although data are lacking for Central and Eastern Europe (CEE).

Methods

The CORDIALLY non-interventional study evaluated the real-world characteristics, modern antidiabetic treatment patterns, and the prevalence of CVD and chronic kidney disease (CKD) in adults with T2D at nonhospital-based practices in CEE. Data were retrospectively collated by medical chart review for patients initiating empagliflozin, another SGLT2i, DPP4i, or GLP-1 RA in autumn 2018. All data were analysed cross-sectionally, except for discontinuations assessed 1 year ± 2 months after initiation.

Results

Patients (N = 4055) were enrolled by diabetologists (56.7%), endocrinologists (40.7%), or cardiologists (2.5%). Empagliflozin (48.5%) was the most prescribed medication among SGLT2i, DPP4i, and GLP-1 RA; > 3 times more patients were prescribed empagliflozin than other SGLT2i (10 times more by cardiologists). Overall, 36.6% of patients had diagnosed CVD. Despite guidelines recommending SGLT2i or GLP-1 RA, 26.8% of patients with CVD received DPP4i. Patients initiating DPP4i were older (mean 66.4 years) than with SGLT2i (62.4 years) or GLP-1 RA (58.3 years). CKD prevalence differed by physician assessment (14.5%) or based on eGFR and UACR (27.9%). Many patients with CKD (≥ 41%) received DPP4i, despite guidelines recommending SGLT2is owing to their renal benefits. 1 year ± 2-months after initiation, 10.0% (7.9–12.3%) of patients had discontinued study medication: 23.7–45.0% due to ‘financial burden of co-payment’, 0–1.9% due to adverse events (no patients discontinued DPP4i due to adverse events). Treatment guidelines were ‘highly relevant’ for a greater proportion of cardiologists (79.4%) and endocrinologists (72.9%) than diabetologists (56.9%), and ≤ 20% of physicians consulted other physicians when choosing and discontinuing treatments.

Conclusions

In CORDIALLY, significant proportions of patients with T2D and CVD/CKD who initiated modern antidiabetic medication in CEE in autumn 2018 were not treated with cardioprotective T2D medications. Use of DPP4i instead of SGLT2i or GLP-1 RA may be related to lack of affordable access, the perceived safety of these medications, lack of adherence to the latest treatment guidelines, and lack of collaboration between physicians. Thus, many patients with T2D and comorbidities may develop preventable complications or die prematurely.

Trial registration NCT03807440.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01631-4.

Associations of Cardiometabolic Multimorbidity With All-Cause and Coronary Heart Disease Mortality Among Black Adults in the Jackson Heart Study

IMPORTANCE

A combination of diabetes, coronary heart disease (CHD), and stroke has multiplicative all-cause mortality risk compared with any individual morbidity in White populations, but there is a lack of studies in Black populations in the US.

OBJECTIVE

To examine the association of cardiometabolic multimorbidity (diabetes, stroke, and CHD) individually and collectively with all-cause and CHD mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included Black adults in the Jackson Heart Study followed over a median of 15 years. Baseline examinations were performed between 2000 and 2004, with follow-up on all-cause and CHD mortality through May 31, 2018. Participants were categorized into mutually exclusive groups at baseline: (1) free of cardiometabolic morbidity, (2) diabetes, (3) CHD, (4) stroke, (5) diabetes and stroke, (6) CHD and stroke, (7) diabetes and CHD, and (8) diabetes, stroke, and CHD. Data were analyzed from 2019 to 2021.

EXPOSURE

Cardiometabolic disease alone or in combination.

MAIN OUTCOMES AND MEASURES

The main outcomes were all-cause mortality and CHD mortality. Cox models estimated hazard ratios (HRs) with 95% CIs adjusted for sociodemographic and cardiovascular risk factors.

RESULTS

Among 5064 participants (mean [SD] age, 55.4 [12.8] years; 3200 [63%] women) in the Jackson Heart Study, 897 (18%) had diabetes, 192 (4%) had CHD, and 104 (2%) had a history of stroke. Among participants with cardiometabolic morbidities, the crude all-cause mortality rates were lowest for diabetes alone (24.4 deaths per 1000 person-years) and highest for diabetes, CHD, and stroke combined (84.1 deaths per 1000 person-years). For people with only 1 cardiometabolic morbidity, risk for all-cause mortality was highest for people with stroke (HR, 1.74; 95% CI, 1.24-2.42), followed by CHD (HR, 1.59 (95% CI, 1.22-2.08) and diabetes (HR, 1.50; 95% CI, 1.22-1.85), compared with no cardiometabolic morbidities. There were also increased risks of mortality with combinations of diabetes and stroke (HR, 1.71; 95% CI, 1.09-2.68), CHD and stroke (HR, 2.23; 95% CI, 1.35-3.69), and diabetes and CHD (HR, 2.28; 95% CI, 1.65-3.15). The combination of diabetes, stroke, and CHD was associated with the highest all-cause mortality (HR, 3.68; 95% CI, 1.96-6.93). Findings were similar for CHD mortality, but with a larger magnitude of association (eg, diabetes, stroke, and CHD: HR, 13.52; 95% CI, 3.38-54.12).

CONCLUSIONS AND RELEVANCE

In this cohort study, an increasing number of cardiometabolic multimorbidities was associated with a multiplicative increase in risk of all-cause mortality among Black adults, with a greater magnitude of association for CHD mortality.

Comparative Effectiveness of Empagliflozin vs Liraglutide or Sitagliptin in Older Adults With Diverse Patient Characteristics

IMPORTANCE

Limited evidence is available on the comparative effectiveness of empagliflozin vs alternative second-line glucose-lowering agents in patients with type 2 diabetes (T2D) receiving routine care who have a broad spectrum of cardiorenal risk.

