Standards of care for type 2 diabetes in China

Diabetes mellitus and Alzheimer's disease: Understanding disease mechanisms, their correlation, and promising dual activity of selected herbs

ETHNOPHARMACOLOGICAL RELEVANCE

This review explores the link between Type 2 Diabetes Mellitus (T2DM) and diabetes-induced Alzheimer's disease (AD). It emphasizes the shared pathophysiological links and mechanisms between the two conditions, focusing on reduced insulin levels and receptors, impaired glucose metabolism, insulin resistance, mitochondrial dysfunction, and oxidative damage in AD-affected brains-paralleling aspects of T2DM. The review suggests AD as a "diabetes of the brain," supported by cognitive enhancement through antidiabetic interventions. It focuses on the traditionally used Indian herbs as a means to manage both conditions while addressing developmental challenges.

AIM OF THE STUDY

This study explores the DM-AD connection, reviewing medicinal herbs with protective potential for both ailments, considering traditional uses and developmental challenges.

MATERIALS AND METHODS

Studied research, reviews, and ethnobotanical and scientific data from electronic databases and traditional books.

RESULTS

The study analyzes the pathophysiological links between DM and AD, emphasizing their interconnected factors. Eight Ayurvedic plants with dual protective effects against T2DM and AD are thoroughly reviewed with preclinical/clinical evidence. Historical context, phytoconstituents, and traditional applications are explored. Innovative formulations using these plants are examined. Challenges stemming from phytoconstituents' physicochemical properties are highlighted, prompting novel formulation development, including nanotechnology-based delivery systems. The study uncovers obstacles in formulating treatments for these diseases.

CONCLUSION

The review showcases the dual potential of chosen medicinal herbs against both diseases, along with their traditional applications, endorsing their use. It addresses formulation obstacles, proposing innovative delivery technologies for herbal therapies, while acknowledging their constraints. The review suggests the need for heightened investment and research in this area.

Clinical efficacy and cost-effectiveness of metformin in different patient populations: A narrative review of real-world evidence

Over the past two decades, diabetes pharmacopoeia has flourished, with new drugs that, on top of their glucose-lowering efficacy, have been shown to protect the heart and the kidney. Despite these new opportunities, metformin retains a pivotal role among glucose-lowering agents. As one of the few available insulin sensitizers, metformin is an effective, safe, and overall well-tolerated drug backed by over 60 years of clinical experience, including evidence for potential benefits beyond glucose reduction across different ages, sexes, genetic backgrounds, geographical areas, and stages of disease. Although there is some discussion of whether metformin offers the most effective front-line option in newly diagnosed type 2 diabetes (T2D), it remains a natural companion to all other glucose-lowering agents. Furthermore, metformin comes at a very low cost and, as such, it has extremely high cost-effectiveness, particularly given the serious economic burden associated with diabetes complications. This financial advantage is particularly relevant in resource-constrained healthcare systems, where the affordability of metformin may be instrumental in implementing an effective treatment in an evergrowing number of individuals. We present here compelling real-world evidence in support of the clinical efficacy and cost-effectiveness of metformin across different patient populations, highlighting areas where more population-based studies are needed to further incorporate and consolidate its use in the pharmacological management of T2D.

Current type 2 diabetes guidelines: Individualized treatment and how to make the most of metformin

