Trends in Prevalence of Diabetes and Control of Risk Factors in Diabetes Among US Adults, 1999-2018

Association of serum uric acid-to-high-density lipoprotein cholesterol ratio with non-alcoholic fatty liver disease in American adults: a population-based analysis

Objective

Non-invasive disease indicators are currently limited and need further research due to the increased non-alcoholic fatty liver disease (NAFLD) prevalence worldwide. The serum uric acid-to-high-density lipoprotein cholesterol ratio (UHR) has been recognized as a novel inflammatory and metabolic marker. Herein, we explored the correlation between UHR and the risk of NAFLD in-depth.

Methods

A total of 3,766 participants were included in our survey, and the National Health and Nutrition Examination Survey (NHANES) 2017-2018 cycle provided the cross-sectional study population. Weighted multivariable logistic regression and multivariate linear regression analyses were performed to assess the association between the UHR and the odds of NAFLD and liver steatosis and fibrosis severity, respectively. Moreover, we explored the non-linear relationship between the UHR and NAFLD by the generalized additive model.

Results

NAFLD probabilities were statistically demonstrated to be positively correlated with the UHR (OR = 1.331 per SD increase, 95% CI: 1.100, 1.611). The positive connection of the UHR with NAFLD risk persisted significantly in female subjects but not in male subjects in subgroup analyses stratified by gender. The non-linear relationship analysis demonstrated that a UHR between ~20 and 30% suggested a saturation effect of NAFLD risk. Furthermore, a dramatically positive correlation was found between the UHR and hepatic steatosis severity but not fibrosis. Finally, the receiver operating characteristic analysis suggested that UHR had a better predictive value for NAFLD than either serum uric acid (sUA) or high-density lipoprotein cholesterol (HDL) alone [UHR (area under curve): 0.6910; 95% CI: 0.6737-0.7083; P < 0.0001].

Conclusion

Our investigation revealed that the elevated UHR level was independently related to an increased NAFLD risk and the severity of liver steatosis in American individuals. The correlation differed according to sex. This non-invasive indicator may enhance the capacity to predict the onset of NAFLD and may uncover alternative therapeutic interventional targets.

"Incorporating a Gym Facility in a Lifestyle Medicine Practice for Patients with Diabetes Mellitus"

Incorporating a gym or fitness facility into a lifestyle-focused clinic is potentially one of the most critical facets of the patient-focused care, especially for those with obesity, cardiometabolic disease, and all types of diabetes mellitus. The evidence for prioritizing physical activity and exercise as medicine is well-researched and universally recommended as first-line therapy plus prevention of many chronic disease states. Having a fitness center on-site as part of any clinic could improve patient utilization, reduce barrier to entry, and decrease hesitation to engage in exercise like resistance training. While the conceptualization may seem simple, the pragmatic application and implementation takes proper planning. Developing such a gym will depend upon gym size preference, program development, cost, and available personnel. Thought needs to be put into deciding which type of exercise and ancillary equipment, ranging from aerobic or resistance machines to free weights, will be included and in what format. Fee and payment options should be carefully considered to assure the budget works financially for both the clinic and patient population. Finally, graphic examples of clinical gyms are described to convey the potential reality of such an optimal setting.

Glucose intolerance in pregnancy and risk of early-onset type 2 diabetes: a population-based cohort study

BACKGROUND

The risk of type 2 diabetes among women with glucose intolerance during pregnancy that does not meet gestational diabetes criteria requires further investigation. We aimed to explore the associations between various degrees of gestational glucose intolerance and the risk of type 2 diabetes in young adulthood.

METHODS

For this population-based cohort study, the national Israeli conscription database was linked to Maccabi Healthcare Services (MHS), the second-largest state-mandated health provider in Israel. We included 177 241 women who underwent a pre-recruitment evaluation at adolescence (age 16-20 years), 1 year before mandatory military service, and later underwent, from Jan 1, 2001, to Dec 31, 2019, two-step gestational diabetes screening with a 50 g glucose challenge test (GCT) based on a threshold of 140 mg/dL (7·8 mmol/L), followed as needed by a 100 g oral glucose tolerance test (OGTT). Abnormal OGTT values were defined according to the Carpenter-Coustan thresholds: 95 mg/dL (5·3 mmol/L) or higher in the fasting state; 180 mg/dL (10·0 mmol/L) or higher at 1 h; 155 mg/dL (8·6 mmol/L) or higher at 2 h; and 140 mg/dL (7·8 mmol/L) or higher at 3 h. The primary outcome was incident type 2 diabetes in the MHS diabetes registry. Cox proportional hazards models were applied to estimate adjusted hazard ratios (HRs) with 95% CIs for incident type 2 diabetes.

FINDINGS

During a cumulative follow-up of 1 882 647 person-years, and with a median follow-up of 10·8 (IQR 5·2-16·4) years, 1262 women were diagnosed with type 2 diabetes. Crude incidence rates of type 2 diabetes were 2·6 (95% CI 2·4-2·9) per 10 000 person-years in women with gestational normoglycaemia, 8·9 (7·4-10·6) per 10 000 person-years in women with an abnormal GCT and normal OGTT, 26·1 (22·4-30·1) per 10 000 person-years in women with one abnormal OGTT value (in the fasting state or 1 h, 2 h, or 3 h post-challenge), and 71·9 (66·0-78·3) per 10 000 person-years in women with gestational diabetes. After adjustment for sociodemographic characteristics, adolescent BMI, and age at gestational screening, the risk of type 2 diabetes was higher, compared to the gestational normoglycaemia group, in women with an abnormal GCT and normal OGTT (adjusted hazard ratio [HR] 3·39 [95% CI 2·77-4·16]; p<0·0001), in women with one abnormal OGTT value (9·11 [7·64-10·86]; p<0·0001), and in women with gestational diabetes (24·84 [21·78-28·34]; p<0·0001). The risk of type 2 diabetes was modestly increased in women with isolated elevated fasting glucose (adjusted HR 11·81 [95% CI 8·58-16·25]; p<0·0001), and in women with gestational diabetes and an abnormal fasting glucose (38·02 [32·41-44·61]; p<0·0001).

INTERPRETATION

Gestational glucose intolerance, including conditions not meeting gestational diabetes criteria of the two-step strategy, confers a high risk of type 2 diabetes in young adulthood. These conditions should be recognised as risk factors for type 2 diabetes, especially among women with abnormal fasting glucose concentrations during pregnancy.

FUNDING

None.

Gardening Is Associated With Better Cardiovascular Health Status Among Older Adults in the United States: Analysis of the 2019 Behavioral Risk Factor Surveillance System Survey

BACKGROUND

Gardening benefits health in older adults, but previous studies have limited generalizability or do not adequately adjust for sociodemographic factors or physical activity (PA).

OBJECTIVE

We examined health outcomes, fruits and vegetables (F&V) intake, and 10-year mortality risk among gardeners and exercisers compared with nonexercisers.

DESIGN

Cross-sectional data of noninstitutionalized US adults in the 2019 Behavioral Risk Factor Surveillance System was collected via landline and cellular phone survey.

PARTICIPANTS/SETTING

Adults 65 years and older reporting any PA (n = 146,047) were grouped as gardeners, exercisers, or nonexercisers.

MAIN OUTCOME MEASURES

Outcomes included cardiovascular disease (CVD) risk factors, mental and physical health, F&V intake, and 10-year mortality risk.

STATISTICAL ANALYSES

Summary statistics were calculated and adjusted logistic regression models were conducted to calculate adjusted odds ratios (aORs) and 95% CIs, accounting for the complex survey design.

RESULTS

The sample included gardeners (10.2%), exercisers (60.0%), and nonexercisers (30.8%). Gardeners, compared with nonexercisers, had significantly lower odds of reporting all studied health outcomes and higher odds of consuming 5 or more F&V per day (CVD: aOR 0.60, 95% CI 0.53 to 0.68; stroke: aOR 0.55, 95% CI 0.47 to 0.64; heart attack: aOR 0.63, 95% CI 0.55 to 0.73, high cholesterol: aOR 0.86, 95% CI 0.79 to 0.93; high blood pressure: aOR 0.74, 95% CI 0.68 to 0.81; diabetes: aOR 0.51, 95% CI 0.46 to 0.56; body mass index ≥25: aOR 0.74, 95% CI 0.68 to 0.80; poor mental health status: aOR 0.50, 95% CI 0.43 to 0.59; poor physical health status: aOR 0.35, 95% CI 0.31 to 0.39; 5 or more F&V per day: aOR 1.56, 95% CI 1.40 to 1.57; high 10-year mortality risk: aOR 0.39, 95% CI 0.36 to 0.42). Male and female gardeners had significantly lower odds of reporting diabetes even when compared with exercisers.

CONCLUSIONS

Among adults 65 years and older, gardening is associated with better CVD health status, including lower odds of diabetes. Future longitudinal or interventional studies are warranted to determine whether promoting gardening activities can be a CVD risk reduction strategy.

Interethnic Differences in Bladder Cancer Incidence and the Association between Type 2 Diabetes and Bladder Cancer in the Multiethnic Cohort Study

Background

Research on the association between type 2 diabetes (T2D) and bladder cancer (BCA) risk among non-European ancestry populations is sparse to nonexistent, and most prior studies rely on a single baseline assessment of T2D status.

Methods

We estimated the T2D-BCA association using the Multiethnic Cohort Study of 185,059 men and women in California and Hawaii. Participants were African American, European American, Japanese American, Latin American, and Native Hawaiian, ages 45-75 years at enrollment (1993-1996). T2D was assessed by self-report at baseline, follow-up surveys, and Medicare claims. Cases were identified using Surveillance, Epidemiology and End Results Program cancer registries through 2016. Associations were estimated by race/ethnicity using Cox proportional hazards regression. Adjusted attributable fractions (AAF) and cumulative absolute risk of bladder cancer were estimated across groups.

Results

Over an average 19.7 years of follow-up 1,890 incident bladder cancer cases were diagnosed. Time-varying T2D was associated with bladder cancer in the multiethnic sample (HR = 1.17; 95% confidence interval, 1.05-1.30); however, the HR did not differ by race/ethnicity (P = 0.85). The AAF was 4.2% in the multiethnic sample and largest among Native Hawaiians (9.8%). Absolute risk of bladder cancer among European Americans without T2D was higher than all other groups with T2D.

Conclusion

T2D is significantly associated with bladder cancer risk in a multiethnic sample.