OBJECTIVE

To evaluate the association of empagliflozin with cardiovascular outcomes relative to liraglutide and sitagliptin, stratified by age, sex, baseline atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective comparative effectiveness cohort study used deidentified Medicare claims data from August 1, 2014, to September 30, 2018, with follow-up from drug initiation until treatment changes, death, or gap in Medicare enrollment (>30 days). Data analysis was performed from October 1, 2021, to April 30, 2022. Medicare fee-for-service beneficiaries older than 65 years with T2D were included. A total of 45 788 patients (22 894 propensity score-matched pairs initiating treatment with either empagliflozin or liraglutide) were included in cohort 1, and 45 624 patients (22 812 propensity score-matched pairs initiating treatment with either empagliflozin or sitagliptin) were included in cohort 2.

EXPOSURES

Empagliflozin vs liraglutide (cohort 1) or empagliflozin vs sitagliptin (cohort 2).

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) modified major adverse cardiovascular events (MACEs), including a composite of myocardial infarction, stroke, and all-cause mortality, and (2) hospitalization for heart failure (HHF). Hazard ratios (HRs) and rate differences (RDs) per 1000 person-years were estimated, adjusting for 143 baseline covariates using 1:1 propensity score matching.

RESULTS

Among 45 788 patients in cohort 1, the mean (SD) age was 71.9 (5.1) years; 23 396 patients (51.1%) were female, 22 392 (48.9%) were male, and 38 049 (83.1%) were White. Among 45 624 patients in cohort 2, the mean (SD) age was 72.1 (5.1) years; 21 418 patients (46.9%) were female, 24 206 (53.1%) were male, and 37 814 (82.9%) were White. Relative to patients initiating liraglutide, those initiating empagliflozin had a similar risk of the modified MACE outcome (HR, 0.90; 95% CI, 0.79-1.03) and a reduced risk of HHF (HR, 0.66; 95% CI, 0.52-0.82). Across subgroups, empagliflozin was associated with a lower risk of the modified MACE outcome in patients with a history of ASCVD (HR, 0.83; 95% CI, 0.71-0.98) and HF (HR, 0.77; 95% CI, 0.60-1.00) compared with liraglutide, and potential heterogeneity in estimates was observed by sex (male: HR, 0.85 [95% CI, 0.71-1.01]; female: HR, 1.16 [95% CI, 0.94-1.42]; P = .02 for homogeneity). However, reductions in the risk of HHF were observed across most subgroups (eg, ASCVD: HR, 0.66 [95% CI, 0.51-0.85]; HF: HR, 0.66 [95% CI, 0.49-0.88]). Compared with sitagliptin, empagliflozin was associated with reduced risks of the modified MACE outcome (HR, 0.68; 95% CI, 0.60-0.77) and HHF (HR, 0.45; 95% CI, 0.36-0.56), which were consistent across all subgroups. Absolute benefits of empagliflozin vs sitagliptin were larger in patients with a history of ASCVD (modified MACE: RD, -17.6 [95% CI, -24.9 to -10.4]; HHF: RD, -16.7 [95% CI, -21.7 to -11.9]), HF (modified MACE: RD, -41.1 [95% CI, -59.9 to -22.6]; HHF: RD, -50.4 [95% CI, -67.5 to -33.9]), or CKD (modified MACE: RD, -26.7 [95% CI, -41.3 to -12.3]; HHF: RD, -31.9 [95% CI, -43.5 to -20.8]).

CONCLUSIONS AND RELEVANCE

In this comparative effectiveness study of older adults, empagliflozin was associated with a lower risk of HHF (relative to both liraglutide and sitagliptin) and the modified MACE outcome (relative to sitagliptin), with larger absolute benefits in patients with established cardiorenal diseases. These findings suggest that older adults with T2D might benefit more from empagliflozin vs liraglutide or sitagliptin with respect to the risk of HHF; with respect to the risk of MACEs, empagliflozin might be preferable to liraglutide only in patients with cardiovascular disease history and to sitagliptin across all patient subgroups.

Role of socioeconomic, lifestyle, and clinical factors in the progression of cardiometabolic multimorbidity in China: A 10-year prospective cohort study

BACKGROUND AND AIMS

Cardiometabolic multimorbidity has become increasingly common over the past few decades. Little is known about how risk factors affect temporal progression of cardiometabolic multimorbidity. We aim to explore the role of socioeconomic, lifestyle, and clinical risk factors in the progression of cardiometabolic multimorbidity.

METHODS AND RESULTS

This prospective cohort study included 56,587 participants aged ≥45 years who were free of diabetes, stroke, and heart disease. Three clusters of risk factors were assessed and each on a 5-point scale: socioeconomic, lifestyle, and clinical factors. We used multi-state models (MSMs) to examine the roles of risk factors in five transitions of multimorbidity trajectory: from healthy to first cardiometabolic disease, first cardiometabolic disease to cardiometabolic multimorbidity, health to mortality, first cardiometabolic disease to mortality, and cardiometabolic multimorbidity to mortality. In MSMs, socioeconomic (HR: 1.21; 95% CI: 1.19-1.25) and clinical (HR: 1.53; 95% CI: 1.51-1.56) scales were associated with the transition from health to first cardiometabolic. Socioeconomic (HR: 2.39; 95% CI: 2.24-2.54) and lifestyle (HR: 1.22; 95% CI: 1.18-1.26) scales were associated with the transitions from first disease to cardiometabolic multimorbidity. In addition, socioeconomic and lifestyle scales were associated with increased risk of mortality in people without cardiometabolic disease, with first cardiometabolic disease, and with cardiometabolic multimorbidity.

CONCLUSIONS

Socioeconomic and lifestyle factors were not only important predictors of multimorbidity in those with existing cardiometabolic disease, but also important in shaping risk of mortality. However, clinical factors were the only key determinants of incidence of a first cardiometabolic disease.

Associations of baseline use of fish oil with progression of cardiometabolic multimorbidity and mortality among patients with hypertension: a prospective study of UK Biobank

PURPOSE

The role of fish oil in the prognosis of hypertensive patients is unknown. This study investigated the associations of fish oil supplementation with the progression of cardiometabolic multimorbidity (CMM) and mortality among patients with hypertension.