Evidence-based guidelines provide the premise for the delivery of quality care to preserve health and prevent disabilities and premature death. The systematic gathering of observational, mechanistic and experimental data contributes to the hierarchy of evidence used to guide clinical practice. In the field of diabetes, metformin was discovered more than 100 years ago, and with 60 years of clinical use, it has stood the test of time regarding its value in the prevention and management of type 2 diabetes. Although some guidelines have challenged the role of metformin as the first-line glucose-lowering drug, it is important to point out that the cardiovascular-renal protective effects of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists were gathered from patients with type 2 diabetes, the majority of whom were treated with metformin. Most national, regional and international guidelines recommend metformin as a foundation therapy with emphasis on avoidance of therapeutic inertia and early attainment of multiple treatment goals. Moreover, real-world evidence has confirmed the glucose-lowering and cardiovascular-renal benefits of metformin accompanied by an extremely low risk of lactic acidosis. In patients with type 2 diabetes and advanced chronic kidney disease (estimated glomerular filtration rate 15-30 mL/min/1.73m2), metformin discontinuation was associated with an increased risk of cardiovascular-renal events compared with metformin persistence. Meanwhile, it is understood that microbiota, nutrients and metformin can interact through the gut-brain-kidney axis to modulate homeostasis of bioactive molecules, systemic inflammation and energy metabolism. While these biological changes contribute to the multisystem effects of metformin, they may also explain the gastrointestinal side effects and vitamin B12 deficiency associated with metformin intolerance. By understanding the interactions between metformin, foods and microbiota, healthcare professionals are in a better position to optimize the use of metformin and mitigate potential side effects. The United Kingdom Prospective Diabetes Study and the Da Qing Diabetes Prevention Program commenced 40 years ago provided the first evidence that type 2 diabetes is preventable and treatable. To drive real-world impact from this evidence, payors, practitioners and planners need to co-design and implement an integrated, data-driven, metformin-based programme to detect people with undiagnosed diabetes and prediabetes (intermediate hyperglycaemia), notably impaired glucose tolerance, for early intervention. The systematic data collection will create real-world evidence to bring out the best of metformin and make healthcare sustainable, affordable and accessible.

Two weeks of acarbose treatment shows no effect on gut microbiome composition in patients with type 2 diabetes: a randomised, placebo-controlled, double-blind, crossover study

Aim

The alpha-glucosidase inhibitor acarbose is approved for the treatment of type 2 diabetes (T2D). It acts in the lumen of the gut by reducing intestinal hydrolysis and absorption of ingested carbohydrates. This reduces postprandial blood glucose concentration and increases the content of carbohydrates in the distal parts of the intestine potentially influencing gut microbiome (GM) composition and possibly impacting the gut microbiome (GM) dysbiosis associated with T2D. Here, we investigated the effect of acarbose on GM composition in patients with T2D.

Methods

Faecal samples were collected in a previously conducted randomised, placebo-controlled, double-blind, crossover study in which 15 individuals with metformin-treated T2D (age 57-85 years, HbA1c 40-74 mmol/mol, BMI 23.6-34.6 kg/m2) were subjected to two 14-day treatment periods with acarbose and placebo, respectively, separated by a 6-week wash-out period. Faecal samples were collected before and by the end of each treatment period. The GM profiles were evaluated by 16S rRNA gene amplicon sequencing.

Results

The GM profiles after the treatment periods with acarbose or placebo remained unaffected (P > 0.7) when compared with the GM profiles before treatment. This applied to the analysis of within-sample diversity (α-diversity) and between-sample bacterial composition diversity (β-diversity). Additionally, no dominant bacterial species differentiated the treatment groups, and only minor increases in the relative abundances of Klebsiella spp. and Escherichia coli (P < 0.05) were observed after acarbose treatment.

Conclusion

In patients with metformin-treated T2D, 14 days of treatment with acarbose showed only minor effects on GM as seen in increased relative abundances of Klebsiella spp. and Escherichia coli.

Investigating the causal association of generalized and abdominal obesity with microvascular complications in patients with type 2 diabetes: A community-based prospective study

AIM

The paradoxical protective association between overweight/obesity and diabetic microvascular complications (DMC), a phenomenon well-known as the obesity paradox, has been considered a non-causal association based on methodological influences. We aimed to investigate the association of generalized and abdominal obesity, as measured by body mass index (BMI) and waist circumference (WC), respectively, with DMC in patients with type 2 diabetes (T2D), using a causal inference approach.

MATERIALS AND METHODS

We enrolled 1436 patients with clinically diagnosed T2D but not DMC at baseline in a community-based prospective cohort in China between 2017 and 2019 and followed them annually until 2022 with new-onset DMC recorded. Marginal structural Cox models with inverse probability weighting were constructed to determine the causal association. Subgroup analyses were performed to identify potential effect modifiers.