Significance

Those with T2D have higher incidence of bladder cancer, regardless of racial/ethnic group. Reducing T2D prevalence could substantially lower bladder cancer incidence among Native Hawaiians due to T2D being more common in this group. High absolute risk of bladder cancer among European Americans, regardless of T2D status, indicates that elevated bladder cancer risk in this group may be due to factors other than T2D. Future studies must explore reasons for this difference in incidence.

Trends in risk factor control and treatment among patients with non-alcoholic fatty liver disease and type 2 diabetes between 2000 and 2020: A territory-wide study

BACKGROUND & AIMS

We aimed to determine the trends in risk factor control and treatment among patients with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D) in 2000-2020.

METHODS

We conducted a territory-wide cohort study of adult patients with NAFLD and T2D diagnosed between 1 January 2000 and 31 July 2021 in Hong Kong. T2D was defined by use of any anti-diabetic agents, laboratory tests and/or diagnosis codes.

RESULTS

This study included 16,084 patients with NAFLD and T2D (mean age, 54.8 ± 12.0 years; 7124 male [44.3%]). The percentage of patients achieving individualised haemoglobin A1c (HbA1c ) targets increased from 44.5% (95% confidence interval [CI], 42.9-46.1) to 64.8% (95% CI, 64.1-65.5), and percentage of patients achieving individualised low-density lipoprotein-cholesterol (LDL-C) targets increased from 23.3% (95% CI, 21.9-24.7) to 54.3% (95% CI, 53.5-55.1) from 2000-2005 to 2016-2020, whereas percentage of patients achieving blood pressure control (<140/90 mm Hg) remained static at 53.1-57.2%. Combination therapy for diabetes increased, especially among those with poor glycaemic control, but there was no increase in combination therapy for hypertension. Fewer cirrhotic patients achieved blood pressure control and individualised LDL-C targets, but they were more likely to achieve individualised HbA1c targets than non-cirrhotics. Metformin and statins were underused in cirrhotic patients. Younger patients (18-44 years) were less likely to achieve individualised HbA1c targets than middle-aged (45-64 years) and older ones (≥65 years).

CONCLUSIONS

From 2000 to 2020, glycaemic and lipid control improved significantly, whereas blood pressure control remained static among patients with NAFLD and T2D.

Race and sex disparities in acute outcomes of patients with acute ischemic stroke and diabetes mellitus. A national inpatient sample study

BACKGROUND

Diabetes Mellitus (DM) disproportionately affects racial minority groups and is a well-established risk factor for ischemic stroke and worse stroke outcomes. Whether racial disparities exist in acute outcomes of patients presenting with Acute Ischemic Stroke (AIS) and comorbid DM, including potential differences in the administration of evidence-based reperfusion therapy, remains unclear. We aimed to assess whether racial and sex differences exist in the acute outcomes and treatment of patients with DM presenting with AIS.

METHODS

January 2016-December 2018 AIS admissions with diabetes were extracted from the US National Inpatient Sample (NIS). Multivariable logistic regressions assessed the association between race, sex, and differences in in-hospital outcomes (mortality, hospitalisation >4 days, routine discharge, and stroke severity). Further models assessed the relationship between race, sex, and receipt of thrombolysis and thrombectomy. All models were adjusted for relevant confounders, including comorbidities and stroke severity.

RESULTS

92,404 records representative of 462,020 admissions were extracted. Median (IQR) age was 72 (61-79), with 49 % women, 64 % White, 23 % African American, and 10 % Hispanic patients. African Americans had lower odds of in-hospital mortality compared to Whites (adjusted odds ratio; 99 % confidence interval=0.72;0.61-0.86), but were more likely to have prolonged hospitalisation (1.46;1.39-1.54), be discharged to locations other than home (0.78;0.74-0.82) and have moderate/severe stroke (1.17;1.08-1.27). Additionally, African American (0.76;0.62-0.93) and Hispanic patients (0.66;0.50-0.89) had lower odds of receiving thrombectomy. Compared to men, women had increased odds of in-hospital mortality (1.15;1.01-1.32).

CONCLUSIONS

Racial and sex disparities exist in both evidence-based reperfusion therapy and in-hospital outcomes amongst patients with AIS and diabetes. Further measures are needed to address these disparities and reduce the excess risk of adverse outcomes among women and African American patients.

A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Trends in Diet Quality and Increasing Inadequacies of Micronutrients Vitamin C, Vitamin B12, Iron and Potassium in US Type 2 Diabetic Adults

BACKGROUND

Prevalence of diabetes was high and rose significantly in the US between 1999 and 2018. A healthy dietary pattern that provides micronutrient adequacy is one of the most important lifestyle choices for battling the progress of diabetes. Yet, the patterns and trends of diet quality of the US type 2 diabetes are understudied.

OBJECTIVES

We aim to examine the patterns and trends of diet quality and major food sources of macronutrients of US type 2 diabetic adults.

METHODS

The 24 h dietary recalls of 7789 type 2 diabetic adults, comprising 94.3% of total adults with diabetes from the US National Health and Nutrition Examination Survey cycles (1999-2018), were analyzed. Diet quality was measured by the total Healthy Eating Index (HEI)-2015 scores and 13 individual components. Trends of usual intakes of vitamin C (VC), vitamin B12 (VB12), iron, and potassium and supplements from two 24 h recalls were also examined for type 2 diabetic population.

RESULTS

Diet quality of type 2 diabetic adults worsened between 1999 and 2018 while that of US adults of general population improved based on the total HEI 2015 scores. For people with type 2 diabetes, consumption of saturated fat and added sugar increased while consumption of vegetables and fruits declined significantly, although consumption of refined grain declined and consumption of seafood and plant protein increased significantly. In addition, usual intakes of micronutrients VC, VB12, iron, and potassium from food sources declined significantly during this period.

CONCLUSIONS

Diet quality generally worsened for US type 2 diabetic adults between 1999 and 2018. Declining consumptions of fruits, vegetables, and non-poultry meat may have contributed to the increasing inadequacies of VC, VB12, iron, and potassium in the US type 2 diabetic adults.

Trends in dietary patterns over the last decade and their association with long-term mortality in general US populations with undiagnosed and diagnosed diabetes

BACKGROUND

Dietary management plays an important role in diabetes care, while the trends in dietary patterns over the last decade in US adults with diagnosed and undiagnosed diabetes remain unknown. This study aims to estimate the dietary patterns over the last decade by baseline diabetes diagnoses and explore their association with long-term prognosis.

METHODS

Participants' data were extracted from the National Health and Nutrition Examination Survey (NHANES) 2007-2018, which were divided into three groups according to the diabetes diagnosis: without diabetes, undiagnosed diabetes, and diagnosed diabetes. Healthy eating index (HEI) and dietary inflammatory index (DII) were used to evaluate dietary patterns. Survival analyses were adopted to estimate the association between HEI/DII scores and long-term all-cause mortality and cause-specific mortality.

RESULTS

The prevalence of diabetes was increasing among US adults over the last decade. HEI scores of all three groups presented a downward trend in recent years. Participants with undiagnosed diabetes (weighted mean: 50.58, 95% CI: 49.79, 51.36) got significantly lower HEI score in comparison to participants with diagnosed diabetes (weighted mean: 51.59, 95% CI: 50.93, 52.25). Compared with participants without diabetes, participants in the undiagnosed or diagnosed diabetes group had higher DII scores, indicating a higher dietary inflammatory potential. Survival analysis found a significant association between HEI scores and all-cause mortality and death of heart diseases. Similar correlation was observed in DII scores.

CONCLUSIONS

Along with the growth in diabetes prevalence in the US, dietary management of people with diabetes is decreasing. The management of US adults' diets needs special attention, and dietary inflammatory potential may be considered in the dietary intervention.

Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Trends in the Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Commercially Insured Adults Aged <65 Years

OBJECTIVE

Examine the 10-year trend in the prevalence and treatment of diabetic macular edema (DME) and vision-threatening diabetic retinopathy (VTDR) among commercially insured adults with diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the 10-year trend (2009-2018) in health care claims for adults aged 18-64 years using the IBM MarketScan Database, a national convenience sample of employer-sponsored health insurance. We included patients continuously enrolled in commercial fee-for-service health insurance for 24 months who had a diabetes ICD-9/10-CM code on one or more inpatient or two or more different-day outpatient claims in the index year or previous calendar year. We used diagnosis and procedure codes to calculate the annual prevalence of patients with one or more claims for 1) any DME, 2) either DME or VTDR, and 3) antivascular endothelial growth factor (anti-VEGF) injections and laser photocoagulation treatment, stratified by any DME, VTDR with DME, and VTDR without DME. We calculated the average annual percent change (AAPC).

RESULTS

From 2009 to 2018, there was an increase in the annual prevalence of patients with DME or VTDR (2.1% to 3.4%; AAPC 7.5%; P < 0.001) and any DME (0.7% to 2.6%; AAPC 19.8%; P < 0.001). There were sex differences in the annual prevalence of DME or VTDR and any DME, with men having a higher prevalence than women. Annual claims for anti-VEGF injections increased among patients with any DME (327%) and VTDR with DME (206%); laser photocoagulation decreased among patients with any DME (-68%), VTDR with DME (-54%), and VTDR without DME (-62%).

CONCLUSIONS

Annual claims for DME or VTDR and anti-VEGF injections increased whereas those for laser photocoagulation decreased among commercially insured adults with diabetes.

Trends in ethnic disparities in clinical cardiovascular health among Chinese adults from 2016-2020

BACKGROUND AND AIMS

Little is known about the long-term trends in ethnic differences in cardiovascular health (CVH) in China in recent years. This study aimed to investigate ethnic differences in CVH and identify long-term trends in China.

METHODS AND RESULTS

This survey was based on the physical examination data of Tacheng Prefecture in China from 2016 to 2020, and included 1,947,938 physical examination participants aged over 20 years for analysis. The American Heart Association (AHA) criteria were used to evaluate the clinical CVH of the subjects. The time trends from 2016 to 2020 were assessed using a weighted linear regression model stratified by ethnicity. The ethnic groups included Han, Kazakh, Hui, Mongolian, Uyghur, among others. The mean ideal clinical cardiovascular score was highest in Hui and lowest in Uyghur. The scores increased from 5.99 (5.95-6.03) to 6.11 (6.08-6.14) in Kazakh males and from 6.05 (5.99-6.11) to 6.11 (6.06-6.16) in Hui males among participants (P_{linear trend} < 0.001). The scores for the other groups declined significantly from 2016 to 2020(P_{linear trend} ＜ 0.05). In the sensitivity analysis, the trend remained unchanged after calculating the body mass index (BMI) cut-off for China.