METHODS

Based on UK Biobank, we enrolled participants with hypertension and free of other cardiometabolic diseases. The exposure was baseline use of fish oil derived from questionnaires at baseline. The primary outcomes were the incidence of CMM and all-cause mortality. Competing risk models and flexible parametric proportion-hazards models were fitted to assess the adjusted hazard ratios (HRs) for the risk of CMM and mortality outcomes, respectively.

RESULTS

Among 81,579 participants involved [50.37%, men; mean age, 59.38 years (standard deviation, 7.23 years)], 15,990 CMM events and 6456 all-cause deaths were reported (median follow-up, 12.23 years). In multivariable-adjusted models, baseline use of fish oil was associated with 8% lower risk of CMM [95% confidence interval (95% CI) 0.89-0.96, P < 0.001] and 10% lower risk of all-cause mortality (95% CI 0.85-0.95, P < 0.001).

CONCLUSION

In individuals with hypertension, baseline use of fish oil was associated with a reduced risk of CMM and all-cause mortality, and further clinical trials are needed to prove this hypothesis.

Long-term exposure to ambient air pollution is a risk factor for trajectory of cardiometabolic multimorbidity: A prospective study in the UK Biobank

BACKGROUND

Although air pollution has been frequently linked to a range of cardiometabolic diseases, its association with the onset, progression, and prognosis of cardiometabolic multimorbidity (CMM) has never been studied.

METHODS

We conducted this prospective analysis based on the UK Biobank cohort. CMM was defined as the coexistence of at least two cardiometabolic diseases, including type 2 diabetes, ischemic heart disease and stroke. Multi-state model was used to analyze the association between air pollution and the trajectory of CMM.

FINDINGS

410,494 middle- and old-age participants were included. During a median follow-up of 12.0 years, 56,877 participants developed first cardiometabolic disease (FCMD), 8616 developed CMM, and 22,423 died. The risks of transitions from baseline to FCMD, from FCMD to CMM, and transitions from baseline and FCMD to all-cause mortality increased by 3% (2%, 5%), 3% (1%, 6%), 5% (2%, 7%) and 2% (-1%, 6%), respectively, per interquartile range increase of fine particulate matter. The corresponding increases were 3% (2%, 5%), 6% (3%, 9%), 4% (2%, 7%) and 6% (2%, 10%), respectively, for nitrogen dioxide. Older participants, males, and individuals with excessive alcohol drinking and lower economic levels were more likely to experience these risks.

INTERPRETATION

Air pollution exposures could play important roles in almost all transition phases of CMM development. Our results highlight clean air as an upstream approach to mitigate both initiation and progression of CMM, especially in vulnerable populations.

FUNDING

Shanghai Municipal Science and Technology Commission (21TQ015); The National Natural Science Foundation of China (92143301 and 92043301).

Cardiac autonomic neuropathy linked to left ventricular dysfunction in type 1 diabetic patients

Type 1 diabetes is a major cause of cardiovascular death; diabetic cardiomyopathy (DCM) is the most important cause of mortality among diabetic patients. There is an increasing body of evidence that the most important inducer of DCM is microvascular injury. The aim of this study is to establish a potential relationship between low frequency/high frequency (LF/HF) ratio and DCM and to set a possible predictive cutoff of LF:HF ratio for early detection of DCM.

Catalogue of multimorbidity mean based severity and associational prevalence rates between 199+ chronic conditions-A nationwide register-based population study

BACKGROUND

Real-world data on multimorbidity represents an important but underutilised source of evidence for the planning of healthcare services, including prevention, treatments, and health economic modelling.

AIMS

This study aimed to estimate means of multimorbidity and provide associated prevalence rates and frequencies between 199 x 199 chronic conditions and disease groups based on the total adult Danish population and sex, age, and educational attainment. Thus, this study provides an off-the-shelf catalogue for use in treatments and planning by clinicians, decision-makers and researchers.

METHODS

The study population contained all Danish residents above 16 years on 1 January 2013 (n = 4,555,439). The data was based on the linkage of six national registers covering hospital contacts, services in general practice, filled-in out-of-hospital prescriptions, and educational attainments. The health registers were used to identify the 199 chronic conditions based on the ICD-10 classification system.

RESULTS

The mean number of chronic conditions (NCC) was 2.2. The mean increased with age, women had a higher mean than men, and there was a social gradient with the mean increasing with lower educational attainment. The mean NCC varied from 3.3-9.8 among all conditions. Across disease groups, the highest mean NCC were found within disease group N (chronic renal failure, mean = 8.8), D (in situ and benign neoplasms; mean = 6.5), K (diseases of the digestive system; mean = 5.7), and H (diseases of the eye and the ear; mean = 5.6). The highest mean NCC among the 29 common diseases was heart failure, ischemic heart diseases, angina pectoris, stroke, and dementia, with a mean above 6.5. Several prevalent conditions like hypertension, arthritis, chronic lower respiratory diseases, depression, type 2 diabetes, and overweight transcended other conditions regarding the associated prevalence rates. As one of the most frequent, hypertensive diseases were highly associated with arthritis (50.4%), depression (37.4%), type 2 diabetes (75.4%), cancers (49.7%), and being overweight (39.7%)-meaning that 50.4% of people with arthritis, 37.4% of people with depression and so on also had hypertensive diseases. The largest differences in means between individuals with no educational attainment and individuals with high educational attainment were found within disease groups J (diseases of the respiratory system, ratio = 1.8), Q (congenital malformations, deformations, and chromosomal abnormalities, ratio = 1.7), and B (viral hepatitis and human immunodeficiency virus disease, ratio = 1.7).

CONCLUSIONS

The current study provides a nationwide off-the-shelf catalogue of multimorbidity means and real-world associations estimates of 199+ chronic conditions for future clinical treatments and health care systems planning. The findings described are just one example of numerous results and underline that multimorbidity is highly prevalent in the adult Danish population and that it is a vital condition transcending all future medical treatment. The data offer essential information on the multimorbidity burden of disease in future differentiated treatments, healthcare planning, and economic, aetiological, and other research.

Effects of potential risk factors on the development of cardiometabolic multimorbidity and mortality among the elders in China

Objectives

To examine the impact of demographic, socioeconomic, and behavioral factors on the development of cardiometabolic multimorbidity and mortality in Chinese elders.

