International clinical harmonization of glycated hemoglobin in Japan: From Japan Diabetes Society to National Glycohemoglobin Standardization Program values

New risk prediction model of coronary heart disease in participants with and without diabetes: Assessments of the Framingham risk and Suita scores in 3-year longitudinal database in a Japanese population

The Framingham Risk Score (FRS) has been reported to predict coronary heart disease (CHD), but its assessment has been unsuccessful in Asian population. We aimed to assess FRS and Suita score (a Japanese CHD prediction model) in a Japanese nation-wide annual health check program, participants aged 40-79 years were followed up longitudinally from 2008 to 2011. Of 35,379 participants analyzed, 1,234 had new-onset CHD. New-onset CHD was observed in diabetic men [6.00%], non-diabetic men [3.96%], diabetic women [5.51%], and non-diabetic women [2.86%], respectively. Area under the curve (AUC) of receiver operating characteristic (ROC) curve for CHD prediction were consistently low in Suita score (TC), FRS (TC) and NCEP-ATPIII FRS (TC), suggesting that these scores have only a limited power. ROC, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA) and Hosmer-Lemeshow goodness-of-fit test did not show clear differences between Suita score (TC) and FRS (TC). New models combining waist circumference ≥85 cm in men or proteinuria ≥1+ in women to Suita score (TC) was superior in diabetic men and women. New models could be useful to predict 3-year risk of CHD at least in Japanese population especially in diabetic population.

Usefulness of hemoglobin A1c and glycated albumin measurements for insulinoma screening: an observational case-control study

Background

Insulinoma represents hypoglycemia as a predominant symptom; the autonomic symptoms may be resolved by chronically recurrent hypoglycemia resulting in the persistence of non-specific symptoms alone. Therefore, it has been estimated that there are many patients in whom the disease takes longer to diagnose and has remained undiagnosed. Although some parameters exist for the definitive diagnosis of the disease, there are currently no indices for early screening. Indices of glycemic control, hemoglobin A1c (HbA1c), and glycated albumin (GA) may be useful for the screening of patients with insulinoma having chronic hypoglycemia because the values become low in such a condition. Because there are no articles that have reported the point, we examine the effective cutoff values of HbA1c and GA for the diagnosis of insulinoma in the present study.

Methods

In a multicenter cross-sectional study, 31 patients with insulinoma were included for comparison with 120 control subjects with normal glucose tolerance based on 75 g oral glucose tolerance tests whose characteristics were matched to the patients. The primary outcomes were optimal cutoff values of HbA1c and GA for the screening of insulinoma.

Results

HbA1c was significantly lower in the insulinoma group at 4.7 ± 0.4% compared to the healthy control group at 5.7 ± 0.3% (p < 0.001), and GA was significantly lower in the insulinoma group at 11.6 ± 1.8% compared to the healthy control group at 14.5 ± 1.0% (p < 0.001). According to a receiver operating characteristic (ROC) analysis, optimal cutoff values of HbA1c and GA for the diagnosis of insulinoma were 5.0 and 12.4%, respectively. Area under the curve values of HbA1c and GA were 0.970 and 0.929, respectively, showing no significant difference (p = 0.399).

Conclusions

In the present study, HbA1c and GA values in patients with insulinoma were significantly lower compared to the healthy controls, and effective cutoff values for screening were shown in the diagnosis of insulinoma for the first time. HbA1c and GA can be useful indices for insulinoma screening. Because malignant insulinoma have a similar diagnostic process to that of benign insulinoma, these could be useful for malignant insulinoma.

Kanagawa Investigation of the Total Check-up Data from the National database (KITCHEN): protocol for data-driven population-based repeated cross-sectional and 6-year cohort studies

INTRODUCTION

The unmitigated incidence of cardiometabolic diseases, such as type 2 diabetes and metabolic syndrome, has gained attention in Japan. 'Big data' can be useful to clarify conflicting observations obtained from studies with small samples and about rare conditions that are often neglected. We epidemiologically address these issues using data from health check-ups conducted in Kanagawa Prefecture, the prefecture with the second largest population in Japan, in the Kanagawa Investigation of the Total Check-up Data from the National Database (KITCHEN).

METHODS AND ANALYSIS

This research consists of a series of population-based cross-sectional studies repeated from 2008-2014 and 6-year cohort studies. Since 2017, we have reviewed the data of people living in Kanagawa Prefecture who underwent a health check-up mainly for general health and the prevention of metabolic syndrome. The sample size ranges from 1.2 million to 1.8 million people in the cross-sectional studies and from 370 000 to 590 000 people in the cohort studies. These are people aged 40-74 years, whose clinical parameters were measured and who responded individually to a questionnaire. We investigate potential associations and causalities of various aetiologies, including diabetes and metabolic syndrome, using clinical data and lifestyle information. With multidisciplinary analysis, including data-driven analysis, we expect to obtain a wide range of novel findings, to confirm indeterminate previous findings, especially in terms of cardiometabolic disease, and to provide new perspectives for human health promotion and disease prevention.

ETHICS AND DISSEMINATION

Ethical approval was received from the Ethics Committee of Kanagawa University of Human Services (10-43). The protocol was approved in December 2016 by the Japanese Ministry of Health, Labour and Welfare (No. 121). The study results will be disseminated through open platforms including journal articles, relevant conferences and seminar presentations.

Combined effect of diabetes and frailty on mortality and incident disability in older Japanese adults

Aim

Evidence is limited on how frailty affects the association between diabetes and adverse outcomes at the population level. The present community‐based study aimed to clarify the relative risks of death and disability in older Japanese adults with diabetes, frailty, both or neither.

Methods

The present prospective study analyzed data from 1271 Japanese residents aged ≥65 years in Kusatsu town in Gunma Prefecture, Japan, who participated in annual health checkups carried out between 2002 and 2011, and were initially free of disability. A Cox proportional hazards regression model was used to identify associations of diabetes and frailty with all‐cause mortality and incident disability.

Results

Among the 1271 participants, 176 (14%) had diabetes (mean hemoglobin A1c 7.5%, body mass index 24.2 kg/m², 45% using diabetes medications) and 151 (12%) had frailty at baseline. Compared with non‐frail participants without diabetes, those with diabetes and frailty had higher risks of mortality (multivariable hazard ratio 5.0, 95% CI 2.4–10.3) and incident disability (hazard ratio 3.9, 95% CI 2.1–7.3). In contrast, non‐frail participants with diabetes did not have a significantly increased risk of mortality, although they had a higher tendency for the incidence of disability, as compared with non‐frail participants without diabetes.

Conclusions

At the population level, the risks of death and disability in persons with mild diabetes were strongly affected by the presence of frailty. From a community‐based perspective, diabetes‐related mortality and disability incidence might be reduced by preventing or improving frailty in conjunction with glycemic control. Geriatr Gerontol Int 2019; 19: 423–428.

Cognitive impairment, brain ischemia and shorter telomeres are predictors of mortality in the Japanese elderly: A 13-year prospective community-based study

OBJECTIVE

To examine whether cognitive impairment, deep white matter hyperintensity (DWMH) on brain MRI, and shorter telomere length would be predictors of mortality in community-dwelling Japanese elderly.

METHODS

We followed 259 individuals (74% of all the residents at age 70) from age 70 to 83 years. The mean observation period was 133 ± 34 months. The key clinical characteristics examined included DWMH on brain MRI and cognitive function. Telomere length was also measured in 81 subjects. Both univariate and multivariate analyses were performed.

RESULTS

Of the 259 subjects, 69 subjects (30 men, 39 women; 26.6%) died during the follow-up period. Cognitive impairment, smoking habits, diabetes mellitus, and moderate to severe DWMH were significant predictors of total mortality in univariate analysis. However, only cognitive impairment and moderate to severe DWMH remained as significant independent predictors of death in multivariate analysis. The rate of mortality increased with additional number of risk factors (cognitive impairment and DWMH). The total mortality of subjects with both cognitive impairment and DWMH was 71.4%. The median telomere length was 7.8 kb in the deceased and 8.2 kb in the living subjects. The deceased subjects had significantly shorter telomere length (P = .0025) than the living subjects. Telomere length with moderate to severe DWMH was higher than without moderate to severe DWMH on brain MRI (P = .017).

CONCLUSIONS

The present study revealed that cognitive impairment, DWMH, and shorter telomere length were significant predictors of total mortality in the community-dwelling Japanese elderly. Furthermore, the combination of cognitive impairment and DWMH increased the mortality rate, as compared with a single risk factor. It is also clarified that a significant difference was present in telomere length by severity of DWMH.

Association between postprandial hyperglycemia at clinic visits and all-cause and cancer mortality in patients with type 2 diabetes: A long-term historical cohort study in Japan

AIMS

To evaluate the effect of postprandial hyperglycemia at clinic visits on all-cause and cancer mortality independent of glycated hemoglobin (HbA1c) levels in a real-world setting in Japanese patients with type 2 diabetes. We also investigated age at death.

METHODS

This historical cohort study included 1582 patients with type 2 diabetes who first visited our clinic from 1995 to 1998 and continued visiting for at least 1 year. The patients were followed up through 2017. Blood glucose levels at 2 h ± 30 min post-breakfast (2h-PBBG) were measured in 926 patients during the first year. The first measurements of 2h-PBBG levels were used as a measure of postprandial hyperglycemia.