CONCLUSION

Clinical CVH differences still exist among different ethnic groups, with a decline in CVH from 2016 to 2020 in all except Kazakh and Hui males. This may indicate a higher incidence and poorer prognosis of cardiovascular disease in the future and can provide guidelines for improving CVH.

Association between Organophosphate Ester Exposure and Insulin Resistance with Glycometabolic Disorders among Older Chinese Adults 60-69 Years of Age: Evidence from the China BAPE Study

BACKGROUND

Organophosphate esters (OPEs) are common endocrine-disrupting chemicals, and OPE exposure may be associated with type 2 diabetes (T2D). However, greater knowledge regarding the biomolecular intermediators underlying the impact of OPEs on T2D in humans are needed to understand biological etiology.

OBJECTIVES

We explored the associations between OPE exposure and glycometabolic markers among older Chinese adults 60-69 years of age to elucidate the underlying mechanisms using a multi-omics approach.

METHODS

This was a longitudinal panel study comprising 76 healthy participants 60-69 years of age who lived in Jinan city of northern China. The study was conducted once every month for 5 months, from September 2018 to January 2019. We measured a total of 17 OPEs in the blood, 11 OPE metabolites in urine, and 4 glycometabolic markers (fasting plasma glucose, glycated serum protein, fasting insulin, and homeostatic model assessment for insulin resistance). The blood transcriptome and serum/urine metabolome were also evaluated. The associations between individual OPEs and glycometabolic markers were explored. An adverse outcome pathway (AOP) was established to determine the biomolecules mediating the associations.

RESULTS

Exposure to five OPEs and OPE metabolites (trimethylolpropane phosphate, triphenyl phosphate, tri-iso-butyl phosphate, dibutyl phosphate, and diphenyl phosphate) was associated with increased levels of glycometabolic markers. The mixture effect analysis further indicated the adverse effect of OPE mixtures. Multi-omics analyses revealed that the endogenous changes in the transcriptional and metabolic levels were associated with OPE exposure. The putative AOPs model suggested that triggers of molecular initiation events (e.g., insulin receptor and glucose transporter type 4) with subsequent key events, including disruptions in signal transduction pathways (e.g., phosphatidylinositol 3-kinase/protein kinase B and insulin secretion signaling) and biological functions (glucose uptake and insulin secretion), may constitute the diabetogenic effects of OPEs.

DISCUSSION

OPEs are associated with the elevated risk of T2D among older Chinese adults 60-69 years of age. Implementing OPE exposure reduction strategies may help reduce the T2D burden among these individuals, if the relationship is causal. https://doi.org/10.1289/EHP11896.

Potential health and economic impact associated with achieving risk factor control in Chinese adults with diabetes: a microsimulation modelling study

Background

The prevalence of diabetes has risen sharply in China. Improving modifiable risk factors such as glycaemia and blood pressure could substantially reduce disease burden and treatment costs to achieve a healthier China by 2030.

Methods

We used a nationally representative population-based survey of adults with diabetes in 31 provinces in mainland China to assess the prevalence of risk factor control. We adopted a microsimulation approach to estimate the impact of improved control of blood pressure and glycaemia on mortality, quality-adjusted life-years (QALYs), and healthcare cost. We applied the validated CHIME diabetes outcomes model over a 10-year time horizon. Baseline scenario of status quo was evaluated against alternative strategies based on World Health Organization and Chinese Diabetes Society guidelines.

Findings

Among 24,319 survey participants with diabetes (age 30-70), 69.1% (95% CI: 67.7-70.5) achieved optimal diabetes control (HbA1c <7% [53 mmol/mol]), 27.7% [26.1-29.3] achieved blood pressure control (<130/80 mmHg) and 20.1% (18.6-21.6) achieved both targets. Achieving 70% control rate for people with diabetes could reduce deaths before age 70 by 7.1% (5.7-8.7), reduce medical costs by 14.9% (12.3-18.0), and gain 50.4 QALYs (44.8-56.0) per 1000 people over 10 years compared to the baseline status quo. The largest health gains were for strategies including strict blood pressure control of 130/80 mmHg, particularly in rural areas.

Interpretation

Based on a nationally representative survey, few adults with diabetes in China achieved optimal control of glycaemia and blood pressure. Substantial health gains and economic savings are potentially achievable with better risk factor control especially in rural settings.

Funding

Chinese Central Government, Research Grants Council of the Hong Kong Special Administrative Region, China [27112518].

Prevalence of diabetes and its correlates among Iranian adults: Results of the first phase of Shahedieh cohort study

Background and Aims

The diabetes is one of the most common noncommunicable diseases, the prevalence of which is increasing worldwide. This study aimed to determine the prevalence, and correlates the factors of diabetes in the setting of Shahedieh cohort study in Yazd, Iran.

Method

The present study is a cross-sectional study conducted on the data of the initial stage of Shahdieh Yazd cohort. This study examined the data of 9747 participants aged from 30 to 73 years. The data included demographic, clinical, and blood test variables. Multivariable logistic regression was used to calculate the adjusted odds ratio (OR), and the risk factors of diabetes were studied. Meanwhile, population attributable risks for diabetes were estimated, and reported.

Results

The prevalence of diabetes was 17.9% (CI95%: 17.1-18.9); 20.5% in women, and 15.4% in men. Based on the results of multivariable logistic regression showed female sex (OR = 1.4, CI95%: 1.24-1.58), waist-hip ratio (OR = 1.4, CI95%: 1.24-1.58), high blood pressure (OR = 2.1, CI95%: 1.84-2.4), cardiovascular diseases (CVD) (OR = 1.52, CI95%: 1.28-1.82), stroke (OR = 1.91, CI95%: 1.24-2.94), age (OR = 1.81, CI95%: 1.67-1.96), hypercholesterolemia (OR = 1.79, CI95% triglyceride: 1.59-2.02), and low-density lipoprotein (LDL) (OR = 1.45, CI95%: 1.4-1.51), as risk factors for diabetes. Among the modifiable risk factors, high blood pressure(52.38%), waist-to-hip ratio (48.19%), the history of stroke (47.64%), hypercholesterolemia (44.13%), history of CVD (34.21%), and LDL ≥ 130 (31.03%) had the greatest population-attributable, respectively.

Conclusion

The results showed that some of the main determinants of diabetes are the modifiable risk factors. Therefore, implementing early detection, and screening programs for people at risk and preventive measures, such as lifestyle modification programs, and control of risk factors can prevent this disease.

Cardiovascular Risk Factor Prevalence, Treatment, and Control in US Adults Aged 20 to 44 Years, 2009 to March 2020

Importance

Declines in cardiovascular mortality have stagnated in the US over the past decade, in part related to worsening risk factor control in older adults. Little is known about how the prevalence, treatment, and control of cardiovascular risk factors have changed among young adults aged 20 to 44 years.

Objective

To determine if the prevalence of cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, obesity, and tobacco use), treatment rates, and control changed among adults aged 20 to 44 years from 2009 through March 2020, overall and by sex and race and ethnicity.

Design, Setting, and Participants

Serial cross-sectional analysis of adults aged 20 to 44 years in the US participating in the National Health and Nutrition Examination Survey (2009-2010 to 2017-March 2020).

Main Outcomes and Measures

National trends in the prevalence of hypertension, diabetes, hyperlipidemia, obesity, and smoking history; treatment rates for hypertension and diabetes; and blood pressure and glycemic control in those receiving treatment.

Results

Among 12 924 US adults aged 20 to 44 years (mean age, 31.8 years; 50.6% women), the prevalence of hypertension was 9.3% (95% CI, 8.1%-10.5%) in 2009-2010 and 11.5% (95% CI, 9.6%-13.4%) in 2017-2020. The prevalence of diabetes (from 3.0% [95% CI, 2.2%-3.7%] to 4.1% [95% CI, 3.5%-4.7%]) and obesity (from 32.7% [95% CI, 30.1%-35.3%] to 40.9% [95% CI, 37.5%-44.3%]) increased from 2009-2010 to 2017-2020, while the prevalence of hyperlipidemia decreased (from 40.5% [95% CI, 38.6%-42.3%] to 36.1% [95% CI, 33.5%-38.7%]). Black adults had high rates of hypertension across the study period (2009-2010: 16.2% [95% CI, 14.0%-18.4%]; 2017-2020: 20.1% [95% CI, 16.8%-23.3%]), and significant increases in hypertension were observed among Mexican American adults (from 6.5% [95% CI, 5.0%-8.0%] to 9.5% [95% CI, 7.3%-11.7%]) and other Hispanic adults (from 4.4% [95% CI, 2.1%-6.8%] to 10.5% [95% CI, 6.8%-14.3%]), while Mexican American adults had a significant rise in diabetes (from 4.3% [95% CI, 2.3%-6.2%] to 7.5% [95% CI, 5.4%-9.6%]). The percentage of young adults treated for hypertension who achieved blood pressure control did not significantly change (from 65.0% [95% CI, 55.8%-74.2%] in 2009-2010 to 74.8% [95% CI, 67.5%-82.1%] in 2017-2020], while glycemic control among young adults receiving treatment for diabetes remained suboptimal throughout the study period (2009-2010: 45.5% [95% CI, 27.7%-63.3%]) to 2017-2020: 56.6% [95% CI, 39.2%-73.9%]).

Conclusions and Relevance

In the US, diabetes and obesity increased among young adults from 2009 to March 2020, while hypertension did not change and hyperlipidemia declined. There was variation in trends by race and ethnicity.

Trends in the Prevalence of Metabolically Healthy Obesity Among US Adults, 1999-2018

IMPORTANCE

Improved understanding of trends in the proportion of individuals with metabolically healthy obesity (MHO) may facilitate stratification and management of obesity and inform policy efforts.

OBJECTIVES

To characterize trends in the prevalence of MHO among US adults with obesity, overall and by sociodemographic subgroups.

DESIGN, SETTING, AND PARTICIPANTS

This survey study included 20 430 adult participants from 10 National Health and Nutrition Examination Survey (NHANES) cycles between 1999-2000 and 2017-2018. The NHANES is a series of cross-sectional and nationally representative surveys of the US population conducted continuously in 2-year cycles. Data were analyzed from November 2021 to August 2022.