Methods

Data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2002–2018 was used in the study. Cardiometabolic multimorbidity was defined as the presence of two or more cardiometabolic disorders, such as hypertension, diabetes, cardiovascular disease (CVD), heart disease, or stroke. Cox regression model and multi-state Markov model were developed to evaluate the association of the study factors with the progression of cardiometabolic conditions and mortality. The outcomes included three states (first cardiometabolic disease, cardiometabolic multimorbidity, and all-cause mortality) and five possible transitions among the three states.

Results

Of the 13,933 eligible individuals, 7,917 (56.8%) were female, and 9,540 (68.50%) were over 80 years old. 2,766 (19.9%) participants had their first cardiometabolic disease, 975 (7.0%) participants suffered from cardiometabolic multimorbidity, and 9,365 (67.2%) participants died. The progression to cardiometabolic multimorbidity was positively associated with being female (HR = 1.42; 95%CI, 1.10 − 1.85), living in the city (HR = 1.41; 95%CI, 1.04 − 1.93), overweight (HR = 1.43; 95%CI, 1.08 − 1.90), and obesity (HR = 1.75; 95% CI, 1.03 − 2.98). A higher risk for the first cardiometabolic disease was associated with being female (HR = 1.26; 95% CI, 1.15 − 1.39), higher socioeconomic status (SES, HR = 1.17; 95%CI, 1.07 − 1.28), lack of regular physical activity (HR = 1.13; 95%CI, 1.04 − 1.23), smoking (HR = 1.20; 95%CI, 1.08 − 1.33), ≤ 5 h sleep time (HR = 1.15; 95%CI, 1.02 − 1.30), overweight (HR = 1.48; 95% CI, 1.32 − 1.66), and obesity (HR = 1.34; 95%CI, 1.06 − 1.69). It also should be noted that not in marriage, lower SES and unhealthy behavioral patterns were risk factors for mortality.

Conclusion

This study emphasized the importance of lifestyle and SES in tackling the development of cardiometabolic conditions among Chinese elders and provided a reference for policy-makers to develop a tailored stage-specific intervention strategy.

Shift Work and the Risk of Cardiometabolic Multimorbidity Among Patients With Hypertension: A Prospective Cohort Study of UK Biobank

Background Although the association between shift work and individual cardiometabolic diseases has been well studied, its role in the progression to cardiometabolic multimorbidity (CMM) remains unclear. In this study, we investigate the association between shift work and the incidence of CMM in patients with hypertension. Methods and Results This study is a population-based and prospective cohort study on 36 939 UK Biobank participants. We used competing risk models to examine the association between shift work and the risk of CMM, which was defined as coexistence of hypertension and diabetes, coronary heart disease, or stroke in our study. We also investigated the association between the frequency and duration of shift work and CMM risks. In addition, we conducted a cross-classification analysis with the combination of frequency and duration of shift work, chronotype and sleep duration as the exposure metrics. During a median follow-up of 11.6 years, a total of 5935 participants developed CMM. We found that usually/always night shift workers were associated with a 16% higher risk of CMM compared with day workers (hazard ratio [HR], 1.16 [95% CI, 1.02-1.31]). We also found that a higher frequency of night shifts (>10/month) was associated with increased risk of CMM (HR, 1.19 [95% CI, 1.06-1.34]) that was more pronounced for >10/month in combination with a morning chronotype or <7 hours or >8 hours of sleep duration (HR, 1.26 [95% CI, 1.02-1.56]; HR, 1.43 [95% CI, 1.19-1.72], respectively). Conclusions We find that night shift work is associated with higher CMM risk in patients with hypertension.

Community prevalence and dyad disease pattern of multimorbidity in China and India: a systematic review

BACKGROUND

Driven by the increasing life expectancy, China and India, the two most populous countries in the world are experiencing a rising burden of multimorbidity. This study aims to explore community prevalence and dyad patterns of multimorbidity in China and India.

METHODS

We conducted a systematic review of five English and Chinese electronic databases. Studies involving adults 18 years or older at a community level, which reported multimorbidity prevalence and/or patterns were included. A modified Newcastle-Ottawa Scale was used for quality assessment. Despite large heterogeneity among reported studies, a systematic synthesis of the results was conducted to report the findings.

RESULTS

From 13 996 studies retrieved, 59 studies met the inclusion criteria (46 in China, 9 in India and 4 in both). The median prevalence of multimorbidity was 30.7% (IQR 17.1, 49.4), ranging from 1.5% to 90.5%. There was a large difference in multimorbidity prevalence between China and India, with median prevalence being 36.1% (IQR 19.6, 48.8) and 28.3% (IQR 8.9, 56.8), respectively. Among 27 studies that reported age-specific prevalence, 19 studies found multimorbidity prevalence increased with age, while 8 studies observed a paradoxical reduction in the oldest age group. Of the 34 studies that reported sex-specific prevalence, 86% (n=32) observed a higher prevalence in females. The most common multimorbidity patterns from 14 studies included hypertensive diseases combined with diabetes mellitus, arthropathies, heart diseases and metabolic disorders. All included studies were rated as fair or poor quality.

CONCLUSION

Multimorbidity is highly prevalent in China and India with hypertensive diseases and other comorbidities being the most observed patterns. The overall quality of the studies was low and there was a lack of representative samples in most studies. Large epidemiology studies, using a common definition of multimorbidity and national representative samples, with sex disaggregation are needed in both countries.

PROSPERO REGISTRATION NUMBER

CRD42020176774.