RESULTS

We observed 360 incident DMC cases, including 109 cases of diabetic nephropathy (DN) and 277 cases of diabetic retinopathy (DR) during four follow-up visits. Multivariable-adjusted hazard ratios (95% confidence intervals) for overall DMC, DN and DR were 1.037 (1.005-1.071), 1.117 (1.062-1.175) and 1.018 (0.980-1.059) for 1 kg/m2 increase in BMI, and 1.005 (0.994-1.017), 1.034 (1.018-1.051) and 1.000 (0.987-1.014) for 1 cm increase in WC, respectively. Similar patterns were observed across the BMI and WC categories, while the positive association appeared to be more pronounced in women.

CONCLUSIONS

Generalized but not abdominal obesity was associated with an increased risk for the overall DMC, whereas both obesities were causally related to DN, albeit not DR, in T2D. Routine weight management should not be neglected in diabetes care, particularly in women.

Association between blood lipids and diabetes mellitus in older Chinese adults aged 65 years or older: a cross-sectional analysis of residents' electronic health records

AIM

This study aimed to investigate how blood lipids are associated with diabetes among older Chinese adults.

METHODS

3,268,928 older Chinese adults without known diabetes were included. Logistic regression and restricted cubic spline (RCS) models were conducted to study associations between blood lipids (total cholesterol [TC], triglycerides [TG], low-density lipoprotein cholesterol [LDL-C], and high-density lipoprotein cholesterol [HDL-C]) and diabetes.

RESULTS

202,832 diabetes cases were included. Compared with the lowest quintiles, TC, TG, and LDL-C in the highest quintiles showed a higher diabetes prevalence risk and HDL-C presented a lower risk in multivariate-adjusted logistic regression models. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for the highest quintiles of TC, TG, and HDL-C were 1.39 (1.37-1.41), 2.56 (2.52-2.60), and 0.73 (0.72-0.74), respectively. For LDL-C, 3-5% lower risk was found in the second and third quintiles, and 4-23% higher risk was found in the fourth and fifth quintiles. RCS curves showed a non-linear relationship between each blood lipid parameters and diabetes (P-non-linear < 0.001). TG and HDL-C curves presented monotonically increasing and L-shaped patterns, respectively, whereas TC and LDL-C curves exhibited a J-shaped pattern. When TC < 4.04 mmol/L or LDL-C < 2.33 mmol/L, ORs of diabetes increased with the decrease of corresponding indexes. However, after excluding participants with lower LDL-C, the J-shaped association with TC disappeared.

CONCLUSIONS

This study demonstrates non-linear associations between lipids and diabetes. Low cholesterol levels are associated with a high risk of diabetes. The cholesterol paradox should be considered during lipid-lowering treatments.

Myosteatosis is associated with coronary artery calcification in patients with type 2 diabetes

BACKGROUND

Myosteatosis, rather than low muscle mass, is the primary etiologic factor of sarcopenia in patients with type 2 diabetes mellitus (T2DM). Myosteatosis may lead to a series of metabolic dysfunctions, such as insulin resistance, systematic inflammation, and oxidative stress, and all these dysfunctions are closely associated with the acceleration of T2DM and atherosclerosis.

AIM

To investigate the association between myosteatosis and coronary artery calcification (CAC) in patients with T2DM.

METHODS

Patients with T2DM, who had not experienced major cardiovascular events and had undergone both abdominal and thoracic computed tomography (CT) scans, were included. The mean skeletal muscle attenuation was assessed using abdominal CT images at the L3 level. The CAC score was determined from thoracic CT images using the Agatston scoring method. Myosteatosis was diagnosed according to Martin's criteria. Severe CAC (SCAC) was defined when the CAC score exceeded 300. Logistic regression and decision tree analyses were performed.

RESULTS

A total of 652 patients with T2DM were enrolled. Among them, 167 (25.6%) patients had SCAC. Logistic regression analysis demonstrated that myosteatosis, age, duration of diabetes, cigarette smoking, and alcohol consumption were independent risk factors of SCAC. Myosteatosis was significantly associated with an increased risk of SCAC (OR = 2.381, P = 0.003). The association between myosteatosis and SCAC was significant in the younger patients (OR = 2.672, 95%CI: 1.477-4.834, P = 0.002), but not the older patients (OR = 1.456, 95%CI: 0.863-2.455, P = 0.188), and was more prominent in the population with lower risks of atherosclerosis. The decision tree analyses prioritized older age as the primary variable for SCAC. In older patients, cigarette smoking was the main contributing factor for SCAC, while in younger patients, it was myosteatosis.