EXPOSURES

National Health and Nutrition Examination Survey cycles from 1999-2000 to 2017-2018.

MAIN OUTCOMES AND MEASURES

Metabolically healthy obesity was defined as a body mass index of 30.0 (calculated as weight in kilograms divided by height in meters squared) without any metabolic disorders in blood pressure, fasting plasma glucose (FPG), high-density lipoprotein cholesterol (HDL-C), or triglycerides based on established cutoffs. Trends in the age-standardized prevalence of MHO were estimated using logistic regression analysis.

RESULTS

This study included 20 430 participants. Their weighted mean (SE) age was 47.1 (0.2) years; 50.8% were women, and 68.8% self-reported their race and ethnicity as non-Hispanic White. The age-standardized prevalence (95% CI) of MHO increased from 3.2% (2.6%-3.8%) in the 1999-2002 cycles to 6.6% (5.3%-7.9%) in the 2015-2018 cycles (P < .001 for trend). There were 7386 adults with obesity. Their weighted mean (SE) age was 48.0 (0.3) years, and 53.5% were women. The age-standardized proportion (95% CI) of MHO among these 7386 adults increased from 10.6% (8.8%-12.5%) in the 1999-2002 cycles to 15.0% (12.4%-17.6%) in the 2015-2018 cycles (P = .02 for trend). Substantial increases in the proportion of MHO were observed for adults aged 60 years or older, men, non-Hispanic White individuals, and those with higher income, private insurance, or class I obesity. In addition, there were significant decreases in the age-standardized prevalence (95% CI) of elevated triglycerides (from 44.9% [40.9%-48.9%] to 29.0% [25.7%-32.4%]; P < .001 for trend) and reduced HDL-C (from 51.1% [47.6%-54.6%] to 39.6% [36.3%-43.0%]; P = .006 for trend). There was also a significant increase in elevated FPG (from 49.7% [95% CI, 46.3%-53.0%] to 58.0% [54.8%-61.3%]; P < .001 for trend) but no significant change in elevated blood pressure (from 57.3% [53.9%-60.7%] to 54.0% [50.9%-57.1%]; P = .28 for trend).

CONCLUSIONS AND RELEVANCE

The findings of this cross-sectional study suggest that the age-standardized proportion of MHO increased among US adults from 1999 to 2018, but differences in trends existed across sociodemographic subgroups. Effective strategies are needed to improve metabolic health status and prevent obesity-related complications in adults with obesity.

Patient Demographics and Clinical Outcomes Among Type 1 Diabetes Patients Using Continuous Glucose Monitors: Data From T1D Exchange Real-World Observational Study

BACKGROUND

The benefits of Continuous Glucose Monitoring (CGM) on glycemic management have been demonstrated in numerous studies; however, widespread uptake remians limited. The aim of this study was to provide real-world evidence of patient attributes and clinical outcomes associated with CGM use across clinics in the U.S. based T1D Exchange Quality Improvement (T1DX-QI) Collaborative.

METHOD

We examined electronic Health Record data from eight endocrinology clinics participating in the T1DX-QI Collaborative during the years 2017-2019.

RESULTS

Among 11,469 type 1 diabetes patients, 48% were CGM users. CGM use varied by race/ethnicity with Non-Hispanic Whites having higher rates of CGM use (50%) compared to Non-Hispanic Blacks (18%) or Hispanics (38%). Patients with private insurance were more likely to use CGM (57.2%) than those with public insurance (33.3%) including Medicaid or Medicare. CGM users had lower median HbA1c (7.7%) compared to nonusers (8.4%). Rates of diabetic ketoacidosis (DKA) and severe hypoglycemia were significantly higher in nonusers compared to CGM users.

CONCLUSION

In this real-world study of patients in the T1DX-QI Collaborative, CGM users had better glycemic control and lower rates of DKA and severe hypoglycemia (SH) events, compared to nonusers; however, there were significant sociodemographic disparities in CGM use. Quality improvement and advocacy measures to promote widespread and equitable CGM uptake have the potential to improve clinical outcomes.

Status of continuous glucose monitoring use and management in tertiary hospitals of China: a cross-sectional study

OBJECTIVE

This study aims to reveal the use and management status of continuous glucose monitoring (CGM) in tertiary hospitals in China and to determine the potential factors affecting the application of CGM, based on which more effective solutions would be produced and implemented.

DESIGN

An online, cross-sectional study was conducted from October 2021 to December 2021.

SETTING

Eighty-three tertiary hospitals in China were involved.

PARTICIPANTS

Eighty-three head nurses and 281 clinical nurses were obtained.

OUTCOME

Current condition of CGM use and management, the factors that hinder the use and management of CGM, scores of current CGM use and management, as well as their influencing factors, were collected.

RESULTS

Among the 83 hospitals surveyed, 57 (68.7%) hospitals used CGM for no more than 10 patients per month. Seventy-three (88.0%) hospitals had developed CGM standard operating procedures, but only 29 (34.9%) hospitals devised emergency plans to deal with adverse effects related to CGM. Comparably, maternal and children's hospitals were more likely to have a dedicated person to assign install CGM than general hospitals (52.2% vs 26.7%). As for the potential causes that hinder the use and management of CGM, head nurses' and nurses' perceptions differed. Head nurses perceived patients' limited knowledge about CGM (60.2%), the high costs of CGM and inaccessibility to medical insurance (59.0%), and imperfect CGM management systems (44.6%) as the top three factors. Different from head nurses, CGM operation nurses considered the age of CGM operators, the type of hospital nurses worked in, the number of patients using CGM per month and the number of CGM training sessions as potential factors (p<0.05).

CONCLUSIONS

The study provides a broad view of the development status of CGM in China. Generally speaking, the use and management of CGM in China are not yet satisfactory, and more efforts are wanted for improvement.

Causes and risk profiles of mortality among individuals with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States and worldwide. Though nonalcoholic fatty liver per se may not be independently associated with an increased risk for all-cause mortality, it is associated with a number of harmful metabolic risk factors, such as type 2 diabetes mellitus, hyperlipidemia, obesity, a sedentary lifestyle, and an unhealthy diet. The fibrosis stage is a predictor of all-cause mortality in NAFLD. Mortality in individuals with NAFLD has been steadily increasing, and the most common cause-specific mortality for NAFLD is cardiovascular disease, followed by extra-hepatic cancer, liver-related mortality, and diabetes. High-risk profiles for mortality in NAFLD include PNPLA3 I148M polymorphism, low thyroid function and hypothyroidism, and sarcopenia. Achieving weight loss through adherence to a high-quality diet and sufficient physical activity is the most important predictor of improvement in NAFLD severity and the benefit of survival. Given the increasing health burden of NAFLD, future studies with more long-term mortality data may demonstrate an independent association between NAFLD and mortality.

Intensive, telemedicine-based, self-management program for rural, underserved patients with diabetes mellitus: Re-entry of retired endocrinologists into practice

INTRODUCTION

Endocrinology workforce data demonstrate a substantial gap in the number of practicing endocrinologists, a phenomenon particularly affecting patients with diabetes in rural, financially challenged, underserved areas. We evaluated the concept that retired endocrinologists could re-enter practice part time and utilize telemedicine in collaboration with personnel in Federally Qualified Community Health Center clinics to conduct an intensive self-management program and provide 6-month concurrent care for patients with diabetes.

METHODS

The program involved intensive glucose control measures and education in diabetes, nutrition, and lifestyle changes over a 6-month period. Key elements included comprehensive initial telehealth evaluations, frequent phone calls, and collaboration with certified diabetes care and education specialists, referring providers, referring-clinic staff, and the University of Virginia Telehealth Center.

RESULTS

The mean A1C in the 139 patients completing the 6-month self-management program decreased from 10.3 ± 1.94% to 7.78 ± 1.51% p < 0.0001. The number of treatment modalities per patient ranged from one to five with several different regimens utilized. The majority of patients maintained the reduction in A1C levels without recidivism over a mean follow-up of 16 months after discharge. Strategies using meal replacements are being implemented to facilitate weight loss.

DISCUSSION

This program resulted in improved A1C levels of patients with diabetes in rural, financially challenged, underserved areas; met recidivism goals; and provided a practical template to reduce the workforce gap of endocrinologists in those areas.

Cardiovascular risk and lifetime benefit from preventive treatment in type 2 diabetes: A post hoc analysis of the CAPTURE study

AIM

To assess the potential gain in the number of life-years free of a (recurrent) cardiovascular disease (CVD) event with optimal cardiovascular risk management (CVRM) and initiation of glucose-lowering agents with proven cardiovascular benefit in people with type 2 diabetes (T2D).

MATERIALS AND METHODS

9,416 individuals with T2D from the CAPTURE study, a non-interventional, cross-sectional, multinational study, were included. The diabetes lifetime-perspective prediction model was used for calculating individual 10-year and lifetime CVD risk. The distribution of preventive medication use was assessed according to predicted CVD risk and stratified for history of CVD. For the estimation of absolute individual benefit from lifelong preventive treatment, including optimal CVRM and the addition of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter-2 inhibitors (SGLT-2is), the model was combined with treatment effects from current evidence.

RESULTS

GLP-1 RA or SGLT-2i use did not greatly differ between patients with and without CVD history, while use of blood pressure-lowering medication, statins and aspirin was more frequent in patients with CVD. Mean (standard deviation [SD]) lifetime benefit from optimal CVRM was 3.9 (3.0) and 1.3 (1.9) years in patients with and without established CVD, respectively. Further addition of a GLP-1 RA and an SGLT-2i in patients with CVD gave an added mean (SD) lifetime benefit of 1.2 (0.6) years.

CONCLUSIONS

Life-years gained free of (recurrent) CVD by optimal CVRM and the addition of a GLP-1 RA or aSGLT-2i is dependent on baseline CVD status. These results aid individualizing prevention and promote shared decision-making in patients with T2D.

Changes in the management of hypertension, diabetes mellitus, and hypercholesterolemia in Korean adults before and during the COVID-19 pandemic: data from the 2010-2020 Korea National Health and Nutrition Examination Survey

OBJECTIVES

This study aimed to analyze the changes in chronic disease management indicators, including hypertension, diabetes mellitus, and hypercholesteremia, from 2010-2020 and before (2019) and during (2020) the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This study included 58,504 individuals aged ≥30 years who participated in the Korea National Health and Nutrition Examination Survey 2010-2020. Trends in the prevalence, awareness, treatment, and control of chronic diseases and the difference in those between before and during the COVID-19 pandemic were analyzed using the SAS program PROC SURVEYREG.