RESULTS

A total of 233 patients died. The average age at death (men/women) was 75.6/80.8 years. A total of 139 patients who had 2h-PBBG levels measured died, including 46 deaths from cancer. Multivariate Cox regression analysis showed that 2h-PBBG levels significantly predicted all-cause and cancer mortality independent of HbA1c levels.

CONCLUSIONS

Postprandial hyperglycemia at clinic visits may be associated with all-cause and cancer mortality in patients with type 2 diabetes independent of HbA1c levels. As this is a small observational study, further studies are warranted to confirm our findings.

Exploratory analysis of comparative clinical trials used for marketing approval in patients with type 2 diabetes in Japan

Background/objectives:

The results of phase 2 and 3 clinical trials, which justify decisions regarding marketing approval for new drugs, are used for comparison of drugs in the post-marketing phase. A number of meta-analyses of approved antidiabetics have been performed, but the heterogeneity of trials has not been fully examined. The aim of this study was to explore factors that may influence baseline HbA1c in trial samples and treatment outcomes (i.e. HbA1c reductions and effect sizes), with the goal of providing unbiased and fair retrospective comparisons between different antidiabetics.

Method:

We conducted three meta-regression analyses using 78 randomized or non-randomized comparative phase 2 or 3 trials of 24 approved antidiabetics in Japan, conducted from 1987 to 2012.

Results:

Baseline HbA1c of each arm was higher in phase 2 trials, trials with a greater number of subjects, trials with a lower proportion of male subjects, trials of combination therapy, or trials with longer subject disease duration. Entry criteria were different among drug classes and caused variations in baseline HbA1c. HbA1c reductions were larger in non-randomized trials, trials with a shorter treatment period, or trials with a lower proportion of male subjects. Effect sizes were larger in phase 2 trials, or trials of combination therapy. Larger effect sizes were observed in drugs with later market entry for alpha-glucosidase inhibitors and glinides.

Conclusion:

Baseline HbA1c, an important characteristic of subjects enrolled in trials of antidiabetics, differed significantly across trials. Differences in features of study subjects were caused by explicit stipulations in eligibility criteria of HbA1c and also by other conditions (e.g. trial design, regulatory guidance, treatment guideline) and/or interventions of investigators and pharmaceutical companies that were specific to drugs and trials. Healthcare professionals should carefully consider these heterogeneities in trials used for marketing approval review when making a retrospective comparison to select the best treatment option for patients.

Repetition of Prediabetes Enhances the Risk of Developing Diabetes

We attempted to clarify the severity of the risk of diabetes mellitus (DM) in the individuals who repeatedly fulfill the criteria for prediabetes in both fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c). The subjects were 2347 individuals who underwent annual health checkup at our hospital. They were classified as normal glucose tolerance or prediabetes as their yearly status of glucose tolerance for three years; furthermore, the individuals classified as prediabetes were subclassified into 3 groups. Among them, we focused the individuals who fulfilled the criteria for prediabetes in both FPG and HbA1c, and this group was named as PD3. Similarly, all subjects were categorized into 4 groups by the frequency of the status of PD3 during three years. Moreover, all subjects were categorized into 8 patterns when PD3 status was positive. Then, we surveyed the development of diabetes for 5 years, and the incidence rates (IRs) and the age- and sex-adjusted odds ratios (ORs) were obtained. A total of 188 subjects developed diabetes. The individuals in the group of PD3 showed the highest IR of DM (33.6%). The values of ORs were 11.5, 20.0, and 63.5 when the frequencies of PD3 were one, two, and three, respectively. In the group whose frequency of PD3 was two, the individuals who had repeated the status of PD3 twice then moved to the status other than PD3 showed smaller risk of DM than the others in the same group. In conclusion, individuals who fulfill the criteria for prediabetes in both FPG and HbA1c were at a high risk of developing DM, and the risk was enhanced by repeating this status. On the other hand, changing the status from PD3 to others might reduce the risk of DM.

Improvement of glycemic control by treatment for insomnia with suvorexant in type 2 diabetes mellitus

Introduction

Acute and chronic insomnia can exacerbate type 2 diabetes mellitus (T2DM). We investigated suvorexant (an anti-insomnia drug that targets the orexin system) effects on sleep architecture and glucose metabolism in T2DM patients with insomnia.

Materials and methods

This 7 day open-label, single-arm, intervention trial included 18 subjects with T2DM and insomnia. After 1 day acclimatization, daily glucose levels, sleep architecture, and autonomic nervous function were evaluated by continuous glucose monitoring (CGM), single-channel electroencephalography, and accelerometry, respectively.

Results

Suvorexant treatment for 3 days significantly increased total sleep time and sleep efficiency, with partial suppression of sympathetic nerve activity. CGM-measured 24 h mean glucose level decreased significantly from 157.7 ± 22.9 to 152.3 ± 17.8 mg/dL, especially in the early glucose surge after the midnight nadir (from 28.3 ± 15.0 to 18.2 ± 9.9 mg/dL), and until supper with a significant improvement in homeostasis model assessment of insulin resistance from 4.0 ± 2.8 to 2.9 ± 1.6, respectively.

Conclusions

Suvorexant treatment for insomnia of subjects with T2DM significantly improved CGM-measured daily glycemic control, which was associated with changes in sympathomimetic tone and/or improved insulin sensitivity. The amelioration of insomnia may therefore be a target for improving glycemic control in T2DM patients with insomnia.

Glutamic Acid Decarboxylase Autoantibody-negative Slowly Progressive Type 1 Diabetes Mellitus: A Case Report and Literature Review

A 59-year-old non-obese Japanese woman developed diabetes mellitus with a negative glutamic acid decarboxylase autoantibody (GADA) test result. Her hyperglycemia was initially well controlled by oral hypoglycemic agents; however, despite continued treatment the hyperglycemia gradually worsened. As she had endogenous insulin deficiency and tested positive for insulin autoantibody (IAA), insulin therapy was initiated. Few studies have investigated GADA-negative patients with slowly progressive type 1 diabetes mellitus (SPT1D). Our IAA-positive SPT1D patient progressed from the clinical onset of diabetes mellitus to starting insulin therapy relatively quickly (1.5 years), similarly to other previously reported non-obese patients with GADA-positive SPT1D.

Malignancy incidences by glycemic control among diabetic patients

BACKGROUND

The aim of this study was to evaluate the difference in malignancy incidence by evaluating time-dependent HbA1c levels among diabetic patients in a longitudinal study.

METHODS

We conducted a retrospective longitudinal study at large academic hospital, Tokyo, Japan, from 2006 to 2016. We included all diabetic patients who were 50 years or older and who underwent health check-ups at the Center for Preventive Medicine. Those patients with a prior history of malignancies were excluded. We categorized patients into five groups on the basis of HbA1c measurements: <5.4, 5.5-6.4, 6.5-7.4, 7.5-8.5, >8.5%. Our primary outcome was the development of any types of malignancy. Longitudinal analyses by a mixed effect model with time-dependent HbA1c levels were applied in order to take into account fluctuations in HbA1c levels within the same patient.

RESULTS

In total, 2729 participants were included in this study, where the mean age was 62.6 (standard deviation (s.d.): 7.8) and 2031 (74.4%) were male. The mean disease duration of diabetes was 7.6 (s.d.: 7.6) years, and 1688 (61.8%) were prescribed medications. Median follow-up was 1443.5 (interquartile range (IQR): 2508) days and 376 (13.8%) developed malignancies. Compared to the reference range of HbA1c (5.5-6.4%), the odds ratios for developing malignancies among the other HbA1c level groups were similar and not statistically different (OR: 0.98, 95% CI:0.31-3.15 (for HbA1c <5.4%); OR: 0.88, 95% CI: 0.69-1.12 (for HbA1c 6.5-7.4%); OR: 0.88, 95% CI: 0.64-1.22 (for HbA1c 7.5-8.4%); OR 1.07, 95% CI: 0.70-1.66 (for HbA1c >8.5%)).

CONCLUSION

In our study, there was no association between glycemic control and the development of future malignancies. Compared to very strictly controlled HbA1c levels, both excessive control and good or bad control had a statistically similar risk of developing malignancies.

Prediction of Glucose Metabolism Disorder Risk Using a Machine Learning Algorithm: Pilot Study

Background

A 75-g oral glucose tolerance test (OGTT) provides important information about glucose metabolism, although the test is expensive and invasive. Complete OGTT information, such as 1-hour and 2-hour postloading plasma glucose and immunoreactive insulin levels, may be useful for predicting the future risk of diabetes or glucose metabolism disorders (GMD), which includes both diabetes and prediabetes.

Objective

We trained several classification models for predicting the risk of developing diabetes or GMD using data from thousands of OGTTs and a machine learning technique (XGBoost). The receiver operating characteristic (ROC) curves and their area under the curve (AUC) values for the trained classification models are reported, along with the sensitivity and specificity determined by the cutoff values of the Youden index. We compared the performance of the machine learning techniques with logistic regressions (LR), which are traditionally used in medical research studies.

Methods

Data were collected from subjects who underwent multiple OGTTs during comprehensive check-up medical examinations conducted at a single facility in Tokyo, Japan, from May 2006 to April 2017. For each examination, a subject was diagnosed with diabetes or prediabetes according to the American Diabetes Association guidelines. Given the data, 2 studies were conducted: predicting the risk of developing diabetes (study 1) or GMD (study 2). For each study, to apply supervised machine learning methods, the required label data was prepared. If a subject was diagnosed with diabetes or GMD at least once during the period, then that subject’s data obtained in previous trials were classified into the risk group (y=1). After data processing, 13,581 and 6760 OGTTs were analyzed for study 1 and study 2, respectively. For each study, a randomly chosen subset representing 80% of the data was used for training 9 classification models and the remaining 20% was used for evaluating the models. Three classification models, A to C, used XGBoost with various input variables, some including OGTT data. The other 6 classification models, D to I, used LR for comparison.