CONCLUSION

Myosteatosis is a novel risk factor for atherosclerosis in patients with T2DM, especially in the population with younger ages and fewer traditional risk factors.

Downregulation of lncRNA XLOC_032768 in diabetic patients predicts the occurrence of diabetic nephropathy

LncRNA XLOC_032768 is reported to prevent renal tubular epithelial cells from cisplatin-induced apoptosis, suggesting its involvement in the development of kidney injury. The present study aimed to explore the role of XLOC_032768 in diabetic nephropathy (DN). The present study enrolled a total of 140 healthy controls (Control group) and 140 patients with type 2 diabetes (Diabetes group). Expression of XLOC_032768 in plasma from these participants was analyzed by performing RT-qPCR. The 140 diabetic patients were followed up for 5 years to monitor the occurrence of diabetic complications. The role of XLOC_032768 in predicting the occurrence of diabetic complications, including DN, diabetic cardiomyopathy (DC), diabetic retinopathy (DR), and diabetic foot (DF) were analyzed by plotting receiver operating characteristic curves and complication-free curves. On the day of admission, plasma levels of XLOC_032768 were not significantly different between Control and Diabetes groups. During follow-up, a total of 22, 15, 13, and 15 cases were diagnosed as DN, DC, DR, and DF, respectively. On the day of diagnosis, plasma levels of XLOC_032768 were only decreased in DN group, but not in other groups, compared to plasma levels of XLOC_032768 on the day of admission. Using plasma levels of XLOC_032768 on the day of admission as a biomarker, potential DN patients were effectively separated from patients with other potential complications and diabetic patients without complications. The 140 diabetic patients were grouped into high and low XLOC_032768 level groups. It was observed that low XLOC_032768 level group showed increased occurrence of DN, but not other complications, compared to high XLOC_032768 level group. Therefore, the downregulation of lncRNA XLOC_032768 in diabetic patients may predict the occurrence of DN.

Association of Visceral Obesity Indices With Incident Diabetic Retinopathy in Patients With Diabetes: Prospective Cohort Study

BACKGROUND

Visceral adipose tissue plays an active role in the pathogenesis of type 2 diabetes and vascular dysfunction. The lipid accumulation product (LAP), visceral adiposity index (VAI), and Chinese VAI (CVAI) have been proposed as simple and validated surrogate indices for measuring visceral adipose tissue. However, the evidence from prospective studies on the associations between these novel indices of visceral obesity and diabetic retinopathy (DR) remains scant.

OBJECTIVE

This study aimed to investigate the longitudinal associations of LAP, VAI, and CVAI with incident DR in Chinese patients with diabetes.

METHODS

This was a prospective cohort study conducted in Guangzhou in southern China. We collected baseline data between November 2017 and July 2020, while on-site follow-up visits were conducted annually until January 2022. The study participants consisted of 1403 patients with a clinical diagnosis of diabetes, referred from primary care, who were free of DR at baseline. The LAP, VAI, and CVAI levels were calculated by sex-specific equations based on anthropometric and biochemical parameters. DR was assessed using 7-field color stereoscopic fundus photographs and graded according to the modified Airlie House Classification scheme. Time-dependent Cox proportional hazard models were constructed to estimate the hazard ratios with 95% CIs. Restricted cubic spline curves were fitted to examine the dose-response relationship between the 3 indices of visceral obesity and new-onset DR. Subgroup analyses were performed to investigate the potential effect modifiers.