Investigating the protective effects of estrogen on β-cell health and the progression of hyperglycemia-induced atherosclerosis

Sex differences in the prevalence and development of diabetes and associated cardiometabolic complications are well established. The objective of this study was to analyze the effects of estrogen on the maintenance of β-cell health/function and atherosclerosis progression, using a mouse model of hyperglycemia-induced atherosclerosis, the ApoE^-/-:Ins2^+/Akita mouse. ApoE^-/-:Ins2^+/Akita mice exhibit sexual dimorphism in the control of blood glucose levels. Male ApoE^-/-:Ins2^+/Akita mice are chronically hyperglycemic due to a significant reduction in pancreatic β-cell mass. Female mice are only transiently hyperglycemic, maintain β-cell mass, and blood glucose levels normalize at 35 ± 1 days of age. To determine the effects of estrogen on pancreatic β-cell health and function, ovariectomies and estrogen supplementation experiments were performed, and pancreatic health and atherosclerosis were assessed at various time points. Ovariectomized ApoE^-/-:Ins2^+/Akita mice developed chronic hyperglycemia with significantly reduced β-cell mass. To determine whether the observed effects on ovariectomized ApoE^-/-:Ins2^+/Akita mice were due to a lack of estrogens, slow-releasing estradiol pellets were inserted subcutaneously. Ovariectomized ApoE^-/-:Ins2^+/Akita mice treated with exogenous estradiol showed normalized blood glucose levels and maintained β-cell mass. Exogenous estradiol significantly reduced atherosclerosis in both ovariectomized female and male ApoE^-/-:Ins2^+/Akita mice relative to controls. Together, these findings suggest that estradiol confers significant protection to pancreatic β-cell health and can directly and indirectly slow the progression of atherosclerosis.NEW & NOTEWORTHY This study examines the effect(s) of estrogen on β cell and cardiometabolic health/function in a novel mouse model of hyperglycemia-induced atherosclerosis (ApoE^-/-:Ins2^+/Akita). Using a combination of estrogen deprivation (ovariectomy) and supplementation strategies, we quantify effects on glucose homeostasis and atherogenesis. Our results clearly show a protective role for estrogen on pancreatic β-cell health and function and glucose homeostasis. Furthermore, estrogen supplementation dramatically reduces atherosclerosis progression in both male and female mice.

Associations between consumption of three types of beverages and risk of cardiometabolic multimorbidity in UK Biobank participants: a prospective cohort study

BACKGROUND

Although the association between beverages and a single cardiometabolic disease has been well studied, their role in disease progression from the single cardiometabolic disease state to cardiometabolic multimorbidity (CMM) state remains unclear. This study examined the associations between three types of beverages: sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs), and pure fruit/vegetable juices, and the incidence of CMM in patients with a single cardiometabolic disease.

METHODS

Our analysis included 37,994 participants from the UK Biobank who completed at least one dietary questionnaire and were diagnosed with only one cardiometabolic disease at the time of recruitment. Competing risk models were used to examine the association between the three types of beverages and incidence of CMM. We conducted analysis both in patients with any single cardiometabolic disease and in patients with specific cardiometabolic disease.

RESULTS

During a median follow-up of 9.1 years (interquartile range [IQR] 9.0-9.8), a total of 6399 participants developed CMM. The consumption of SSBs and ASBs (>1 serving per day) was associated with a higher risk of CMM (SSBs: hazard ratio [HR] 1.19, 95% confidence interval [95% CI] 1.08-1.31; ASBs: HR 1.15, 95% CI 1.04-1.27). Intake of pure fruit/vegetable juices was inversely associated with the incidence of CMM (0-1 serving per day: HR 0.90, 95% CI 0.85-0.94; >1 serving per day: HR 0.90, 95% CI 0.81-0.99). However, the association of the high-level consumption of pure fruit/vegetable juices (>1 serving per day) was not statistically significant after correcting for multiple testing. In the analysis of patients with specific cardiometabolic diseases, positive associations were observed in patients with hypertension for SSBs consumption, while inverse associations persisted in patients with cardiovascular disease (coronary heart disease or stroke) and in hypertensive patients for pure fruit/vegetable juice consumption.

CONCLUSIONS

Consuming >1 serving of SSBs and ASBs per day was associated with a higher risk of CMM in patients with a single cardiometabolic disease. In contrast, intake of pure fruit/vegetable juices was inversely associated with the risk of CMM. Our findings highlight the need to limit the use of SSBs and ASBs in patients with a single cardiometabolic disease.

Bidirectional Control between Cholesterol Shuttle and Purine Signal at the Central Nervous System

Recent studies have highlighted the mechanisms controlling the formation of cerebral cholesterol, which is synthesized in situ primarily by astrocytes, where it is loaded onto apolipoproteins and delivered to neurons and oligodendrocytes through interactions with specific lipoprotein receptors. The “cholesterol shuttle” is influenced by numerous proteins or carbohydrates, which mainly modulate the lipoprotein receptor activity, function and signaling. These molecules, provided with enzymatic/proteolytic activity leading to the formation of peptide fragments of different sizes and specific sequences, could be also responsible for machinery malfunctions, which are associated with neurological, neurodegenerative and neurodevelopmental disorders. In this context, we have pointed out that purines, ancestral molecules acting as signal molecules and neuromodulators at the central nervous system, can influence the homeostatic machinery of the cerebral cholesterol turnover and vice versa. Evidence gathered so far indicates that purine receptors, mainly the subtypes P2Y2, P2X7 and A2A, are involved in the pathogenesis of neurodegenerative diseases, such as Alzheimer’s and Niemann–Pick C diseases, by controlling the brain cholesterol homeostasis; in addition, alterations in cholesterol turnover can hinder the purine receptor function. Although the precise mechanisms of these interactions are currently poorly understood, the results here collected on cholesterol–purine reciprocal control could hopefully promote further research.

Control of Blood Pressure and Risk of Cardiovascular Disease and Mortality in Elderly Chinese: A Real-World Prospective Cohort Study

BACKGROUND

The STEP trial (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) showed that older hypertensive patients might benefit from a target systolic blood pressure (SBP) of 110 to <130 mm Hg. We examined whether this target SBP is associated with a decreased risk of cardiovascular disease (CVD) and all-cause mortality among elderly Chinese in real-world settings.

METHODS

This prospective study included 13 383 CVD-free participants aged 60 to 80 years and with SBP within 110 to <150 mm Hg at baseline. Inverse probability of treatment weighting was used to adjust for baseline differences. Weighted Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% CIs of CVD and all-cause mortality associated with normalized SBP (110 to <130 mm Hg).