Results

For study 1, the AUC values ranged from 0.78 to 0.93. For study 2, the AUC values ranged from 0.63 to 0.78. The machine learning approach using XGBoost showed better performance compared with traditional LR methods. The AUC values increased when the full OGTT variables were included. In our analysis using a particular setting of input variables, XGBoost showed that the OGTT variables were more important than fasting plasma glucose or glycated hemoglobin.

Conclusions

A machine learning approach, XGBoost, showed better prediction accuracy compared with LR, suggesting that advanced machine learning methods are useful for detecting the early signs of diabetes or GMD. The prediction accuracy increased when all OGTT variables were added. This indicates that complete OGTT information is important for predicting the future risk of diabetes and GMD accurately.

The association between glycemic control and lung function impairment in individuals with diabetes: the Saku study

Aim

Though diabetes is a risk factor for lung function impairment, whether the glycemic control level affects lung function in individuals with diabetes remains unclear. The present study aimed to assess the association between glycemic control level and restrictive or obstructive lung function impairment in individuals with diabetes.

Methods

This cross-sectional study included 1028 individuals with diabetes, aged 40-69 years, who underwent a medical checkup between April 2008 and March 2014. Hemoglobin A1c (HbA1c) was categorized as  < 6.9%, 7.0-7.9%, and  ≥ 8.0%. Restrictive and obstructive lung function impairment was defined by a forced vital capacity (FVC) < 80% predicted and a forced expiratory volume in 1 s to FVC ratio < 0.70.

Results

Of the participants, 8.7% and 6.3% were classified as having restrictive and obstructive lung function impairment, respectively. The multivariable-adjusted odds ratios and 95% confidence intervals for restrictive lung function impairment were 1.43 (0.84-2.42) in individuals with HbA1c 7.0-7.9%, and 2.42 (1.38-4.26) in individuals with HbA1c ≥ 8.0%, compared with those who had HbA1c < 6.9% (p for trend = 0.002). In contrast, glycemic control level was not associated with obstructive lung function impairment (p for trend = 0.749).

Conclusions

Poor glycemic control was associated with restrictive lung function impairment in individuals with diabetes. Good glycemic control would be important to minimize restrictive lung function impairment in individuals with diabetes.

Trends in the prevalence of type 2 diabetes and prediabetes in a Japanese community, 1988-2012: the Hisayama Study

Objective

We estimated secular trends in the prevalence of type 2 diabetes (T2DM) and prediabetes, and examined potential explanatory factors for these trends in a Japanese community.

Methods

4 cross-sectional examinations were conducted among subjects aged 40-79 years in 1988 (n = 2,490), 2002 (n = 2,856), 2007 (n = 2,761), and 2012 (n = 2,644). Glucose tolerance status was defined by a 75g oral glucose tolerance test.

Results

The age-standardized prevalence of T2DM increased significantly in both sexes from 1988 to 2002, and thereafter it remained stable in men, and decreased nonsignificantly in women from 2002 to 2012. The age-standardized prevalence of prediabetes in men increased significantly between 1988 and 2002, but then decreased significantly. A similar trend was observed in women. The age-specific prevalence of T2DM increased greatly in men aged 60-79 years and women aged 70-79 years from 1988 to 2002, and then plateaued at a high level, while a significant decreasing trend was observed in women aged 40-49 years. The mean values of body mass index (BMI) increased steeply in these elderly subjects from 1988 to 2002, and remained at a high level, whereas those in middle-aged women decreased appreciably over the study period.

Conclusions

Our findings suggest that in Japanese, there was no further increase in the prevalence of T2DM or prediabetes in either men or women in the 2000s. Secular change in the BMI level was likely to contribute to trends in the prevalence of T2DM, and thus the management of obesity may be important to reduce the prevalence of T2DM.

Differences Between Coronary Artery Calcification and Aortic Artery Calcification in Relation to Cardiovascular Disease Risk Factors in Japanese Men

AIMS

Calcification in the coronary and aortic arteries has been linked to cardiovascular morbidity and mortality. The pathophysiological influence of aortic artery calcification (AAC) differs from that of coronary artery calcification (CAC). We aimed to compare the relationships between CAC and AAC and cardiovascular disease (CVD) risk factors.

METHODS

We examined a random sample of 1035 Japanese men aged 40-79 years. CAC and AAC were measured by computed tomography and scored according to the Agatston method. Using a logistic regression, we calculated the odds ratio (OR) as being in the highest quintile (Q5) of the calcification score compared to the lower quintiles (Q1-Q4) per 1 standard deviation higher CVD risk factor. Models were simultaneously adjusted for age, body mass index (BMI), systolic blood pressure, smoking (pack-year), alcohol intake, hemoglobin A1c, uric acid, estimated glomerular filtration rate (eGFR), serum lipids, and C-reactive protein. Differences in ORs were investigated using a generalized estimating equation. We performed a multiple linear regression using log-transformed CAC and AAC values as dependent variables.

RESULTS

CAC and AAC were independently associated with age (OR, 95% CI: 2.30 [1.77-2.98] for CAC and 3.48 [2.57-4.73] for AAC), p for difference ＜0.001), systolic blood pressure (1.29 [1.08-1.53] and 1.28 [1.07-1.54], p for difference=0.270), and smoking (1.22, [1.04-1.43] and 1.34 [1.13-1.58]) p for difference=0.071). Alcohol correlated with AAC only (1.17 [0.97-1.41] for CAC and 1.42 [1.16-1.73] for AAC, p for difference= 0.020).

CONCLUSIONS

CAC and AAC were associated with similar CVD risk factors. The strength of association slightly differed between CAC and AAC.

Inverse association of light-to-moderate alcohol drinking with cardiometabolic index in men with diabetes mellitus

AIMS

Cardiometabolic index (CMI), calculated as the product of waist-to-height ratio and triglycerides-to-HDL cholesterol ratio, has been proposed as a discriminator of diabetes and has been reported to be associated with progression of atherosclerosis. The purpose of this study was to determine the relationship between alcohol drinking and CMI in men with diabetes.

METHODS

The subjects were Japanese male workers aged from 35 to 65 years with diabetes mellitus (n = 1411). The subjects were divided by average daily alcohol consumption (g ethanol/day) into 4 categories of alcohol drinking (nondrinkers; light drinkers, < 22; moderate drinkers, ≥ 22 and < 44; heavy drinkers, ≥ 44). CMI and variables comprising CMI were compared in the nondrinker and each of the drinker groups. Age, habits of smoking and regular exercise, and a present history of medication therapy for diabetes were adjusted in each analysis.

RESULTS

Log-transformed CMI was significantly lower in light and moderate drinkers than in nondrinkers. Waist-to-height ratio was significantly lower in moderate drinkers than in nondrinkers, while log-transformed triglycerides was significantly higher in heavy drinkers than in nondrinkers. HDL cholesterol tended to be higher with an increase of alcohol consumption. Odds ratios with their 95% confidence intervals vs. nondrinkers for high CMI were 0.53 (0.36-0.78) in light drinkers, 0.61 (0.46-0.80) in moderate drinkers, and 0.74 (0.55-1.00) in heavy drinkers.

CONCLUSIONS

In men with diabetes, CMI is lower in light-to-moderate drinkers than in nondrinkers, and this results mainly from a positive association between alcohol drinking and HDL cholesterol.

Characterization of changes in HbA1c in patients with and without secondary failure after metformin treatments by a population pharmacodynamic analysis using mixture models

The objective of the present study was to develop a population pharmacodynamic (PPD) model to describe the glycated hemoglobin (HbA1c)-lowering effects of metformin in type 2 diabetes mellitus patients with and without secondary failure and to characterize changes in HbA1c levels in the two subpopulations using a mixture model. Information on patients was collected retrospectively from electronic medical records. In this study, the mixture model was used to characterize the bimodal effects of metformin. A PPD analysis was performed using NONMEM 7.3.0. A physiological indirect response model, based on 829 HbA1c levels of 69 patients, described the time course for the HbA1c-lowering effects of metformin. Evidence for the different effectiveness of metformin subpopulations was provided using the mixture model. In the final PPD model, the inhibition effect was constant over a study duration in a patient subpopulation without secondary failure. In contrast, the inhibition effect decreased as a function of time after start of metformin treatment in a subpopulation with secondary failure. These results indicated that HbA1c improvements appeared to deteriorate over time in patients with secondary failure. In a PPD analysis of metformin, it was possible to assign patients with secondary failure using the mixture model.

Shortened mean erythrocyte age in female patients with type 2 diabetes mellitus

BACKGROUND

The hyperglycemic state is known to shorten the erythrocyte life span. Erythrocyte creatine (EC) reflects the mean erythrocyte age and is useful as an indicator of hemolysis. Here, we studied the relationship between EC and glycemic control indicators [HbA1c or glycated albumin (GA)] in non-diabetic subjects and diabetic patients.

METHODS

This study included 119 patients with type 2 diabetes mellitus (T2DM) and 76 non-diabetic subjects matched by sex and age. We studied the relationships between EC and HbA1c or GA in patients with T2DM and non-diabetic subjects.