RESULTS

The mean age of study participants was 64.5 (SD 7.6) years, and over half (816/1403, 58.2%) were female. During a median follow-up of 2.13 years, 406 DR events were observed. A 1-SD increment in LAP, VAI, or CVAI was consistently associated with increased risk for new-onset DR, with a multivariable‑adjusted hazard ratio of 1.24 (95% CI 1.09-1.41; P=.001), 1.22 (95% CI 1.09-1.36; P<.001), and 1.48 (95% CI 1.19-1.85; P=.001), respectively. Similar patterns were observed across tertiles in LAP (P for trend=.001), VAI (P for trend<.001), and CVAI (P for trend=.009). Patients in the highest tertile of LAP, VAI, and CVAI had an 84%, 86%, and 82% higher hazard of DR, respectively, compared to those in the lowest tertile. A nonlinear dose-response relationship with incident DR was noted for LAP and VAI (both P for nonlinearity<.05), but not for CVAI (P for nonlinearity=.51). We did not detect the presence of effect modification by age, sex, duration of diabetes, BMI, or comorbidity (all P for interaction>.10).

CONCLUSIONS

Visceral obesity, as measured by LAP, VAI, or CVAI, is independently associated with increased risk for new-onset DR in Chinese patients with diabetes. Our findings may suggest the necessity of incorporating regular monitoring of visceral obesity indices into routine clinical practice to enhance population-based prevention for DR.

Risk factors for cognitive impairment in middle-aged type 2 diabetic patients: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate risk factors for cognitive impairment (CI) and explore the relationship between obesity and cognition in hospitalised middle-aged patients with type 2 diabetes (T2DM).

METHODS

Subjects were divided into normal cognitive function (NCF) (n=320) and CI (n=204) groups based on the results of the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE). The risk factors for CI were determined by logistic regression analysis and generalised linear modelling. The associations between obesity parameters (body mass index (BMI) and waist circumference (WC)) and cognitive ability were studied with the use of linear regression analysis, piecewise regression modelling and interaction analysis. The receiver operating characteristic curve analysis was used to examine the diagnostic value of influencing factors for cc RESULTS: The prevalence of CI was 38.9% in hospitalised middle-aged T2DM patients (median age, 58 years). Age, WC, hypoglycaemic episode within past 3 months and cerebrovascular disease (CVD) were identified as independent risk factors for CI, while the independent protective factors were education, diabetic dietary pattern, overweight and obesity. BMI was a protective factor for the MoCA score within a certain range, whereas WC was a risk factor for the MMSE and MoCA scores. The area under the curve for the combination of BMI and WC was 0.754 (p<0.001).

CONCLUSION

Age, education, diabetic dietary pattern, WC, overweight, obesity, hypoglycaemic episode in 3 months and CVD may be potential influencing factors for the occurrence of CI in hospitalised middle-aged population with T2DM. The combination of BMI and WC may represent a good predictor for early screening of CI in this population. Nevertheless, more relevant prospective studies are still needed.

The association between creatinine to body weight ratio and the risk of progression to diabetes from pre-diabetes: a 5-year cohort study in Chinese adults

OBJECTIVE

Evidence on the association between the creatinine to body weight (Cre/BW) ratio and the risk of pre-diabetes to diabetes development remains limited. Our study aimed to examine the association between the Cre/BW ratio and incident diabetes in pre-diabetic patients.

METHODS

This retrospective cohort study included 24,506 pre-diabetic participants who underwent health checks from 2010 to 2016 in China. We used the Cox proportional-hazards regression model to explore the relationship between baseline Cre/BW ratio and diabetes risk in pre-diabetes patients. Using a Cox proportional hazards regression with cubic spline function and smooth curve fitting (cubical spline smoothing), we were able to determine the non-linear relationship between them. We also carried out a number of subgroup and sensitivity analyses.