RESULTS

During a median follow-up of 13.01 years, we identified 1727 cases of CVD and 3742 deaths. After inverse probability of treatment weighting, compared with non-normalized SBP, normalized SBP was associated with a decreased risk of CVD (HR, 0.81 [95% CI, 0.76-0.87]) and all-cause mortality (HR, 0.89 [95% CI, 0.85-0.93]). Beneficial effects of longitudinal normalized SBP presented by the updated mean SBP were also observed for CVD (HR, 0.88 [95% CI, 0.78-0.93]) and all-cause mortality (HR, 0.93 [95% CI, 0.88-0.97]). Multiple sensitivity analyses yielded similar results.

CONCLUSIONS

The SBP target of 110 to <130 mm Hg recommended by the STEP trial was associated a lower risk of CVD and all-cause mortality than was SBP of 130 to <150 mm Hg among elderly Chinese in real-world settings.

Redox Status of Postmenopausal Women with Single or Multiple Cardiometabolic Diseases Has a Similar Response to Mat Pilates Training

Postmenopausal women have a high prevalence of cardiometabolic diseases and that may associate with higher oxidative stress. Exercise can contribute to the treatment of such diseases, but some modalities, such as Mat Pilates, need to be further studied in terms of their physiological responses. Our aim was to investigate the effects of 12 weeks of Mat Pilates on redox status in postmenopausal women with one or multiple comorbidities of cardiometabolic diseases. Forty-four postmenopausal women were divided into two groups: SINGLE, composed of women with one cardiometabolic disease (n = 20) and MULT, with multimorbidity (n = 24). Mat Pilates training was conducted three times a week for 12 weeks, and each session lasted 50 min. Plasma samples were collected before and after training to analyze the following redox markers: superoxide dismutase, catalase, glutathione peroxidase, total antioxidant capacity due to ferric-reducing antioxidant power (FRAP), reduced glutathione (GSH), uric acid, and carbonyl protein. ANCOVA showed interaction effects in FRAP (p = 0.014). Both groups had reduced levels of catalase (p = 0.240) and GSH (p = 0.309), and increased levels of carbonyl protein (p = 0.053) after intervention. In conclusion, the redox status of postmenopausal women shows no changes mediated by Mat Pilates training between SINGLE and MULT, except for greater reductions of FRAP in SINGLE.

Association of Dietary Factors With Grip Strength, Body Fat, and Prevalence of Sarcopenic Obesity in Rural Korean Elderly With Cardiometabolic Multimorbidity

Background and Aims

Aging accompanied by cardiometabolic multimorbidity (CM) promotes chronic low-grade inflammation, increased oxidative stress, and insulin resistance (IR), which result in loss of muscle mass and functional impairment. Better quality diets have been directly associated with muscle health and decreased risk of all-cause mortality. However, no study has investigated the relationship of dietary factors with grip strength, body composition, and prevalence of sarcopenic obesity (SO) in Korean rural residents according to their CM pattern. Therefore, we aimed to examine this association among this population.

Materials and Methods

This cross-sectional study utilized data from 932 rural residents aged ≥ 65 years. An exploratory tetrachoric factor analysis revealed four multimorbidity patterns: CM, inflammatory disease, respiratory disease, and cancer and other diseases. All participants were categorized into the CM and non-CM groups. Skeletal muscle mass and the prevalence of sarcopenia were estimated using bioelectrical impedance analysis (BIA). Dietary assessment was analyzed using a validated 106-item food frequency questionnaire. Adjusted multiple linear regression and multivariate logistic regression were employed to examine the association of dietary factors with muscle strength, quality, and SO prevalence ratio in elderly participants.

Results

The mean age of the participants was 71.8 ± 0.1 years (65.8% women). Dietary fat and protein intake were positively correlated with handgrip strength in women with CM, after adjusting for covariates (p = 0.001). Similarly, protein intake (g/kg) was positively associated with appendicular skeletal muscle mass (ASM; kg/m²) and ASM (%) in both sexes in the CM and non-CM groups. Regarding the tertiles of wheat intake (g/d), 2.1-fold increase in SO prevalence ratios [prevalence ratio (PR): 2.149, confidence intervals (CIs): 1.134–4.071] was observed in the highest tertile (T3: 269.1 g/d), compared to the lowest tertile (Q1: 8.6 g/d) in the CM group. Higher tertile of meat intake (T2: 34.8 g/d, T3: 99.5 g/d) had a 2-fold increase in SO (PR: 1.932, CIs: 1.066–3.500) compared to the lowest tertile (T1: 9.2 g/d) in the CM group.

Conclusion

Overconsumption of wheat and meat negatively impacted the development of SO, while protein intake was positively associated with grip strength and skeletal muscle mass in elderly Koreans with CM.

Comparison between Machine Learning and Multiple Linear Regression to Identify Abnormal Thallium Myocardial Perfusion Scan in Chinese Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) patients have a high risk of coronary artery disease (CAD). Thallium-201 myocardial perfusion scan (Th-201 scan) is a non-invasive and extensively used tool in recognizing CAD in clinical settings. In this study, we attempted to compare the predictive accuracy of evaluating abnormal Th-201 scans using traditional multiple linear regression (MLR) with four machine learning (ML) methods. From the study, we can determine whether ML surpasses traditional MLR and rank the clinical variables and compare them with previous reports.In total, 796 T2DM, including 368 men and 528 women, were enrolled. In addition to traditional MLR, classification and regression tree (CART), random forest (RF), stochastic gradient boosting (SGB) and eXtreme gradient boosting (XGBoost) were also used to analyze abnormal Th-201 scans. Stress sum score was used as the endpoint (dependent variable). Our findings show that all four root mean square errors of ML are smaller than with MLR, which implies that ML is more precise than MLR in determining abnormal Th-201 scans by using clinical parameters. The first seven factors, from the most important to the least are:body mass index, hemoglobin, age, glycated hemoglobin, Creatinine, systolic and diastolic blood pressure. In conclusion, ML is not inferior to traditional MLR in predicting abnormal Th-201 scans, and the most important factors are body mass index, hemoglobin, age, glycated hemoglobin, creatinine, systolic and diastolic blood pressure. ML methods are superior in these kinds of studies.