RESULTS

Erythrocyte creatine in T2DM patients was significantly higher than that in non-diabetic subjects, and the ratio of high EC levels (>1.8 μmol/g Hb) in T2DM patients was significantly higher as well. Furthermore, female EC was significantly higher than male EC, and the ratio of high EC levels in females was significantly higher than in the males as well. While male EC had no significant correlation with HbA1c or GA, female EC had significant positive correlations with both. Male EC had no significant difference between T2DM patients and non-diabetic subjects, while the EC in female patients with T2DM was significantly higher than in female non-diabetic subjects.

CONCLUSIONS

The significant positive correlations of EC with HbA1c and GA in female patients with T2DM suggested that the mean erythrocyte age decreased in female diabetic patients with poor glycemic control.

ALDH2 Polymorphism rs671, but Not ADH1B Polymorphism rs1229984, Increases Risk for Hypo-HDL-Cholesterolemia in a/a Carriers Compared to the G/G Carriers

It has been reported that polymorphisms within the gene-encoding enzymes related to alcohol metabolism are associated with levels of serum HDL-cholesterol (HDL-C) in East Asian populations. We evaluated the effects of genetic variants within the aldehyde dehydrogenase-2 (ALDH2) gene and the alcohol dehydrogenase-1B (ADH1B) gene on changes in the lipid profile in an 11-year longitudinal study. We genotyped rs1229984 within ADH1B and rs671 within ALDH2. We combined the genetic data with longitudinal clinical and biochemical data from 2002 to 2013 and designed a retrospective longitudinal study of 1436 Japanese males. There were significant negative relationships between rs671 within ALDH2 and HDL-C levels according to multiple linear regression analysis. Next, we assessed the association between the development of hypo-HDL cholesterolemia and rs1229984 within ADH1B or rs671 within ALDH2. In logistic regression analysis, rs671 A allele homozygote carriers have 2.65 times higher risk of developing hypo-HDL cholesterolemia than G allele homozygote carriers. Even after adjusting for possible confounding factors, a significant association was observed. However, no association between rs1229984 within ADH1B and the development of hypo-HDL cholesterolemia was observed. Rs671 within ALDH2 but not rs1229984 within ADH1B was associated with lower HDL-C levels in Japanese males.

Change in Pericardial Fat Volume and Cardiovascular Risk Factors in a General Population of Japanese Men

BACKGROUND

Pericardial fat volume (PFV), defined as the volume of ectopic fat in and around the heart, is associated with the atherosclerotic process in coronary arteries. The magnitude of change in PFV over time and the factors affecting this change in a general population, however, have not been investigated.

METHODS AND RESULTS

Cardiac computed tomography (CT) was carried out at baseline and at follow-up in 623 Japanese men aged 40-79 years without a history of cardiovascular disease who were selected randomly in Kusatsu (Shiga, Japan). PFV was measured on cardiac CT in a qualified laboratory. Age, heart rate, triglycerides, and obesity measurements (weight, body mass index, and waist circumference) were significantly and positively associated with PFV at baseline. Over an average interval of 4.7 years, median PFV increased significantly from 64.1 cm3 (IQR, 47.2-90.0 cm3) to 73.6 cm3 (IQR, 53.3-98.1 cm3; P<0.001). Current smoking and heart rate were significantly and independently associated with changes in PFV (B=3.336, P<0.001 and B=6.409, P=0.003, respectively).

CONCLUSIONS

PFV increased significantly over time in a population-based observational study of Japanese men. PFV change was significantly and independently associated with smoking status and heart rate, suggesting that quitting smoking might help reduce PFV, which could be expected to decrease the risk of coronary artery disease.

Haemoglobin A1c and hearing impairment: longitudinal analysis using a large occupational health check-up data of Japan

OBJECTIVES

The aim of this study was to determine whether haemoglobin A1c (HbA1c) level is associated with the incidence of hearing impairment accounting for smoking status and diabetic condition at baseline.

METHODS

Participants were 131 689 men and 71 286 women aged 30-65 years and free of hearing impairment at baseline (2008) who attended Japanese occupational annual health check-ups from 2008 to 2015. We defined low-frequency hearing impairment at a hearing threshold >30 dB at 1 kHz and high frequency at >40 dB at 4 kHz in the better ear in pure-tone audiometric tests. HbA1c was categorised into seven categories. The association between HbA1c and hearing impairment was assessed using the Cox proportional hazards model.

RESULTS

On 5 years mean follow-up, high HbA1c was associated with high-frequency hearing impairment. In non-smokers, HbA1c≥8.0% was associated with high-frequency hearing impairment, with a multivariable HR (95% CI) compared with HbA1c 5.0%-5.4% of 1.46 (1.10 to 1.94) in men and 2.15 (1.13 to 4.10) in women. There was no significant association between HbA1c and hearing impairment in smokers. A J-shaped association between HbA1c and high-frequency hearing impairment was observed for participants with diabetes at baseline. HbA1c was not associated with low-frequency hearing impairment among any participants.

CONCLUSIONS

HbA1c ≥8.0% of non-smokers and ≥7.3% of participants with diabetes was associated with high-frequency hearing impairment. These findings indicate that appropriate glycaemic control may prevent diabetic-related hearing impairment.

Relationships of oxidized HDL with blood coagulation and fibrinolysis in patients with type 2 diabetes mellitus

Although oxidization of LDL is known to be a crucial step for atherosclerotic progression, the significance of oxidized HDL remains to be clarified. The purpose of this study was to determine the relationships of oxidized HDL with blood coagulation and fibrinolysis in patients with diabetes. The subjects were outpatients with type 2 diabetes (n = 163; median hemoglobin A1c, 6.9%). Activities of blood coagulation and fibrinolysis were evaluated by levels of thrombin-anti-thrombin complex (TAT) and plasmin-α2 plasmin inhibitor complex (PIC), respectively. Relationships of oxidized HDL with TAT and PIC were investigated by using linear regression analysis and logistic regression analysis. Oxidized HDL showed a significant inverse correlation with TAT and a marginally significant correlation with PIC (Spearman's rank correlation coefficient: TAT, - 0.205 [p < 0.01]; PIC, - 0.135 [p = 0.087]). Prevalence of high TAT was significantly lower in the 3rd tertile group for oxidized HDL than in its 1st tertile (20.4 vs. 5.6%, p < 0.05), and prevalence of high PIC was marginally significantly lower in the 3rd tertile group for oxidized HDL than in its 1st tertile (40.7 vs. 24.1%, p = 0.099). In multivariate logistic regression analysis using age, gender, smoking, alcohol drinking, BMI, hemoglobin A1c, therapy for dyslipidemia, therapy for diabetes and anti-coagulation therapy as explanatory variables, odds ratios for high TAT and high PIC in the 3rd tertile group for oxidized HDL versus its 1st tertile group were significantly lower than the reference level of 1.00 (high TAT: 0.19 [0.04-0.99], p < 0.05; high PIC: 0.33 [0.12-0.95], p < 0.05). The frequency of high TAT or high PIC was lower in the higher tertile group for oxidized HDL than in its lower tertile group. Thus, oxidized HDL is thought to be inversely associated with both blood coagulation and fibrinolysis in patients with type 2 diabetes.

Cross-cultural comparison of predictors for self-care behaviors in patients with type 2 diabetes

The aim of the present study was to evaluate how culture moderates the behavioral and psychosocial predictors of diabetes self-care activities. Patients with type 2 diabetes were recruited in the outpatient department at two sites: Kyoto University hospital in Japan and the Christiana Care Health System in the USA. The data were collected by survey using questionnaires including questions on the frequency of self-care activities, behavioral and psychosocial predictors, and other background information from 149 Japanese patients and 48 American patients. The cultural impact was observed by multiple regression analyses with interaction terms on the association between emotional support and self-care activities in diet in female patients. The findings of the present study serve as an example of how cultural context can affect patients with diabetes, and lead to a better understanding of culturally sensitive behavioral intervention.

Fulminant type 1 diabetes mellitus in Japanese children and adolescents: multi-institutional joint research of the Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes

Fulminant type 1 diabetes mellitus (FT1DM) is a subtype of type 1 diabetes mellitus characterized by a remarkably abrupt onset. In Japan, FT1DM accounts for approximately 20% of acute-onset adult type 1 diabetes mellitus cases; however, reports of pediatric-onset FT1DM are rare. We aimed to determine the frequency and clinical characteristics of FT1DM in Japanese children and adolescents by conducting a 2-phase questionnaire survey among the members of the Japanese Study Group of Insulin Therapy for Childhood and Adolescent Diabetes (JSGIT) regarding their clinical experience with FT1DM. Responses were obtained from 54 of the 79 participating hospitals (68.4%). Of these, 8 hospitals managed a total of 15 pediatric patients with FT1DM (4 patients in each of 2 hospitals, 2 patients in 1 hospital, and 1 patient in each of 5 hospitals). The distribution of patient age was biphasic, with peaks in children younger than 5 years and older than 8 years of age. The clinical characteristics of FT1DM in this population (such as the duration from onset of symptoms to diagnosis, severity of symptoms, preceding flu-like episodes, and abnormal laboratory data) did not differ from those of patients with adult-onset FT1DM. The frequency of pediatric-onset FT1DM is low compared with that of adult-onset FT1DM. The genetic background and susceptibility patterns of pediatric patients with FT1DM may differ from those typical of adults with FT1DM, but both age groups share similar clinical characteristics.