RESULTS

From 2010-2020, the awareness, treatment, and control in adults aged ≥30 years for hypertension and hypercholesterolemia continuously improved, whereas no significant change in the management indicators of diabetes mellitus was observed. The prevalence of hypertension, diabetes mellitus, and hypercholesterolemia in men increased from before to during the COVID- 19 pandemic. However, there was no significant change in the management indicators of hypertension and diabetes mellitus in men and women, and the awareness, treatment, and control rates for hypercholesterolemia increased by 5.5%p, 6.9%p, and 4.1%p respectively.

CONCLUSIONS

In 2020, the first year of the COVID-19 pandemic, the prevalence of hypertension, diabetes mellitus, and hypercholesterolemia increased, but the management indicators of the chronic diseases did not significantly deteriorate. Considering the ongoing COVID-19 pandemic, it is necessary to monitor changes in chronic disease management indicators and to develop efficient and accessible chronic disease prevention and management programs.

The National Clinical Care Commission Report to Congress: Background, Methods, and Foundational Recommendations

Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.

Association of metformin use and survival in patients with cutaneous melanoma and diabetes

BACKGROUND

Metformin use has been associated with improved survival in patients with different types of cancer, but research regarding the effect of metformin on cutaneous melanoma (CM) survival is sparse and inconclusive.

OBJECTIVES

To investigate the association between metformin use and survival among patients with CM and diabetes.

METHODS

All adult patients with a primary invasive CM between 2007 and 2014 were identified in the Swedish Melanoma Registry and followed until death, or end of follow-up on 31 December 2017 in this population-based cohort study. Patients with both CM and type 2 diabetes mellitus were assessed further. Overall survival (OS) and melanoma-specific survival (MSS) were the primary endpoints. Cox proportional hazard models estimating crude and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were used comparing peridiagnostic use vs. nonuse of metformin. Dose response was evaluated based on defined daily doses.

RESULTS

Among a total of 23 507 patients, 1162 patients with CM and type 2 diabetes mellitus were included in the final cohort, with a median follow-up time of 4.1 years (interquartile range 2.4-6.1). Peridiagnostic metformin use was associated with a significantly decreased risk of death by any cause (HR 0.68, 95% CI 0.57-0.81). Cumulative pre- and postdiagnostic metformin use was also associated with improved OS: the HR for prediagnostic use was 0.90 (95% CI 0.86-0.95) for every 6 months of use and the HR for postdiagnostic use ranged from 0.98 (95% CI 0.97-0.98) for 0-6 months to 0.59 (0.49-0.70) for 24-30 months of use. No association was found for metformin use and MSS.

CONCLUSIONS

Metformin use was associated with improved OS in patients with CM and diabetes regardless of timing (pre-, post- or peridiagnostic use) and followed a dose-response pattern. However, further research regarding the underlying mechanisms is warranted.

Evaluation of pharmacist consults within a collaborative enhanced primary care team model to improve diabetes care

BACKGROUND

An enhanced primary care team model was implemented to provide proactive, longitudinal care to patients with diabetes, grounded in close partnership between primary care providers (PCPs), nurses, and Medication Management Services (MMS) pharmacists. The purpose of this study is to evaluate the impact of the MMS pharmacist involvement in the enhanced primary care model for patients with diabetes.

METHODS

This retrospective cohort study compared the quality of diabetes care between patients referred to a pharmacist and propensity score matched controls who were not. Eligible patients were adults (age 18 to 75 years) enrolled in the enhanced primary care team process who did not meet at least one of four diabetes quality indicators at 13 Mayo Clinic Rochester primary care practice locations. The intervention examined was asynchronous e-consults by pharmacists affiliated with the primary care practice.

MAIN MEASURES

The primary outcome was change in the proportion of patients meeting the composite of four diabetes treatment goals (D4), including hemoglobin A1c (HbA1c) control, blood pressure control, aspirin use, and statin use at six months from enrollment among patients who received pharmacist intervention compared to matched patients who did not. Secondary outcomes were each of the D4 goal individually.

RESULTS

The proportion of patients meeting the D4 increased with pharmacist e-consults (N = 85) compared to matched controls with no review (N = 170) (27% vs 7.0%, p<0.001). The change in patients meeting treatment goals of HbA1c (12.9% vs 4.1%, p = 0.020), blood pressure (9.4% vs 2.4%, p = 0.023), aspirin use (10.6% vs 2.9%, p = 0.018), and statin use (17.6% vs -1.2%, p<0.001) all increased with pharmacist e-consults.

CONCLUSIONS

Pharmacist engagement in the enhanced primary care team improved diabetes management. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care.

Emerging Antimicrobial and Immunomodulatory Fiber-Based Scaffolding Systems for Treating Diabetic Foot Ulcers

Diabetic foot ulcers (DFUs) are one of the main complications of diabetes and are characterized by their complexity and severity, which are frequently aggravated by overexpressed inflammatory factors and polymicrobial infections. Most dressing systems offer a passive action in the treatment of DFUs, being frequently combined with antibiotic or immunomodulatory therapies. However, in many instances due to these combined therapies' inability to properly fight microbial presence, and provide a suitable, breathable and moist environment that is also capable of protecting the site from secondary microbial invasions or further harm, aggravation of the wound state is unavoidable and lower limb amputations are necessary. Considering these limitations and knowing of the urgent demand for new and more effective therapeutic systems for DFU care that will guarantee the quality of life for patients, research in this field has boomed in the last few years. In this review, the emerging innovations in DFU dressing systems via fiber-based scaffolds modified with bioactive compounds have been compiled; data focused on the innovations introduced in the last five years (2017-2022). A generalized overview of the classifications and constraints associated with DFUs healing and the bioactive agents, both antimicrobial and immunomodulatory, that can contribute actively to surpass such issues, has also been provided.

Association between dietary inflammatory index and atherosclerosis cardiovascular disease in U.S. adults

Objective

To evaluate the association between dietary inflammatory index (DII) and Atherosclerotic cardiovascular disease (ASCVD) among U.S. adults.

Methods

We collected data from National Health and Nutrition Examination Survey (NHANES) between 1999 and 2018. Adults who reported complete information to diagnose ASCVD and calculate DII were included. We used three models to differentially adjust the covariates, including age, sex, race or ethnicity, education level, smoking status, poverty, insurance, body mass index, hyperlipemia, hypertension, and diabetes. Logistic regression was used to estimate the Odds Ratio (OR) and 95% confidence interval (95% CI) for ASCVD grouped by DII deciles. We additionally conducted spline smoothing with the generalized additive model (GAM) and the log-likelihood ratio to examine the non-linear relationship between DII and ASCVD. If exists, the segmented linear regression will be used to detect the cutoff point. The subgroup analyses were stratified by various atherosclerotic cardiovascular diseases (i.e., CHD, angina, heart attack, and stroke) and sex.

Results

A total of 48,733 participants (mean age, 47.13 ± 0.19 years) with 51.91% women were enrolled, of which 5,011 were diagnosed with ASCVD. In the crude model, participants in the five highest deciles (D6, 7, 8, 9, and 10) of DII score had a significantly higher risk of having ASCVD compared to those in the first decile. In the fully adjusted model, those in the tenth decile [OR = 1.47, 95% CI = (1.18,1.84)] of DII had a significantly increased risk of ASCVD compared to the first decile. Notably, when DII is above 3, the ASCVD risk increased by 41% for each one increase in DII [OR = 1.41, 95% CI = (1.15,1.73)]. This relationship was more pronounced in females.

Conclusion

Our study revealed a positive and non-linearly association between DII and ASCVD in U.S. adults. This relationship was more pronounced in females. The findings provide a reference for future research and diet recommendations.

Trends in Use of High-Cost Antihyperglycemic Drugs Among US Adults with Type 2 Diabetes

BACKGROUND

Some antihyperglycemic drugs can reduce cardiovascular events, slow the progression of kidney disease, and prevent death, but they are more expensive than older drugs.

OBJECTIVES

(1) To estimate trends in use of antihyperglycemic drugs by cost; (2) to examine use of high-cost drugs by race/ethnicity, income, and insurance status DESIGN: Cross-sectional analysis of the 2003-2018 National Health and Nutrition Examination Survey PARTICIPANTS: US adults ≥18 years with type 2 diabetes EXPOSURES: Race/ethnicity, income, and insurance status MAIN MEASURES: Low-cost noninsulin medications included any drugs that had at least one generic version approved by the Food and Drug Administration. Human regular, NPH, and premixed NPH/regular 70/30 insulins were classified as low-cost. All other noninsulin medications and insulins were considered high-cost KEY RESULTS: The sample included 7,394 patients. Prevalence of use of low-cost noninsulin drugs increased from 37% in 2003-2004 to 52% in 2017-2018. Use of high-cost noninsulin drugs decreased from 2003-2004 to 2013-2014 and then slowly increased. Use of low-cost insulin decreased from 7 to 2% while high-cost insulin rose from 4 to 16%. In multivariable analysis, non-White patients had 25-35% lower odds of receiving high-cost drugs than non-Hispanic Whites. Health insurance was associated with more than twice the odds of having high-cost drugs compared to no insurance. Patients with higher HbA1c or moderate obesity were also more likely to use high-cost drugs. Sex, income, and insurance type were not associated with receipt of high-cost drugs.

CONCLUSIONS

There was a shift in utilization from high- to low-cost noninsulin drugs, but since 2013-2014 the trend has slowly reversed with increased use of newer, more expensive drug classes. High-cost insulin analogs have almost completely replaced lower cost human insulins. Disparities in receipt of diabetes drugs by race/ethnicity and insurance must be addressed to ensure that cost is not a barrier for disadvantaged populations.

Sleep Duration and Risks of Incident Cardiovascular Disease and Mortality Among People With Type 2 Diabetes

OBJECTIVE

People with type 2 diabetes may have insufficient or prolonged sleep that could accelerate cardiovascular disease (CVD) onset, but existing evidence from prospective studies has been limited. We examined the association of sleep duration with CVD incidence and mortality in this high-risk population.