Advancing multimorbidity management in primary care: a narrative review

BACKGROUND

Multimorbidity, defined as the coexistence of two or more chronic conditions in the same individual, is becoming a crucial health issue in primary care. Patients with multimorbidity utilize health care at a higher rate and have higher mortality rates and poorer quality of life compared to patients with single diseases.

AIMS

To explore evidence on how to advance multimorbidity management, with a focus on primary care. Primary care is where a large number of patients with multimorbidity are managed and is considered to be a gatekeeper in many health systems.

METHODS

A narrative review was conducted using four major electronic databases consisting of PubMed, Cochrane, World Health Organization database, and Google scholar. In the first round of reviews, priority was given to review papers summarizing the current issues and challenges in the management of multimorbidity. Thematic analysis using an inductive approach was used to build a framework on how to advance management. The second round of review focused on original articles providing evidence within the primary care context.

RESULTS

The review found that advancing multimorbidity management in primary care requires a health system approach and a patient-centered approach. The health systems approach includes three major areas: (i) improves access to care, (ii) promotes generalism, and (iii) provides a decision support system. For the patient-centered approach, four key aspects are essential for multimorbidity management: (i) promoting doctor-patient relationship, (ii) prioritizing health problems and sharing decision-making, (iii) supporting self-management, and (iv) integrating care.Advancement of multimorbidity management in primary care requires integrating concepts of multimorbidity management guidelines with concepts of patient-centered and chronic care models. This simple integration provides an overarching framework for advancing the health care system, connecting the processes of individualized care plans, and integrating care with other providers, family members, and the community.

Establishment of a diagnostic model of coronary heart disease in elderly patients with diabetes mellitus based on machine learning algorithms

OBJECTIVE

To establish a prediction model of coronary heart disease (CHD) in elderly patients with diabetes mellitus (DM) based on machine learning (ML) algorithms.

METHODS

Based on the Medical Big Data Research Centre of Chinese PLA General Hospital in Beijing, China, we identified a cohort of elderly inpatients (≥ 60 years), including 10,533 patients with DM complicated with CHD and 12,634 patients with DM without CHD, from January 2008 to December 2017. We collected demographic characteristics and clinical data. After selecting the important features, we established five ML models, including extreme gradient boosting (XGBoost), random forest (RF), decision tree (DT), adaptive boosting (Adaboost) and logistic regression (LR). We compared the receiver operating characteristic curves, area under the curve (AUC) and other relevant parameters of different models and determined the optimal classification model. The model was then applied to 7447 elderly patients with DM admitted from January 2018 to December 2019 to further validate the performance of the model.

RESULTS

Fifteen features were selected and included in the ML model. The classification precision in the test set of the XGBoost, RF, DT, Adaboost and LR models was 0.778, 0.789, 0.753, 0.750 and 0.689, respectively; and the AUCs of the subjects were 0.851, 0.845, 0.823, 0.833 and 0.731, respectively. Applying the XGBoost model with optimal performance to a newly recruited dataset for validation, the diagnostic sensitivity, specificity, precision, and AUC were 0.792, 0.808, 0.748 and 0.880, respectively.

CONCLUSIONS

The XGBoost model established in the present study had certain predictive value for elderly patients with DM complicated with CHD.

Adherence to a Healthy Sleep Pattern and Incidence of Cardiometabolic Multimorbidity Among Hypertensive Patients: A Prospective Study of UK Biobank

Study Objectives

To investigate whether a healthy sleep pattern would reduce the risk of cardiometabolic multimorbidity (CMM) among hypertensives.

Methods

This is a prospective cohort analysis from the UK Biobank. A total of 69 524 hypertensives without a history of diabetes mellitus, coronary heart disease, or stroke at baseline were enrolled. Five dimensions of healthy sleep at baseline including early chronotype, sleep 7–8 h/d, free of insomnia, no snoring, and no frequent excessive daytime sleepiness were used to generate a healthy sleep score ranging from 0 to 5 (one point was given for each dimension of healthy sleep). A higher score indicated a healthier sleep pattern. We set five groups corresponding to the healthy sleep score of 5, 4, 3, 2, and 0–1, respectively. The primary outcome was the incidence of overall CMM among enrolled hypertensives. We assessed the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) by Fine-Gray subdistribution hazard models.

Results

We found the full-adjusted HR (95% CI) for overall CMM was 0.93 (0.91–0.95) for a 1-point increase in the healthy sleep score. Compared to hypertensives with a healthy sleep score of 0–1, those with a score of 5 had a 27% lower risk of overall CMM, and 37%, 23%, and 20% lower risks of diabetes mellitus, coronary heart disease, and stroke, respectively, after adjusting for sociodemographic characteristic, lifestyle, and clinical factors.

Conclusions

Our results indicated that a healthy sleep pattern was associated with lower risks of CMM outcomes among hypertensives.

Association between sleep and multimorbidity in Chinese elderly: Results from the Chinese Longitudinal Healthy Longevity Survey (CLHLS)

OBJECTIVE

Abnormal sleep duration and poor sleep quality were associated with multiple diseases. However, the association between sleep behavior (including sleep duration and quality) and multimorbidity among the elderly remains unclear. Thus, our study aimed to explore this association in the Chinese elderly.

METHODS

We conducted a cross-sectional study using data from the Chinese Longitudinal Healthy Longevity Survey (2014 wave). Nineteen chronic diseases were used to measure multimorbidity. Self-reported nighttime sleep duration and sleep quality were used as exposures. Multivariate logistic regression analysis and stratification were used to explore the association between sleep behavior and multimorbidity in different groups. Restrictive cubic splines were used to examine the exposure-response relationship.