Effects of behavioral counseling on cardiometabolic biomarkers: A longitudinal analysis of the Japanese national database

In Japan, health insurers are obliged to conduct Specific Health Checkup (SHC) for middle-aged and elderly persons. High-risk persons are referred to Specific Health Guidance (SHG) to receive behavioral counseling based on individual action plans including targets for modification of daily energy balance through diet and physical activity. Using individual-level observational data, we examined the effects of diet and physical activity counseling on cardiometabolic biomarkers across the country. Subjects were 363,440 high-risk persons aged 40-64 who participated in intensive support in SHG for ≥3 months between April 2008 and March 2012. We considered participants as receiving counseling on diet alone, physical activity alone, combined, or neither if they had targets for diet only, physical activity only, both, or neither, respectively. Biomarkers included body mass index, waist circumference, systolic and diastolic blood pressure, high-density lipoprotein cholesterol, and hemoglobin A1c. Under the difference-in-differences approach, we used multivariable linear regression on repeated measures of biomarkers at SHCs before and after SHG and estimated the effects of each counseling type as an interaction with time of SHC. Compared with neither counseling, diet and physical activity counseling, alone or combined, were significantly associated with additional improvements in biomarkers after SHG, for example, body mass index (men: 0.03-0.06 kg/m², women: 0.10-0.15 kg/m²) and waist circumference (men: 0.16-0.29 cm, women: 0.43-0.47 cm) in both sexes and high-density lipoprotein cholesterol in men (0.13-0.29 mg/dL). Modest improvements in biomarkers were associated with diet and physical activity counseling, although effect sizes were small.

Identification of Novel Urinary Biomarkers for Predicting Renal Prognosis in Patients With Type 2 Diabetes by Glycan Profiling in a Multicenter Prospective Cohort Study: U-CARE Study 1

OBJECTIVE

Because quantifying glycans with complex structures is technically challenging, little is known about the association of glycosylation profiles with the renal prognosis in diabetic kidney disease (DKD).

RESEARCH DESIGN AND METHODS

In 675 patients with type 2 diabetes, we assessed the baseline urinary glycan signals binding to 45 lectins with different specificities. The end point was a decrease of estimated glomerular filtration rate (eGFR) by ≥30% from baseline or dialysis for end-stage renal disease.

RESULTS

During a median follow-up of 4.0 years, 63 patients reached the end point. Cox proportional hazards analysis revealed that urinary levels of glycans binding to six lectins were significantly associated with the outcome after adjustment for known indicators of DKD, although these urinary glycans, except that for DBA, were highly correlated with baseline albuminuria and eGFR. Hazard ratios for these lectins were (+1 SD for the glycan index) as follows: SNA (recognizing glycan Siaα2-6Gal/GalNAc), 1.42 (95% CI 1.14-1.76); RCA120 (Galβ4GlcNAc), 1.28 (1.01-1.64); DBA (GalNAcα3GalNAc), 0.80 (0.64-0.997); ABA (Galβ3GalNAc), 1.29 (1.02-1.64); Jacalin (Galβ3GalNAc), 1.30 (1.02-1.67); and ACA (Galβ3GalNAc), 1.32 (1.04-1.67). Adding these glycan indexes to a model containing known indicators of progression improved prediction of the outcome (net reclassification improvement increased by 0.51 [0.22-0.80], relative integrated discrimination improvement increased by 0.18 [0.01-0.35], and the Akaike information criterion decreased from 296 to 287).

CONCLUSIONS

The urinary glycan profile identified in this study may be useful for predicting renal prognosis in patients with type 2 diabetes. Additional investigation of glycosylation changes and urinary glycan excretion in DKD is needed.

Similar Intrapatient Blood Glucose Variability with LY2963016 and Lantus® Insulin Glargine in Patients with Type 1 (T1D) or Type 2 Diabetes, Including a Japanese T1D Subpopulation

INTRODUCTION

LY2963016 insulin glargine (LY IGlar) and Lantus® (IGlar), both with identical primary amino acid sequences, were compared in two phase 3 studies for intrapatient blood glucose variability.

METHODS

ELEMENT-1 was a 52-week study in patients with type 1 diabetes (T1D), which included Japanese patients, and ELEMENT-2 was a 24-week study in non-Japanese patients with type 2 diabetes (T2D). In ELEMENT-1, 535 patients with T1D were evaluable (268 LY IGlar and 267 IGlar). Of these, 100 were Japanese patients (49 LY IGlar and 51 IGlar). In ELEMENT-2, 756 patients with T2D were evaluable (376 LY IGlar and 380 IGlar). We evaluated and compared intrapatient blood glucose variability of LY IGlar and IGlar in these studies from three different perspectives: intrapatient between-day fasting blood glucose variability, intrapatient between-day daily mean blood glucose variability, and intrapatient within-day blood glucose variability.

RESULTS

Overall, evaluations of all three indices showed that intrapatient blood glucose variability was similar between LY IGlar and IGlar throughout the study periods both in the overall populations of patients with T1D and T2D and also in the subgroup of Japanese patients with T1D.

CONCLUSION

Intrapatient blood glucose variability between LY IGlar and IGlar was shown to be similar in patients with T1D or T2D.

CLINICAL TRIAL REGISTRATION

NCT01421147 (ELEMENT-1) and NCT01421459 (ELEMENT-2).

FUNDING

Eli Lilly and Company (Indianapolis, IN, USA); Boehringer-Ingelheim (Ridgefield, CT, USA); Eli Lilly Japan K.K. (Kobe, Japan) and Nippon Boehringer Ingelheim Co., Ltd. (Tokyo, Japan).

Fatty liver index predicts incident diabetes in a Japanese general population with and without impaired fasting glucose

AIM

Fatty liver is associated with the development of diabetes. However, to our knowledge, no study has examined the relationship between the fatty liver index (FLI), calculated scores of hepatic steatosis, and the development of diabetes among individuals without impaired fasting glucose (IFG). We aimed to examine whether FLI predicts the development of diabetes in individuals with and without IFG in a Japanese general population.

METHODS

We selected 1498 men and 2941 women who participated in Specific Health Checkups in Japan. We divided all participants into six groups according to tertiles of FLI (low, moderate, and high) and the presence or absence of IFG, by sex. We calculated hazard ratios for incident diabetes for each group using a Cox proportional hazard model, adjusting for potential confounders.

RESULTS

During a mean follow-up period of 3.0 years, 176 cases of diabetes in men and 320 cases in women were identified. Compared with the low FLI group without IFG, the high FLI group without IFG was significantly associated with incident diabetes in both men (hazard ratio, 1.90; 95% confidence interval, 1.08-3.36) and women (hazard ratio, 1.72; 95% confidence interval, 1.18-2.51). All IFG groups were significantly associated with incident diabetes regardless of FLI levels.

CONCLUSIONS

Our results showed that FLI is associated with the development of diabetes regardless of sex and the presence or absence of IFG, and that it may be a useful predictor of future risk of incident diabetes even in individuals without IFG.

Physical Fitness Tests and Type 2 Diabetes Among Japanese: A Longitudinal Study From the Niigata Wellness Study

BACKGROUND

Simple physical fitness test can be a useful potential predictor of type 2 diabetes (T2DM). We examined the association between performances on simple physical fitness tests and the incidence of T2DM.

METHODS

This longitudinal study was conducted in 21,802 nondiabetic Japanese (6,649 women) aged 20 to 92 years, who underwent all physical fitness tests at baseline (April 2001 to March 2002). From April 2001 to March 2008, physical fitness tests, including grip strength, vertical jump, single-leg balance with eyes closed, forward bending, whole-body reaction time, and supine legs-up, were performed every year. Participants had physical fitness tests at least two times during the period. T2DM was also annually determined based on fasting blood glucose, glycated hemoglobin, and self-reported diabetes during the period. Discrete-time logit models were used to examine the influence of the serial level of each physical fitness test on the incidence of T2DM.

RESULTS

During the entire study period, 972 participants developed diabetes. Lower relative grip strength (grip strength/body weight) and single-leg balance performance were associated with a higher incidence of T2DM. For relative grip strength, as compared with the fourth quartile group, the odds ratios for other groups ranged from 1.16 to 1.56 (P for trend < 0.001). For single-leg balance, the odds ratios ranged from 1.03 to 1.49 (P for trend < 0.001).

CONCLUSION

The performance of a simple single-leg balance test as well as that of a grip strength test were negatively associated with the risk of T2DM among Japanese.

Improved cardiometabolic risk factors in Japanese patients with type 2 diabetes treated with ipragliflozin: a pooled analysis of six randomized, placebo-controlled trials

To examine differential improvements among cardiovascular risk factors in response to treatment with ipragliflozin in Japanese type 2 diabetes mellitus (T2DM) patients, we conducted a pooled analysis of six randomized, double-blind trials of Japanese T2DM patients who received ipragliflozin 50 mg/day or placebo and had patient-level data for cardiometabolic risk parameters. Risk factors included glycated hemoglobin (HbA1c), body weight, homeostatic model assessment for insulin resistance and beta-cell function (HOMA-R and HOMA-beta, respectively), systolic blood pressure, fasting serum insulin concentrations, and the concentration of uric acid, lipids, and liver enzymes from baseline to end of treatment (EOT; 12-24 weeks). The primary endpoint of each trial was the change in HbA1c from baseline to EOT. Changes in risk factors from baseline to EOT were compared between ipragliflozin-treated and placebo groups, and between two subgroups (high- and low-risk groups for each parameter). All parameters, except low-density lipoprotein cholesterol (LDL-C) and non high-density lipoprotein cholesterol (non HDL-C), improved significantly in the ipragliflozin group. Subgroup analysis revealed a significantly greater improvement in the high-risk group versus low-risk group in HbA1c, HOMA-R, HOMA-beta, aspartate transaminase, alanine transaminase, and gamma-glutamyltransferase, but not in any of the lipid parameters or blood pressure. Liver function improvement in the ipragliflozin group was significantly correlated with changes in body weight, HbA1c, HOMA-beta, and HOMA-R. This analysis demonstrated that, in Japanese T2DM patients, ipragliflozin 50 mg/day was associated with improvements in cardiometabolic risk factors, except for LDL-C and non HDL-C.