RESEARCH DESIGN AND METHODS

This prospective study included 18,876 participants with type 2 diabetes in the UK Biobank who were free of CVD and cancer at baseline. Habitual sleep duration was obtained using a baseline questionnaire. Cox proportional hazards regression models were used to examine the association between sleep duration and CVD events.

RESULTS

During an average follow-up of 11.0-12.0 years, we documented 2,570 incident cases of atherosclerotic cardiovascular disease (ASCVD) and 598 CVD deaths. Compared with sleeping for 7 h/day, the multivariable-adjusted hazard ratios of ≤5 and ≥10 h/day were 1.26 (95% CI 1.08, 1.48) and 1.41 (1.16, 1.70) for incident ASCVD, 1.22 (0.99, 1.50) and 1.16 (0.88, 1.52) for coronary artery disease, 1.70 (1.23, 2.35) and 2.08 (1.44, 3.01) for ischemic stroke, 1.02 (0.72, 1.44) and 1.45 (1.01, 2.10) for peripheral artery disease, and 1.42 (1.02, 1.97) and 1.85 (1.30, 2.64) for CVD mortality. Similar results were observed in most sensitivity analyses that aimed to address potential reverse causation and in the joint analyses of sleep duration and metabolic control or diabetes severity status.

CONCLUSIONS

Short and long sleep durations were independently associated with increased risks of CVD onset and death among people with type 2 diabetes.

The efficacy and safety of Chinese herbal medicine as an add-on therapy for type 2 diabetes mellitus patients with carotid atherosclerosis: An updated meta-analysis of 27 randomized controlled trials

Background: Type 2 diabetes mellitus (T2DM) is a clinical metabolic syndrome characterized by persistent hyperglycemia. Patients with T2DM are more likely to have carotid atherosclerosis (CAS), which can lead to dizziness, amaurosis or even stroke. Chinese herbal medicine (CHM) has shown possible efficacy and safety in treating T2DM patients with CAS. However, the existing evidence was not robust enough and the results were out of date. Objective: This meta-analysis aimed to summarize the current evidence and systematically evaluate the effects of CHM on carotid plaque, glucose and lipid metabolism and vascular endothelial parameters in T2DM patients with CAS, providing a reference for subsequent research and clinical practice. Methods: This study was registered in PROSPERO as CRD42022346274. Both Chinese and English databases were searched from their inceptions to 16 July 2022. All retrieved studies were screened according to inclusion and exclusion criteria. Randomized controlled trials (RCTs) using oral CHM to treat T2DM patients with CAS were included. The literature quality was assessed using the risk of bias assessment tool in the Cochrane Handbook. Data extraction was conducted on the selected studies. Review Manager 5.4 and Stata 16.0 were used for meta-analysis. Sources of heterogeneity were explored by meta-regression or subgroup analysis. Funnel plot and Egger's test were used to assess publication bias and the evidence quality was assessed by Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: 27 eligible studies, involving 2638 patients, were included in this study. Compared with western medicine (WM) alone, the addition of CHM was significantly better in improving carotid intima-media thickness (CIMT) [mean difference (MD) = -0.11mm, 95% confidence interval (CI): -0.15 to -0.07, p < 0.01], carotid plaque Crouse score [MD = -1.21, 95%CI: -1.35 to -1.07, p < 0.01], total cholesterol (TC) [MD = -0.34 mmol/L, 95%CI: -0.54 to -0.14, p < 0.01], triglyceride (TG) [MD = -0.26 mmol/L, 95%CI: -0.37 to -0.15, p < 0.01], low-density lipoprotein cholesterol (LDL-C) [MD = -0.36 mmol/L, 95%CI: -0.47 to -0.25, p < 0.01], high-density lipoprotein cholesterol (HDL-C) [MD = 0.22 mmol/L, 95%CI: 0.13 to 0.30, p < 0.01], glycated hemoglobin (HbA1c) [MD = -0.36%, 95%CI: -0.51 to -0.21, p < 0.01], fasting blood glucose (FBG) [MD = -0.33 mmol/L, 95%CI: -0.50 to -0.16, p < 0.01], 2-h postprandial glucose (2hPG) [MD = -0.52 mmol/L, 95%CI: -0.95 to -0.09, p < 0.01], homeostasis model assessment of insulin resistance (HOMA-IR) [standardized mean difference (SMD) = -0.88, 95%CI: -1.36 to -0.41, p < 0.01] and homeostasis model assessment of beta-cell function (HOMA-β) [MD = 0.80, 95%CI: 0.51 to 1.09, p < 0.01]. Due to the small number of included studies, it is unclear whether CHM has an improving effect on nitric oxide (NO), endothelin-1 (ET-1), peak systolic velocity (PSV) and resistance index (RI). No serious adverse events were observed. Conclusion: Based on this meta-analysis, we found that in the treatment of T2DM patients with CAS, combined with CHM may have more advantages than WM alone, which can further reduce CIMT and carotid plaque Crouse score, regulate glucose and lipid metabolism, improve insulin resistance and enhance islet β-cell function. Meanwhile, CHM is relatively safe. However, limited by the quality and heterogeneity of included studies, the efficacy and safety of CHM remain uncertain. More high-quality studies are still needed to provide more reliable evidence for the clinical application of CHM. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022346274.

Quantifying the contribution of 31 risk factors to the increasing prevalence of diabetes among US adults, 2005-2018

Introduction

No study has comprehensively quantified the individual and collective contributions of various risk factors to the growing burden of diabetes in the United States.

Methods

This study aimed to determine the extent to which an increase in the prevalence of diabetes was related to concurrent changes in the distribution of diabetes-related risk factors among US adults (aged 20 years or above and not pregnant). Seven cycles of series of cross-sectional National Health and Nutrition Examination Survey data between 2005-2006 and 2017-2018 were included. The exposures were survey cycles and seven domains of risk factors, including genetic, demographic, social determinants of health, lifestyle, obesity, biological, and psychosocial domains. Using Poisson regressions, percent reduction in the β coefficient (the logarithm used to calculate the prevalence ratio for prevalence of diabetes in 2017-2018 vs. 2005-2006) was computed to assess the individual and collective contribution of the 31 prespecified risk factors and seven domains to the growing burden of diabetes.

Results

Of the 16,091 participants included, the unadjusted prevalence of diabetes increased from 12.2% in 2005-2006 to 17.1% in 2017-2018 [prevalence ratio: 1.40 (95% CI, 1.14-1.72)]. Individually, genetic domain [17.3% (95% CI, 5.4%-40.8%)], demographic domain [41.5% (95% CI, 24.4%-76.8%)], obesity domain [35.3% (95% CI, 15.8%-70.2%)], biological domain [46.2% (95% CI, 21.6%-79.1%)], and psychosocial domain [21.3% (95% CI, 9.5%-40.1%)] were significantly associated with a different percent reduction in β. After adjusting for all seven domains, the percent reduction in β was 97.3% (95% CI, 62.7%-164.8%).

Conclusion

The concurrently changing risk factors accounted for the increasing diabetes prevalence. However, the contribution of each risk factor domain varied. Findings may inform planning cost-effective and targeted public health programs for diabetes prevention.

Obesity-Associated Dyslipidemia Is Moderated by Habitual Intake of Marine-Derived n-3 Polyunsaturated Fatty Acids in Yup'ik Alaska Native People: A Cross-Sectional Mediation-Moderation Analysis

BACKGROUND

Obesity leads to insulin resistance, altered lipoprotein metabolism, dyslipidemia, and cardiovascular disease. The relationship between long-term intake of n-3 polyunsaturated fatty acids (n-3 PUFAs) and prevention of cardiometabolic disease remains unresolved.

OBJECTIVES

The aim of this study was to explore direct and indirect pathways between adiposity and dyslipidemia, and the degree to which n-3 PUFAs moderate adiposity-induced dyslipidemia in a population with highly variable n-3 PUFA intake from marine foods.

METHODS

In total, 571 Yup'ik Alaska Native adults (18-87 y) were enrolled in this cross-sectional study. The red blood cell (RBC) nitrogen isotope ratio (15N/14N, or NIR) was used as a validated objective measure of n-3 PUFA intake. EPA and DHA were measured in RBCs. Insulin sensitivity and resistance were estimated by the HOMA2 method. Mediation analysis was conducted to evaluate the contribution of the indirect causal path between adiposity and dyslipidemia mediated through insulin resistance. Moderation analysis was used to assess the influence of dietary n-3 PUFAs on the direct and indirect paths between adiposity and dyslipidemia. Outcomes of primary interest included plasma total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), non-HDL-C, and triglycerides (TG).

RESULTS

In this Yup'ik study population, we found that up to 21.6% of the total effects of adiposity on plasma TG, HDL-C, and non-HDL-C are mediated through measures of insulin resistance or sensitivity. Moreover, RBC DHA and EPA moderated the positive association between waist circumference (WC) and TC or non-HDL-C, whereas only DHA moderated the positive association between WC and TG. However, the indirect path between WC and plasma lipids was not significantly moderated by dietary n-3 PUFAs.

CONCLUSIONS

Intake of n-3 PUFAs may independently reduce dyslipidemia through the direct path resulting from excess adiposity in Yup'ik adults. NIR moderation effects suggest that additional nutrients contained in n-3 PUFA-rich foods may also reduce dyslipidemia.

Medical Care Needs of Laundromat Users in San Antonio, Texas: A Potentially Unique Setting for Health Interventions

Innovative community-based public-private partnerships are forming to address health needs of underserved communities. This study partnered with laundromats in San Antonio, Texas to understand the health and healthcare needs of laundromat users as a possible underserved population. A total of 193 laundromat users across eight laundromats participated in a survey based on the Texas Behavioral Risk Factor Surveillance System (BRFSS) that asked about health status, access to care, vaccinations, and use of preventive healthcare services. Responses were compared to population estimates from Bexar County and the state of Texas. Results showed that over half of the sample of laundromat users were female, racial/ethnic minorities, living at poverty level, and did not have health insurance coverage. Compared to county and state population estimates, laundromat users were significantly more likely to report poor health and physical impairment; and were less likely to have a primary care provider, to have received a routine medical checkup in the past year, and to have been tested for HIV. Laundromat users were also less likely to receive some gender-specific preventive healthcare screenings such as pap smears and mammograms for women, and prostate exams for men than county or state population estimates. In the laundromat sample, 78% expressed interest in receiving healthcare services on-site at laundromats. Together, these findings suggest laundromats may be a unique setting for healthcare intervention to reach undeserved, racial/ethnic minority communities. Pilot programs that target this setting are needed to explore this opportunity to deliver community-based public health practice.