RESULTS

Compared with those with nighttime sleep duration between 7 and 9 h, participants with shorter (<7 h) and longer (>9 h) sleep duration had a higher prevalence of multimorbidity (odds ratio [OR], 95% confidence interval [CI] were 1.38, 1.18-1.61 and 1.30, 1.09-1.56 respectively). Besides, poor sleep quality (OR = 2.25, 95% CI:1.82-2.72) and moderate sleep quality (OR = 1.35, 95% CI:1.16-1.58) were positively associated with multimorbidity.

CONCLUSIONS

Although the role of sleep behavior in multimorbidity has not been fully understood, this study highlighted the importance of normal nighttime sleep duration and good sleep quality in preventing multimorbidity.

Associations of handgrip strength with morbidity and all-cause mortality of cardiometabolic multimorbidity

BACKGROUND

Cardiometabolic multimorbidity (CM) is an increasing public health and clinical concern. However, predictors for the development and prognosis of CM are poorly understood. The aims of this study were to investigate the relation between handgrip strength (HGS) and the risk of CM and to examine the association of HGS with all-cause mortality risk among patients with CM.

METHODS

This prospective cohort study involved 493,774 participants from the UK Biobank. CM was defined as the simultaneous occurrence of two or more of the following conditions: type 2 diabetes, stroke, and coronary heart disease (CHD). Cox proportional hazards models were performed to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

During a median follow-up of 12.1 years, 4701 incident CM cases were documented among participants with none cardiometabolic disease at baseline. Compared with the fourth quartile (Q4), the multivariable adjusted HR (95% CI) value of Q1 of HGS for developing CM was 1.46 (1.34-1.60). In participants with one cardiometabolic disease at baseline, participants in Q1 of HGS also possessed higher risk of CM than those in Q4, with HRs (95% CIs) being 1.35 (1.23-1.49) in patients with type 2 diabetes, 1.23 (1.04-1.46) in patients with stroke, and 1.23 (1.11-1.36) in patients with CHD. For participants with CM at recruitment, HGS was also associated with the risk of all-cause mortality (Q1 vs. Q4 HR: 1.57, 95% CI: 1.36-1.80).

CONCLUSIONS

Our study provided novel evidence that HGS could be an independent predictor of morbidity and all-cause mortality of CM.

Cardiometabolic multimorbidity, genetic risk, and dementia: a prospective cohort study

Background

Individual cardiometabolic disorders and genetic factors are associated with an increased dementia risk; however, the relationship between dementia and cardiometabolic multimorbidity is unclear. We investigated whether cardiometabolic multimorbidity increases the risk of dementia, regardless of genetic risk, and examined for associated brain structural changes.

Methods

We examined health and genetic data from 203 038 UK Biobank participants of European ancestry, aged 60 years or older without dementia at baseline assessment (2006-10) and followed up until March 31, 2021, in England and Scotland and Feb 28, 2018, in Wales, as well as brain structural data in a nested imaging subsample of 12 236 participants. A cardiometabolic multimorbidity index comprising stroke, diabetes, and myocardial infarction (one point for each), and a polygenic risk score for dementia (with low, intermediate, and high risk groups) were calculated for each participant. The main outcome measures were incident all-cause dementia and brain structural metrics.

Findings

The dementia risk associated with high cardiometabolic multimorbidity was three times greater than that associated with high genetic risk (hazard ratio [HR] 5·55, 95% CI 3·39-9·08, p<0·0001, and 1·68, 1·53-1·84, p<0·0001, respectively). Participants with both a high genetic risk and a cardiometabolic multimorbidity index of two or greater had an increased risk of developing dementia (HR 5·74, 95% CI 4·26-7·74, p<0·0001), compared with those with a low genetic risk and no cardiometabolic conditions. Crucially, we found no interaction between cardiometabolic multimorbidity and polygenic risk (p=0·18). Cardiometabolic multimorbidity was independently associated with more extensive, widespread brain structural changes including lower hippocampal volume (F2, 12 110 = 10·70; p<0·0001) and total grey matter volume (F2, 12 236 = 55·65; p<0·0001).

Interpretation

Cardiometabolic multimorbidity was independently associated with the risk of dementia and extensive brain imaging differences to a greater extent than was genetic risk. Targeting cardiometabolic multimorbidity might help to reduce the risk of dementia, regardless of genetic risk.

Funding

Wellcome Trust, Alzheimer's Research UK, Alan Turing Institute/Engineering and Physical Sciences Research Council, the National Institute for Health Research Applied Research Collaboration South West Peninsula, National Health and Medical Research Council, JP Moulton Foundation, and National Institute on Aging/National Institutes of Health.

Cardiometabolic multimorbidity and activity limitation: a cross-sectional study of adults using the Canadian Longitudinal Study on Aging data

BACKGROUND

Cardiometabolic multimorbidity (CM) is the diagnosis of 2 or more cardiometabolic conditions. Multimorbidity and individual cardiometabolic conditions have been associated with activity limitation, a common form of disability, but few studies have investigated the association between CM and activity limitation.

OBJECTIVES

To estimate the prevalence of activity limitation among Canadians with CM and to quantify the association between CM and activity limitation.

METHODS

Using data from the Canadian Longitudinal Study on Aging, we conducted a cross-sectional analysis of activity limitation among Canadians aged 45-85 (n = 50,777; weighted n = 13,118,474). CM was defined as the diagnosis of 2 or more of diabetes/prediabetes, myocardial infarction, and stroke, and activity limitation was evaluated using the Older Americans Resources and Services scale. Descriptive statistics and logistic and multinomial logistic regression analyses were conducted to determine the association between CM and activity limitation.

RESULTS

The estimated prevalence of activity limitation among participants living with CM was 27.4% compared with 7.5% with no cardiometabolic conditions. Activity limitation increased in prevalence and severity with the number of cardiometabolic conditions. People with CM had increased odds of activity limitation compared with those without any cardiometabolic conditions (adjusted relative risk ratio = 3.99, 95% confidence interval [3.35-4.75]), and the odds increased with each additional condition. Stroke survivors had greater odds of activity limitation than those without a history of stroke and the same number of cardiometabolic conditions.

CONCLUSION

Activity limitation is common among Canadians living with CM. Odds of activity limitation increase with each additional cardiometabolic condition, especially for stroke survivors.