Associations of non-standard employment with cardiovascular risk factors: findings from nationwide cross-sectional studies in Japan

This study aimed to examine the cross-sectional association of non-standard employment with cardiovascular disease risk factors. Five yr of data from the Comprehensive Survey of Living Conditions and National Health and Nutritional Survey were combined. We used logistic regression to examine the association of employment contract (non-standard [part-time, dispatched, or contract] vs. standard [full-time and permanent]) with eight cardiovascular disease risk factors among 1,636 men and 2,067 women aged 40-60 yr. There were significant associations between non-standard employment and cardiovascular disease risk factors such as current smoking among men (odds ratio [OR] 1.39; 95% confidential interval [CI], 1.13-1.86) and diabetes among women (OR 1.83; 95% CI, 1.10-3.09). Non-standard employment was associated with a few cardiovascular disease risk factors in this middle-aged cohort in Japan.

Characteristics and clinical course of type 1 diabetes mellitus related to anti-programmed cell death-1 therapy

Aims

We conducted a national survey to clarify the characteristics and clinical course of type 1 diabetes related to anti-programmed cell death-1 therapy.

Methods

We analyzed the detailed data of 22 patients that were collected using a Japan Diabetes Society survey and a literature database search.

Results

Among the 22 patients, 11 (50.0%) met the criteria for fulminant type 1 diabetes and 11 (50.0%) met the criteria for acute-onset type 1 diabetes. The average patient age was 63 years. The mean duration between the date of the first anti-PD-1 antibody injection and development of type 1 diabetes was 155 days and ranged from 13 to 504 days. Flu-like symptoms, abdominal symptoms, and drowsiness were observed in 27.8, 31.6, and 16.7% patients, respectively. Mean ± standard deviation or median (first quartile-third quartile) glucose levels, HbA1c levels, urinary C-peptide immunoreactivity levels, and fasting serum C-peptide immunoreactivity levels were 617 ± 248 mg/dl, 8.1 ± 1.3%, 4.1 (1.4-9.4) μg/day, and 0.46 (0.20-0.70) ng/ml, respectively. Seventeen of 20 patients (85.0%) developed ketosis, and 7 of 18 patients (38.9%) developed diabetic ketoacidosis. Ten of 19 patients (52.6%) showed at least one elevated pancreatic enzyme level at the onset and two of seven patients showed this elevation before diabetes onset. Only one of 21 patients was anti-glutamic acid decarboxylase antibody positive.

Conclusions

Anti-programmed cell death-1 antibody-related type 1 diabetes varies from typical fulminant type 1 diabetes to acute-onset type 1 diabetes. However, diabetic ketoacidosis was frequently observed at the onset of diabetes. An appropriate diagnosis and treatment should be provided to avoid life-threatening metabolic alterations.

Estimation of glycaemic control in the past month using ratio of glycated albumin to HbA1c

AIMS

To evaluate comprehensively the use of the glycated albumin to HbA_1c ratio for estimation of glycaemic control in the previous month.

METHODS

A total of 306 children with Type 1 diabetes mellitus underwent ≥10 simultaneous measurements of glycated albumin and HbA_1c . Correlation and concordance rates were examined between HbA_1c measurements taken 1 month apart (ΔHbA_1c ) and glycated albumin/HbA_1c ratio fluctuations were calculated as Z-scores from the cohort value at enrolment of this study cohort (method A) or the percent difference from the individual mean over time (method B).

RESULTS

Fluctuations in glycated albumin/HbA_1c ratio (using both methods) were weakly but significantly correlated with ΔHbA_1c , whereas concordance rates were significant for glycaemic deterioration but not for glycaemic improvement. Concordance rates were higher using method B than method A.

CONCLUSIONS

The glycated albumin/HbA_1c ratio was able to estimate glycaemic deterioration in the previous month, while estimation of glycaemic improvement in the preceding month was limited. Because method B provided a better estimate of recent glycaemic control than method A, the individual mean of several measurements of the glycated albumin/HbA_1c ratio over time may also identify individuals with high or low haemoglobin glycation phenotypes in a given population, such as Japanese children with Type 1 diabetes, thereby allowing more effective diabetes management.

Retrospective analysis of liraglutide and basal insulin combination therapy in Japanese type 2 diabetes patients: The association between remaining β-cell function and the achievement of the glycated hemoglobin target 1 year after initiation

AIMS/INTRODUCTION

The glucose-lowering effects of the glucagon-like peptide-1 receptor agonist, liraglutide, have been shown to rely on remaining β-cell function. However, the possible associations of remaining β-cell function with the glucose-lowering effects of liraglutide in combination with basal insulin remain unknown and warrant investigation.

MATERIALS AND METHODS

This was a single-center, retrospective, observational study carried out in a private hospital in Osaka, Japan. Type 2 diabetes patients who received a prescription change from insulin therapy, both multiple-dose insulin and basal insulin-supported oral therapy, to liraglutide and basal insulin combination and continued the therapy for 54 weeks without additional oral antidiabetic drugs or bolus insulin were retrospectively analyzed.

RESULTS

Among the 72 participants who received a prescription change from multiple-dose insulin and basal insulin-supported oral therapy to liraglutide and basal insulin combination, 57 continued the therapy for 54 weeks. Of those who continued the therapy without receiving additional oral antidiabetic drugs or bolus insulin, seven participants achieved glycated hemoglobin < 7.0% at 54 weeks, but 30 participants did not. The participants who achieved glycated hemoglobin < 7.0% at 54 weeks had a significantly higher C-peptide immunoreactivity index, a β-cell function-related index frequently used in Japanese clinical settings. The receiver operating curve analysis showed that the C-peptide immunoreactivity index cut-off value for the achievement of glycated hemoglobin <7.0% at 54 weeks is 1.103.

CONCLUSIONS

The current findings show that the glucose-lowering effects of liraglutide rely on remaining β-cell function, even when used with basal insulin; and suggest that liraglutide and basal insulin combination might require additional bolus insulin to fully compensate insulin insufficiency in individuals with reduced β-cell function.

The National Integrated Project for Prospective Observation of Non-communicable Disease and its Trends in the Aged 2010 (NIPPON DATA2010): Objectives, Design, and Population Characteristics

Background

The structure and risk factors for cardiovascular diseases (CVD) in Japan may change because lifestyle, particularly nutrition, socioeconomic status, and medical care, which affect CVD, may markedly change over time. Therefore, a new prospective cohort study on a representative general Japanese population based on national surveys is required.

Methods

In November 2010, the baseline survey of the National Integrated Project for Prospective Observation of Non-communicable Disease and its Trends in the Aged 2010 (NIPPON DATA2010) was performed with the National Health and Nutrition Survey of Japan (NHNS2010) in 300 randomly selected districts throughout Japan. The survey included a questionnaire, electrocardiogram, urinalysis, and blood biomarkers added to the NHNS2010 examinations. Physical measurements, blood biomarkers, and dietary data were also obtained in NHNS2010. Socioeconomic factors were obtained by merging with the Comprehensive Survey of Living Conditions 2010 (CSLC2010) dataset. Participants are followed annually for the incidence of diabetes mellitus, CVD events (acute coronary events, heart failure, atrial fibrillation, and stroke), and cause-specific mortality. The activities of daily living are followed every 5 years.

Results

A total of 2,898 individuals aged 20 years or older agreed to participate in the baseline survey of NIPPON DATA2010. The participation rate was 74.6%. Of these, data from NHNS2010 was merged for 2,891 participants (1,236 men and 1,655 women). The data of 2,807 participants were also merged with CSLC2010 data.

Conclusions

We established NIPPON DATA2010 as a cohort study on a representative general Japanese population that covers all of Japan.

Increase in Adiponectin Level Prevents the Development of Type 2 Diabetes in Japanese Men With Low Adiponectin Levels

Context

Low serum adiponectin (Ad) level is an important risk factor for the development of type 2 diabetes mellitus (T2DM).

Objective

To determine whether the changes in Ad in subjects with low baseline serum Ad levels can reduce the rate of development of T2DM.

Design/Setting/Participants

We performed a large-scale longitudinal study of 7052 healthy Japanese men who underwent general health checkups more than twice between April 2007 and May 2015 at the Physical Check up Center, Sumitomo Hospital. The participants were divided into quartile groups according to baseline Ad level. Subjects of the lowest baseline Ad group (≤5.2 μg/mL) were subdivided into quartile subgroups according to the percent change in Ad (%ΔAd) and into two subgroups according to endpoint Ad (>5.2 and ≤5.2 μg/mL).

Main Outcome Measures

The cumulative incidence rate of T2DM.