Comparative Effectiveness of Team-Based Care With and Without a Clinical Decision Support System for Diabetes Management : A Cluster Randomized Trial

BACKGROUND

Uncontrolled hyperglycemia, hypercholesterolemia, and hypertension are common in persons with diabetes.

OBJECTIVE

To compare the effectiveness of team-based care with and without a clinical decision support system (CDSS) in controlling glycemia, lipids, and blood pressure (BP) among patients with type 2 diabetes.

DESIGN

Cluster randomized trial. (ClinicalTrials.gov: NCT02835287).

SETTING

38 community health centers in Xiamen, China.

PATIENTS

11 132 persons aged 50 years or older with uncontrolled diabetes and comorbid conditions, 5475 receiving team-based care with a CDSS and 5657 receiving team-based care alone.

INTERVENTION

Team-based care was delivered by primary care physicians, health coaches, and diabetes specialists in all centers. In addition, a computerized CDSS, which generated individualized treatment recommendations based on clinical guidelines, was implemented in 19 centers delivering team-based care with a CDSS.

MEASUREMENTS

Coprimary outcomes were mean reductions in hemoglobin A_1c (HbA_1c) level, low-density lipoprotein cholesterol (LDL-C) level, and systolic BP over 18 months and the proportion of participants with all 3 risk factors controlled at 18 months.

RESULTS

During the 18-month intervention, HbA_1c levels, LDL-C levels, and systolic BP significantly decreased by -0.9 percentage point (95% CI, -0.9 to -0.8 percentage point), -0.49 mmol/L (CI, -0.53 to -0.45 mmol/L) (-19.0 mg/dL [CI, -20.4 to -17.5 mg/dL]), and -9.1 mm Hg (CI, -9.9 to -8.3 mm Hg), respectively, in team-based care with a CDSS and by -0.6 percentage point (CI, -0.7 to -0.5 percentage point), -0.32 mmol/L (CI, -0.35 to -0.29 mmol/L) (-12.5 mg/dL [CI, -13.6 to -11.3 mg/dL]), and -7.5 mm Hg (CI, -8.4 to -6.6 mm Hg), respectively, in team-based care alone. Net differences were -0.2 percentage point (CI, -0.3 to -0.1 percentage point) for HbA_1c level, -0.17 mmol/L (CI, -0.21 to -0.12 mmol/L) (-6.5 mg/dL [CI, -8.3 to -4.6 mg/dL]) for LDL-C level, and -1.5 mm Hg (CI, -2.8 to -0.3 mm Hg) for systolic BP. The proportion of patients with controlled HbA_1c, LDL-C, and systolic BP was 16.9% (CI, 15.7% to 18.2%) in team-based care with a CDSS and 13.0% (CI, 11.7% to 14.3%) in team-based care alone.

LIMITATION

There was no usual care control, and clinical outcome assessors were unblinded; the analysis did not account for multiple comparisons.

CONCLUSION

Compared with team-based care alone, team-based care with a CDSS significantly reduced cardiovascular risk factors in patients with diabetes, but the effect was modest.

PRIMARY FUNDING SOURCE

Xiamen Municipal Health Commission.

High HBV-DNA serum levels are associated with type 2 diabetes in adults with positive HBsAg: An observational study

BACKGROUND

The prevalence of diabetes is higher in hepatitis B virus (HBV)-infected population. We aimed to examine the relationship between different serum HBV-DNA levels and type 2 diabetes in adults with positive HBV surface antigen (HBsAg).

METHODS

We conducted cross-sectional analyses of data obtaining from the Clinical Database System of Wuhan Union Hospital. Diabetes was defined by self-report of type 2 diabetes, fasting plasma glucose (FPG) ≥7mmol/L, or glycated hemoglobin (HbA1c) ≥6.5%. Binary logistic regression analyses were performed to investigate the factors associated with diabetes.

RESULTS

Among 12,527 HBsAg-positive adults, 2,144 (17.1%) were diabetic. Patients with serum HBV-DNA <100, 100-2000, 2000-20000 and ≥20000 IU/mL accounted for 42.2% (N=5,285), 22.6% (N=2,826), 13.3% (N=1,665) and 22.0% (N=2,751), respectively. The risk of type 2 diabetes, FPG ≥7mmol/L and HbA1c ≥6.5% in individuals with highly elevated serum HBV-DNA level (≥20000 IU/mL) were 1.38 (95% confidence interval [CI]: 1.16 to 1.65), 1.40 (95% CI: 1.16 to 1.68) and 1.78 (95% CI: 1.31 to 2.42) times relative to those with negative or lowly elevated serum HBV-DNA (<100 IU/mL). However, the analyses showed no association of moderately (2000-20000 IU/mL) to slightly (100-2000 IU/mL) raised serum HBV-DNA levels with type 2 diabetes (OR=0.88, P=0.221; OR=1.08, P=0.323), FPG ≥7mmol/L (OR=1.00, P=0.993; OR=1.11, P=0.250) and HbA1c ≥6.5% (OR=1.24, P=0.239; OR=1.17, P=0.300).

CONCLUSION

In HBsAg-positive adults, highly elevated level rather than moderately to slightly raised levels of serum HBV-DNA is independently associated with an increased risk of type 2 diabetes.

Dysregulation of TSP2-Rac1-WAVE2 axis in diabetic cells leads to cytoskeletal disorganization, increased cell stiffness, and dysfunction

Fibroblasts are a major cell population that perform critical functions in the wound healing process. In response to injury, they proliferate and migrate into the wound space, engaging in extracellular matrix (ECM) production, remodeling, and contraction. However, there is limited knowledge of how fibroblast functions are altered in diabetes. To address this gap, several state-of-the-art microscopy techniques were employed to investigate morphology, migration, ECM production, 2D traction, 3D contraction, and cell stiffness. Analysis of cell-derived matrix (CDM) revealed that diabetic fibroblasts produce thickened and less porous ECM that hindered migration of normal fibroblasts. In addition, diabetic fibroblasts were found to lose spindle-like shape, migrate slower, generate less traction force, exert limited 3D contractility, and have increased cell stiffness. These changes were due, in part, to a decreased level of active Rac1 and a lack of co-localization between F-actin and Waskott-Aldrich syndrome protein family verprolin homologous protein 2 (WAVE2). Interestingly, deletion of thrombospondin-2 (TSP2) in diabetic fibroblasts rescued these phenotypes and restored normal levels of active Rac1 and WAVE2-F-actin co-localization. These results provide a comprehensive view of the extent of diabetic fibroblast dysfunction, highlighting the regulatory role of the TSP2-Rac1-WAVE2-actin axis, and describing a new function of TSP2 in regulating cytoskeleton organization.

Trends in risk factor control in patients with gout: data from the National Health and Nutrition Examination Survey, 2007-2018

OBJECTIVES

To explore trends in risk factor control (hypertension, diabetes mellitus, hyperlipidaemia) in patients with gout and medication use among those whose risk factor control targets were not achieved.

METHODS

We used the data from National Health and Nutrition Examination Survey (NHANES) between 2007-2008 and 2017-2018 for analyses. The study samples were weighted so that they could be representative of the non-institutionalized US population. We conducted a cross-sectional analysis to assess trends in risk factor control and medication use, and employed logistic regression analyses to explore patient characteristics associated with risk factor control.

RESULTS

The prevalence of participants in whom blood pressure control target was achieved decreased from 64.6% in 2007-2008 to 55.3% in 2017-2018 (P-value for trend = 0.03). The percentage of participants whose glycaemic, lipid or all three risk factor control targets were achieved remained stable temporally (P > 0.05). Some patient characteristics were significantly related to risk factor control, including age 45-64, age ≥65, Asian Americans, non-Hispanic Blacks, higher family income, and being overweight and obese. A trend towards increased use of glucose-lowering medication was found (from 71.0% in 2007-2008 to 94.7% in 2017-2018, P < 0.01), while the prevalence of taking blood pressure-lowering and lipid-lowering medications remained stable (P > 0.05).

CONCLUSION

Based on NHANES data, a significant trend towards decreased blood pressure control was observed in patients with gout, while glycaemic and lipid control levelled off. These findings emphasize that more endeavours are needed to improve management of cardiovascular risk factors in patients with gout.

Trends and influence factors in the prevalence, intervention, and control of metabolic syndrome among US adults, 1999-2018

AIM

We aimed to describe the trends in the prevalence, intervention, and control of metabolic syndrome (MetS) among US adults through 1999-2018. Additionally, the influence factors of MetS and its control were further explored.

METHODS

We included participants older than 20 using the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 (n = 22,114). The rate of prevalence, intervention, and control of MetS were caculated by survey weights. Joinpoint regression and survey-weighted generalized linear models were used to analyze trends and influence factors, respectively.

RESULTS

The prevalence of MetS increased from 28.23 to 37.09% during 1999-2018 (P for trend < 0.05). The former smoker (OR = 1.20, 95%CI: 1.07, 1.36) and current smoker (OR = 1.27, 95%CI: 1.11, 1.45) increased the prevalence of MetS. While vigorous activity (OR = 0.53, 95%CI: 0.47, 0.61) decreased it. Among MetS components, the prevalence of elevated blood-glucose (from 21.18 to 34.68%) and obesity (from 44.81 to 59.06%) raised (P for trend < 0.05), with an uptrend in the use of antidiabetic (from 9.87 to 28.63%) and a downtrend of vigorous activity (from 23.79 to 16.53%) (P for trend < 0.05). Decreased trends were observed in the control of Hb1Ac (< 7%) (from 87.13 to 84.06%) and BMI (<25 kg/m²) (from 11.36 to 7.49%). Among MetS underwent antidiabetic, 45-64 years old and male decreased the control of Hb1Ac (< 7%). The control of BMI (<25 kg/m²) among individuals with physical activity was reduced mainly in the population of younger (aged 20-44 years old), male, non-Hispanic black, middle income and smoker (former and current).

CONCLUSIONS

The prevalence of MetS increased significantly through 1999-2018. Elevated blood glucose and obesity were the main causes of MetS burden. Quitting smoking and increasing physical activity may decrease the prevalence of MetS. In the control of blood-glucose and obesity, we should screen out the focus population to modify treatment and improve lifestyle.

Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill

Context

The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM).

Objective

This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM).

Methods

This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality).

Results

Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM.