Results

The cumulative incidence rate of T2DM of the lowest baseline Ad group (≤5.2 μg/mL) was significantly higher than the other quartile groups. The cumulative incidence rates of T2DM were significantly lower in the largest (≥21.5%) and the second largest (9.3% to 21.4%) %ΔAd-increased subgroups compared with the %ΔAd-decreased subgroup (P < 0.001 and P = 0.005, respectively). The cumulative incidence rates of T2DM were significantly lower in the endpoint Ad >5.2 μg/mL subgroup than in the ≤5.2 μg/mL subgroup (P < 0.001).

Conclusions

Increases in serum Ad levels of at least ~10% or >5.2 μg/mL can potentially reduce the risk of development of T2DM in Japanese men with low baseline Ad levels who are at a high risk of developing T2DM.

Dipstick proteinuria and all-cause mortality among the general population

BACKGROUND

Dipstick proteinuria, but not albuminuria, is used for general health screening in Japan. How the results of dipstick proteinuria tests correlate with mortality and, however, is not known.

METHODS

Subjects were participants of the 2008 Tokutei-Kenshin (Specific Health Check and Guidance program) in six districts in Japan. On the basis of the national database of death certificates from 2008 to 2012, we used a personal identifier in two computer registries to identify participants who might have died. The hazard ratio (95% confidence interval, CI) was calculated by Cox-proportional hazard analysis.

RESULTS

Among a total of 140,761 subjects, we identified 1641 mortalities that occurred by the end of 2012. The crude mortality rates were 1.1% for subjects who were proteinuria (-), 1.5% for those with proteinuria (+/-), 2.0% for those with proteinuria (1+), 3.5% for those with proteinuria (2+), and 3.7% for those with proteinuria (≥ 3+). After adjusting for sex, age, body mass index, estimated glomerular filtration rate, comorbid condition, past history, and lifestyle, the hazard ratio (95% CI) for dipstick proteinuria was 1.262 (1.079-1.467) for those with proteinuria (+/-), 1.437 (1.168-1.748) for those with proteinuria (1+), 2.201 (1.688-2.867) for those with proteinuria (2+), and 2.222 (1.418-3.301) for those with proteinuria (≥ 3+) compared with the reference of proteinuria (-).

CONCLUSION

Dipstick proteinuria is an independent predictor of death among Japanese community-based screening participants.

Fujiyoshi A, Arima H, Tanaka-Mizuno S, Hisamatsu T, Kadowaki S, Kadota A, Zaid M, Sekikawa A, Yamamoto T, Horie M, Miura K, Ueshima H. Association of Coronary Artery Calcification with Estimated Coronary Heart Disease Risk from Prediction Models in a Community-Based Sample of Japanese Men: The Shiga Epidemiological Study of Subclinical Atherosclerosis (SESSA)

AIM

The clinical significance of coronary artery calcification (CAC) is not fully determined in general East Asian populations where background coronary heart disease (CHD) is less common than in USA/Western countries. We cross-sectionally assessed the association between CAC and estimated CHD risk as well as each major risk factor in general Japanese men.

METHODS

Participants were 996 randomly selected Japanese men aged 40-79 y, free of stroke, myocardial infarction, or revascularization. We examined an independent relationship between each risk factor used in prediction models and CAC score ≥100 by logistic regression. We then divided the participants into quintiles of estimated CHD risk per prediction model to calculate odds ratio of having CAC score ≥100. Receiver operating characteristic curve and c-index were used to examine discriminative ability of prevalent CAC for each prediction model.

RESULTS

Age, smoking status, and systolic blood pressure were significantly associated with CAC score ≥100 in the multivariable analysis. The odds of having CAC score ≥100 were higher for those in higher quintiles in all prediction models (p-values for trend across quintiles ＜0.0001 for all models). All prediction models showed fair and similar discriminative abilities to detect CAC score ≥100, with similar c-statistics (around 0.70).

CONCLUSIONS

In a community-based sample of Japanese men free of CHD and stroke, CAC score ≥100 was significantly associated with higher estimated CHD risk by prediction models. This finding supports the potential utility of CAC as a biomarker for CHD in a general Japanese male population.

Optimal cutoff values of fasting plasma glucose (FPG) variability for detecting retinopathy and the threshold of FPG levels for predicting the risk of retinopathy in type 2 diabetes: A longitudinal study over 27 years

AIMS

To determine the cutoff values of fasting plasma glucose (FPG) variability for detecting retinopathy and examine the threshold of FPG levels for predicting retinopathy incidence in type 2 diabetes.

METHODS

Subjects comprised 170 patients with type 2 diabetes who had no retinopathy at their first visit, and continuously visited thereafter for 27 years. Retinopathy was evaluated by ophthalmologists at least annually.

RESULTS

114 patients developed retinopathy. 46 of them had advanced retinopathy. The optimal cutoff values of intrapersonal mean and standard deviation (SD) of FPG over 27 years and intrapersonal mean HbA1c from the initial measurement to the last visit for detecting retinopathy were 7.4 mmol/L, 1.4 mmol/L, and 7.2% (56 mmol/mol), respectively. Similarly, for advanced retinopathy, 7.7 mmol/L, 1.9 mmol/L, and 7.5% (59 mmol/mol), respectively. Hazard ratios of deciles of intrapersonal mean FPG (mmol/L) during the initial 2 years for retinopathy incidence significantly increased from eighth-decile (6.9-7.4), and were sharply elevated from ninth-decile (7.4-8.7).

CONCLUSIONS

Our study provides new cutoff values for FPG variability. Cutoff values of FPG and HbA1c were slightly higher than recommended targets of the current guideline. The threshold of FPG levels (6.9 mmol/L) is proposed to predict retinopathy incidence during the subsequent 25 years.

Twelve-year trends of increasing overweight and obesity in patients with diabetes: the Shiga Diabetes Clinical Survey

The prevalence of obesity is increasing globally in patients with diabetes. This study aimed to examine 12-year trends of increasing obesity in Japanese patients with diabetes, and their clinical features. The study used results of the Shiga Diabetes Clinical Survey, which recorded medical performance in diabetic patients in 2000, 2006 and 2012. Data were analyzed from 14,205, 14,407 and 21,449 adult patients in these three years, respectively. Overweight and obesity prevalence and the clinical features of diabetes patients were examined, stratified by body mass index (BMI) and age. The prevalence of overweight (BMI 25-30 kg/m²) and obesity (BMI ≥30 kg/m²) were 27.0% and 5.1% in 2000, 28.9% and 7.3% in 2006 and 30.9% and 10.0% in 2012. Glycemic control, blood pressure and serum lipid profile improved over 12 years in all BMI categories. However, glycemic and triglyceride control were insufficient in obese patients aged <65 years (hemoglobin A1c 7.5 ± 1.4%, triglyceride 197.7 ± 178.4 mg/dL in 2012). The percentage of patients who used antihypertensive and lipid-lowering drugs increased and patients with higher BMI had increased frequency of using these drugs, both in young and old age groups. Higher BMI was significantly and positively associated with albuminuria. In summary, overweight and obesity have increased in Japanese diabetic patients, particularly for younger generations. Findings suggest that obesity may lead to poorer glycemic control, blood pressure and lipid profiles. Overweight and obesity are important modifiable risk factors for diabetes, suggesting that more active weight-control interventions are warranted.

Association between dipstick proteinuria and hearing impairment in health check-ups among Japanese workers: a cross-sectional study

OBJECTIVE

Prevention of hearing impairment is important because it is difficult to recover from it. Epidemiological studies have examined the risk factors for hearing impairment; however, the association between dipstick proteinuria and hearing impairment has not been previously examined. This study aimed to clarify the association between dipstick proteinuria and hearing impairment.

DESIGN

Cross-sectional study.

SETTING

Office and factory workers from all over Japan.

PARTICIPANTS

The total number of subjects was 7005. All were employees of the same company. Of these, we recruited 6192 subjects who underwent dipstick urine test and hearing test by audiometry in annual health check-ups (mean age 44.9 years, men 88.3%).

PRIMARY OUTCOMES

Hearing tests were performed at two frequencies (1 kHz, 4 kHz) as prescribed by law in Japan. We defined the inability of subjects to respond to 30 dB at 1 kHz and/or 40 dB at 4 kHz as overall moderate hearing impairment. In addition, we defined moderate hearing impairment at 1 kHz (4 kHz) as an abnormal finding at 1 kHz (4 kHz). We examined the associations between degree of dipstick proteinuria and hearing impairment after adjustment for age, sex, body mass index, hypertension, diabetes mellitus, serum creatinine level and history of noisy work environment.

RESULTS

Overall moderate hearing impairment was noted in 324 subjects (5.2%). Of these, 107 subjects (1.7%) had moderate hearing impairment at 1 kHz and 278 subjects (4.5%) at 4 kHz. Dipstick proteinuria was significantly associated with overall moderate hearing impairment, as well as moderate hearing impairment at both 1 kHz and 4 kHz. The prevalence of overall moderate hearing impairment among subjects with proteinuria ≥2+ was 23.5%, while that among subjects without proteinuria was 5.2% (p<0.01).

CONCLUSIONS

Dipstick proteinuria was associated with moderate hearing impairment in Japanese workers.

Potential common factors associated with predisposition to common cold in middle-aged and elderly Japanese: A community-based cross-sectional study

People worldwide frequently catch a common cold, which occasionally develops into secondary severe conditions such as pneumonia. However, it is unclear whether predisposition to the common cold is associated with the individual's characteristics including age, body weight, lifestyles, diets, and intestinal functions, besides exposure to a responsible pathogen. We addressed this issue epidemiologically considering many relevant clinical factors.We reviewed data from a cross-sectional study consisting of 39,524 apparently healthy Japanese aged 40 to 79 years (26,975 men and 12,549 women) who underwent a checkup in 2007. Self-reported predisposition to common cold (SPCC) and relevant clinical conditions and parameters were considered.We observed no significant difference in most clinical parameters including age, body mass index (BMI), glycated hemoglobin (HbA1c), and prevalence of men and current smokers between subjects with and without SPCC. In univariate analysis, circulating white blood cell (WBC) count and serum alanine-aminotransferase (ALT) were significantly higher in subjects with SPCC than in those without, whereas serum high-density lipoprotein cholesterol (HDL-C) and duration of sleep were lower. In logistic regression analysis after full adjustment for relevant confounding factors, BMI categories except BMI of ≥27.0 kg/m were significantly associated with SPCC compared with BMI of 23.0 to 24.9 kg/m. Short duration of sleep (≤5 hours), occasional alcohol drinking, and no-exercise were significantly associated with SPCC compared with 7 hours sleep duration, no-drinking alcohol, and low frequent exercise (twice per month), respectively. All gastrointestinal disorders (gastric complaints, constipation, and diarrhea) were independently associated with SPCC. Imbalanced diet and taking a snack were also associated with SPCC in a degree dependent manner. Furthermore, WBC count, serum ALT, and HDL-C (as continuous variables) were associated with SPCC (HDL-C was inversely), whereas no significant association was observed between SPCC and age, smoking, HbA1c, and pharmacotherapy for diabetes, hypertension, and dyslipidemia.Our results demonstrated that multifactorial conditions and parameters might be simultaneously associated with the predisposition to common cold. Prospective studies including detailed common cold questionnaire and measurements are needed to confirm currently suspected causative and protective factors.

A prospective study of the impact of diabetes mellitus on restrictive and obstructive lung function impairment: The Saku study

BACKGROUND

To assess the impact of diabetes on restrictive and obstructive lung function impairment.

METHODS

This 5-year prospective study included 7524 participants aged 40-69years without lung function impairment at baseline who underwent a comprehensive medical check-up between April 2008 and March 2009 at Saku Central Hospital. Diabetes was defined by fasting plasma glucose ≥7.0mmol/l (126mg/dl), HbA1c≥6.5% (48mmol/mol), or a history of diabetes, as determined by interviews conducted by the physicians. Restrictive and obstructive lung function impairment were defined as forced vital capacity (FVC) <80% predicted and forced expiratory volume in 1s (FEV₁) to FVC ratio (FEV₁/FVC) <0.70, respectively. Participants were screened until they developed restrictive or obstructive lung function impairment or until March 2014.

RESULTS

During the follow-up period, 171 and 639 individuals developed restrictive and obstructive lung function impairment, respectively. Individuals with diabetes had a 1.6-fold higher risk of restrictive lung function impairment than those without diabetes after adjusting for sex, age, height, abdominal obesity, smoking status, exercise habits, systolic blood pressure, HDL-cholesterol, log-transformed high-sensitivity C-reactive protein, and baseline lung function [multivariable-adjusted HR and 95% CI; 1.57 (1.04-2.36)]. In contrast, individuals with diabetes did not have a significantly higher risk of obstructive lung function impairment [multivariable-adjusted HR and 95% CI; 0.93 (0.72-1.21)].

CONCLUSION

Diabetes was associated with restrictive lung function impairment but not obstructive lung function impairment.

Urinary type IV collagen excretion is involved in the decline in estimated glomerular filtration rate in the Japanese general population without diabetes: A 5-year observational study

Urinary type IV collagen (U-Col4) and albumin excretion is evaluated to monitor the development of diabetic kidney disease. However, U-Col4 excretion in the general population without diabetes has not yet been fully elucidated. In this study, 1067 participants without diabetes and with urinary albumin-creatinine ratio <300 mg/gCr (normo- or microalbuminuria) who underwent an annual health examination in 2004 were enrolled and observed for 5 years. They were divided according to the amount of U-Col4 or urinary albumin excreted. The decline in estimated glomerular filtration rate (eGFR) was calculated. In participants with eGFR ≥80 mL/min, abnormal U-Col4 excretion was indicated as a significant independent risk factor for 10% eGFR change per year, which is one of the prognostic factors for the development of end-stage kidney disease. Moreover, in contrast to urinary albumin excretion, U-Col4 excretion was not related to age or kidney function, suggesting that some individuals with abnormal U-Col4 excretion can have an independent hidden risk for the development of kidney dysfunction. In conclusion, it is important to measure U-Col4 excretion in the general population without diabetes to determine changes in renal features in every individual and help detect future complications such as diabetic kidney disease. If U-Col4 excretion is abnormal, kidney manifestation should be carefully followed up, even if the kidney function and urinalysis findings are normal.

Unexpected association between subclinical hearing loss and restorative sleep in a middle-aged and elderly Japanese population

OBJECTIVE

Hearing loss may be associated with certain sleep abnormalities. We recently reported that subclinical hearing loss (SHL) was more prevalent in individuals in a broad Japanese population who slept longer than 8 h; however, the underlying mechanism was unknown. Therefore, we investigated the association between SHL and self-reported restorative sleep (RS), assessed by questionnaire, in a database of 33,888 Japanese aged 40-69 years without overt or diagnosed hearing loss (20,225 men, 13,663 women).

RESULTS

The proportion of individuals with RS (more than half of the subjects) was significantly higher in the group with bilateral than with unilateral SHL at 4000 Hz and intact hearing; however, that was not the case at 1000 Hz, independent of age (P < 0.0001, two-way analysis of variance). Multivariate logistic regression analysis showed that bilateral SHL at 4000 Hz, but not at 1000 Hz, was significantly associated with RS. This relationship was independent of potential relevant confounders, including age, sex, and cardiometabolic risk factors. The present study extends our earlier work by revealing an unexpected association between early hearing impairment and satisfactory sleep in a middle-aged and elderly population. This association requires further confirmation regarding the possible underlying mechanism and clinical relevance.

Serum magnesium, phosphorus, and calcium levels and subclinical calcific aortic valve disease: A population-based study

BACKGROUND AND AIMS

Calcific aortic valve disease (CAVD) is the most common valve disease. Although micronutrients are known to contribute to cardiovascular disease, the relationship with CAVD remains poorly evaluated. We examined the association of serum levels of magnesium, phosphorus, and calcium with prevalence, incidence, and progression of aortic valve calcification (AVC).

METHODS

We conducted a prospective study in a population-based sample of Japanese men aged 40-79 years without known cardiovascular disease and chronic kidney disease at baseline, and quantified AVC from serial computed tomographic images with the Agatston method.

RESULTS

Of 938 participants at baseline (mean age, 63.7 ± 9.9 years), AVC prevalence was observed in 173 (18.4%). Of 596 participants without baseline AVC at follow-up (median duration, 5.1 years), AVC incidence was observed in 138 (23.2%). After adjustment for demographics, behaviors and cardiovascular risk factors, relative risks (95% confidence intervals) in the highest versus lowest categories of serum magnesium, phosphorus, and calcium were 0.62 (0.44-0.86), 1.45 (1.02-2.04), and 1.43 (0.95-2.15), respectively, for AVC prevalence and 0.62 (0.42-0.92), 1.93 (1.28-2.91), and 1.09 (0.77-1.55), respectively, for AVC incidence. Their linear trends of serum magnesium and phosphorus were also all statistically significant. Of 131 participants with baseline AVC, there was no association of any serum micronutrients with AVC progression.

CONCLUSIONS

Serum magnesium was inversely associated, while serum phosphorus was positively associated with AVC prevalence and incidence, suggesting that these serum micronutrients may be potential candidates for risk prediction or prevention of CAVD, and warranting further studies.

Effect of Sleep-Disordered Breathing on Albuminuria in 273 Patients With Type 2 Diabetes

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) can induce hyperglycemia, hypertension, and oxidative stress, conditions that are known to cause kidney damage. Therefore, SDB may exacerbate albuminuria, which is an established marker of early-stage kidney damage in patients with type 2 diabetes mellitus (T2DM). The association between SDB and albuminuria in patients with T2DM was investigated in this study.

METHODS

This cross-sectional study included 273 patients with T2DM who underwent portable sleep testing and measurement of urine albumin to creatinine ratio (UACR). The association between the severity of SDB and albuminuria was investigated. Patients were divided into three groups according to the respiratory event index (REI): the no or mild group (REI < 15 events/h), moderate (REI 15 to < 30 events/h), and severe (REI ≥ 30 events/h). Albuminuria was defined as UACR ≥ 3.4 mg/mmol creatinine. Logistic regression analysis for albuminuria included the categorical REI as the independent variable.

RESULTS

The median (interquartile range) REI of all patients (age 57.9 ± 11.9 years, mean ± standard deviation, male sex 81.7%, body mass index 26.7 [24.2-29.5] kg/m2, estimated glomerular filtration rate 82 [65-97] mL/min/1.73 m2) was 13.0 (7.0-24.2) events/h. The REI, as a categorical variable, was significantly associated with albuminuria after adjustment for other risk factors for albuminuria; REI 15 to < 30 events/h: odds ratio (OR) 3.35, 95% confidence interval (95% CI), 1.68-6.67, P < .001; REI ≥ 30: OR 8.52, 95% CI, 3.52-20.63, P < .001). In addition, the natural logarithm-transformed REI of all patients also correlated significantly with albuminuria.

CONCLUSIONS

The severity of SDB is associated with albuminuria in patients with T2DM.