Conclusion

These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.

Association between dietary theobromine with depression: a population-based study

OBJECTIVE

The purpose of this study is to investigate the possible link between dietary theobromine intake and symptoms of depression.

MATERIALS AND METHODS

These results are based on the responses of 3637 people who took part in the National Health and Nutrition Examination Survey in 2017-2018. Participants' daily theobromine intake was determined using a 24-h food questionnaire from the 2017-2018 cycle. Presence of depression was defined as a score of 5 or above on the Patient Health Questionnaire. Association between theobromine intake and depression was examined using a multivariate logistic regression adjusting for several relevant sociodemographic, lifestyle and health-related factors.

RESULTS

A total of 6903 participants were included in the study. The results of multivariate logistic regression showed a correlation between depressive symptoms and theobromine intake (OR:1.17, 95%CI:1.02-1.34).

CONCLUSIONS

Our cross-sectional population based study suggests that increased theobromine intake is associated with increased risk for depression. Nevertheless, more investigations are needed to confirm our findings.

Metformin and testosterone replacement therapy inversely associated with hormone-associated cancers (prostate, colorectal and male breast cancers) among older White and Black men

BACKGROUND

The independent and joint association of metformin and testosterone replacement therapy (TTh) with the incidence of prostate, colorectal, and male breast cancers remain poorly understood, including the investigation of the risk of these cancers combined (HRCs, hormone-associated cancers) among men of different racial and ethnic background.

METHODS

In 143,035 men (≥ 65 yrs old) of SEER-Medicare 2007-2015, we identified White (N = 110,430), Black (N = 13,520) and Other Race (N = 19,085) men diagnosed with incident HRC. Pre-diagnostic prescription of metformin and TTh was ascertained for this analysis. Weighted multivariable-adjusted conditional logistic and Cox proportional hazards models were conducted.

RESULTS

We found independent and joint associations of metformin and TTh with incident prostate (odds ratio [OR]joint  = 0.44, 95% confidence interval [CI]: 0.36-0.54) and colorectal cancers (ORjoint  = 0.47, 95% CI: 0.34-0.64), but not with male breast cancer. There were also inversed joint associations of metformin and TTh with HRCs (ORjoint  = 0.45, 95% CI: 0.38-0.54). Similar reduced associations with HRCs were identified among White, Black, and Other Race men.

CONCLUSION

Pre-diagnostic use of metformin and TTh were, independently and jointly, inversely associated with incident prostate and colorectal cancers. The risk of HRCs was also reduced among White, Black and Other Race men. Greatest reduced associations of prostate and colorectal cancers and HRCs were mainly observed in combination of metformin and TTh. Larger studies are needed to confirm the independent and joint association of metformin plus TTh with these cancers in understudied and underserved populations.

Association between Parkinson's Disease and Diabetes Mellitus: From Epidemiology, Pathophysiology and Prevention to Treatment

Diabetes mellitus (DM) and Parkinson's disease (PD) are both age-related diseases of global concern being among the most common chronic metabolic and neurodegenerative diseases, respectively. While both diseases can be genetically inherited, environmental factors play a vital role in their pathogenesis. Moreover, DM and PD have common underlying molecular mechanisms, such as misfolded protein aggregation, mitochondrial dysfunction, oxidative stress, chronic inflammation, and microbial dysbiosis. Recently, epidemiological and experimental studies have reported that DM affects the incidence and progression of PD. Moreover, certain antidiabetic drugs have been proven to decrease the risk of PD and delay its progression. In this review, we elucidate the epidemiological and pathophysiological association between DM and PD and summarize the antidiabetic drugs used in animal models and clinical trials of PD, which may provide reference for the clinical translation of antidiabetic drugs in PD treatment.

Iron metabolism in non-alcoholic fatty liver disease: A promising therapeutic target

Non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease worldwide, and is closely associated with the increased risk of the prevalence of obesity and diabetes. NAFLD begins with the presence of >5% excessive lipid accumulation in the liver, and potentially develops into non-alcoholic steatohepatitis, fibrosis, cirrhosis and hepatocellular carcinoma. Therefore, insight into the pathogenesis of NAFLD is of key importance to its effective treatment. Iron is an essential element in the life of all mammalian organisms. However, the free iron deposition is positively associated with histological severity in NAFLD patients due to the production of reactive oxygen species via the Fenton reaction. Recently, several iron metabolism-targeted therapies, such as phlebotomy, iron chelators, nanotherapeutics. and ferroptosis, have shown their potential as a therapeutic option in the treatment of NAFLD and as a clinical strategy to intervene in the progression of NAFLD. Herein, we review the recent overall evidence on iron metabolism and provide the mechanism of hepatic iron overload-induced liver pathologies and the recent advances in iron metabolism-targeted therapeutics in the treatment of NAFLD.

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of cardiovascular disease and all-cause mortality in individuals with prediabetes and diabetes: Evidence from two prospective cohorts

AIMS

To investigate the impacts of frailty on the progression of prediabetes to diabetes, cardiovascular disease (CVD) and all-cause mortality in individuals with prediabetes and diabetes.

METHODS

7,933 subjects with prediabetes and diabetes were included from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA). Frailty status was assessed by frailty index and classified as robust, pre-frail, and frail. Logistic regression was used to calculate risks of progression to diabetes. Cox regression was used to calculate risks of CVD and all-cause mortality.

RESULTS

In prediabetes, frail subjects had significantly increased risks of progression to diabetes (CHARLS, OR = 1.55, 95 %CI: 1.09-2.20; ELSA, OR = 1.86, 95 %CI: 1.02-3.37) compared with robust subjects. Frail subjects with prediabetes also presented significantly increased risks of CVD (CHARLS: HR = 1.90, 95 %CI: 1.45-2.48; ELSA: HR = 1.94, 95 %CI: 1.31-2.88) and all-cause mortality (CHARLS: HR = 2.45, 95 %CI: 1.79-3.36; ELSA: HR = 2.13, 95 %CI: 1.46-3.10) than robust subjects with prediabetes. In diabetes, frailty still increased risks of CVD (CHARLS, HR = 2.72, 95 %CI: 1.97-3.77; ELSA, HR = 2.41, 95 %CI: 1.43-4.06) and all-cause mortality (CHARLS, HR = 2.28, 95 %CI: 1.56-3.33; ELSA, HR = 2.28, 95 %CI: 1.47-3.53).

CONCLUSIONS

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of CVD and all-cause mortality in individuals with prediabetes and diabetes.

TSH levels within the normal range and risk of cardiovascular and all-cause mortality among individuals with diabetes

BACKGROUND

Evidence regarding thyroid-stimulating hormone (TSH) levels within the normal range and mortality in adults with diabetes is scarce. This study aimed to identify the association between TSH levels and cardiovascular disease (CVD) and all-cause mortality among euthyroid patients with diabetes.

METHODS

This prospective cohort study included 1830 adults with diabetes from the Third National Health and Nutrition Examination Survey III. Mortality outcomes were ascertained by linkage to National Death Index records through December 31, 2019. Participants were categorized by tertiles of TSH levels (low-normal, 0.39-1.30 mIU/L; medium-normal, 1.30-2.09 mIU/L; high-normal, 2.09-4.60 mIU/L). Multivariable Cox proportional hazards models were used to explore the association between TSH levels within the normal range and overall and CVD mortality. Furthermore, restricted cubic spline analyses were used to determine the nonlinear relationship between TSH levels and mortality.

RESULTS

During a median follow-up of 17.1 years, 1324 all-cause deaths occurred, including 525 deaths from CVD. After multivariate adjustment, a U-shaped relationship was observed between TSH levels in euthyroid status and all-cause or CVD mortality among patients with diabetes (both P < 0.05 for nonlinearity). Compared with participants with medium-normal TSH levels, those with high-normal TSH levels had a significantly higher risk of all-cause (hazard ratio, 1.31; 95% confidence interval, 1.07-1.61) and CVD (1.52; 1.08-2.12) mortality. Similarly, low-normal TSH levels also increased all-cause (1.39; 1.12-1.73) and CVD (1.69; 1.17-2.44) mortality risk. In stratum-specific analyses, we found that high-normal TSH levels were associated with higher mortality risk in younger (< 60 years) patients with diabetes but not in older (≥ 60 years) participants.

CONCLUSION

Low- and high-normal serum TSH levels were associated with increased all-cause and CVD mortality in euthyroid adults with diabetes. Further studies are needed to confirm the present observation in a wider population.

Association between Blood Manganese Levels and Visceral Adipose Tissue in the United States: A Population-Based Study

Background: Manganese (Mn) is an essential trace element with a narrow toxic margin for human health. The association between Mn exposure and adverse visceral adipose tissue (VAT) accumulation is unclear. Objective: This study aimed to estimate the associations of blood Mn levels with VAT mass or visceral obesity in the general population in the United States. Method: This cross-sectional study included data of 7297 individuals released by National Health and Nutrition Examination Survey (NHANES). VAT was quantified with dual-energy X-ray absorptiometry, and blood Mn was measured using inductively coupled plasma mass spectrometry. The generalized linear model and generalized additive model (GAM) were applied to estimate the linear and non-linear associations between Mn levels and VAT mass, respectively. Logistic regression was used to estimate the associations between blood Mn levels and the risk of visceral obesity. Results: Fully adjusted generalized linear regression revealed that individuals in the higher quantile of Mn had increased VAT mass compared with those in the lower quantile (β per quantile change = 0.025; 95% CI of 0.017, 0.033; p < 0.001). Positive associations were also observed in males and females (males: β per quantile change = 0.012, 95% CI of 0.002, 0.022 (p = 0.020); female: β per quantile change = 0.036; 95% CI of 0.023, 0.048 (p < 0.001)). The GAM illustrated that the non-linear associations between blood Mn levels and VAT mass were in U-shape patterns (effective degree of freedom >1 in total participants, males, and females). A stratified analysis found significant interactions between Mn and the family income-to-poverty ratio (PIR) in males, with stronger associations in males with a PIR < 1.3 (β = 0.109; 95% CI of 0.048, 0.170). Additional analyses revealed that individuals in the highest quantile of Mn had a 39% higher risk of visceral obesity (OR = 1.39; 95% CI of 1.15−1.69; p < 0.001). Conclusions: Higher blood Mn levels were positively associated with increased VAT mass and visceral obesity risk. The adverse VAT phenotype associated with excessive blood Mn levels should be further investigated.