RESULTS

The age range of the participants included in this study was 20-99 years, with a majority of 16,232 individuals (66.24%) being men. The mean baseline Cre/BW ratio was 1.06 (SD 0.22) umol/L/kg. 2512 (10.25%) participants received a diabetes final diagnosis over a median follow-up period of 2.89 years. After adjusting for covariates, the Cre/BW ratio had a negative association with incident diabetes in participants with pre-diabetes, per umol/L/kg increase in Cre/BM ratio was accompanied by a 55.5% decrease in diabetes risk (HR = 0.445, 95%CI 0.361 to 0.548). The Cre/BW ratio and risk of diabetes had a non-linear connection, with 1.072 umol/L/kg serving as the ratio's inflection point. The HR were 0.294 (95%CI:0.208-0.414) and 0.712 (95%CI:0.492-1.029), respectively, on the left and right sides of the inflection point. The sensitivity analysis demonstrated the robustness of these results. Subgroup analyses indicated that the Cre/BW ratio was strongly associated with the risk of diabetes among participants who were younger than 50 years, as well as among those with diastolic blood pressure (DBP) < 90 mmHg and triglyceride (TG) < 1.7 mmol/L. In contrast, among participants 50 years of age or older, those with DBP ≥ 90 mmHg, and those with TG ≥ 1.7 mmol/L, the relationship between the Cre/BW ratio and the risk of diabetes was attenuated.

CONCLUSION

This study demonstrates a negative, non-linear relationship between the Cre/BW ratio and the risk of diabetes among the Chinese population with pre-diabetes. From a therapeutic standpoint, it is clinically meaningful to maintain the Cre/BW ratio levels above the inflection point of 1.072 umol/L/kg.

Rationale and design for the Blood Pressure Control Target in Diabetes (BPROAD) study

BACKGROUND

Diabetes and hypertension are major modifiable risk factors for cardiovascular disease. Previous clinical trials have demonstrated that intensive blood pressure reduction lowers the risk of cardiovascular disease and all-cause mortality compared to standard blood pressure reduction among patients without diabetes. However, optimal levels of blood pressure control in patients with diabetes remain uncertain.

METHODS

The Blood Pressure Control Target in Diabetes (BPROAD) study is a multicenter, randomized controlled trial conducted in mainland China. We plan to enroll 12 702 participants aged ≥50 years with type 2 diabetes, an increased cardiovascular risk, and systolic blood pressure ≥130 mm Hg from 150 study centers. Participants are randomly assigned to intensive (a systolic target of <120 mm Hg) or standard (a systolic target of <140 mm Hg) blood pressure treatment group. Participants will be followed monthly for blood pressure management in the first 3 months and then every 3 months afterward. The primary study outcome is a composite of major cardiovascular events including nonfatal myocardial infarction, nonfatal stroke, treated or hospitalized heart failure, and cardiovascular death. Data will be collected every 3 months for up to 5 years and a blinded outcome committee will adjudicate all clinical outcomes. The BPROAD study is designed to have 90% statistical power to detect a 20% reduction in the primary study outcome at a two-sided significance level of 0.05.

CONCLUSIONS

The BPROAD study will provide important evidence as to whether intensive blood pressure management has additional benefits on cardiovascular disease and all-cause mortality among patients with type 2 diabetes.

Serum Uric Acid Levels and Their Association with Renal Function Decline and Kidney Disease Progression in Middle-Aged and Elderly Populations: A Retrospective Cohort Study

Objective

To evaluate the associations between serum uric acid (SUA) levels and estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD), with a focus on gender differences, and variations among women pre-and post-menopausal stages.

Design

A retrospective cohort study.

Setting

A large community-based survey was conducted every two years from 2010 to 2018 in Hangzhou, Zhejiang Province, Southeastern China.

Participants

10,218 participants (40 years or above) without CKD at baseline who underwent three physical examinations were enrolled. CKD was defined as an eGFR of less than 60 mL/min/1.73m2.

Methods

Participants with SUA levels were divided into four groups (Q1-Q4) based on baseline SUA quartiles. The Q1 was the reference. By stratifying participants by gender, the relationships between SUA levels and eGFR were investigated using the generalized additive mixture model. The associations of SUA and the risk of incident CKD were examined using multivariate logistic regression models in the generalized estimating equation.

Results

After adjusting for confounding variables, a nonlinear association between SUA and eGFR was observed in females, while an approximately linear relationship was observed in males, suggesting that elevated SUA levels are associated with renal function decline. Furthermore, the highest quartile of SUA was associated with a 2.16-fold (95% CI: 1.31-3.58) increased risk of CKD in males and a 2.76-fold (95% CI: 1.59-4.78) increased risk in females, compared with the lowest quartile. And the spline curves demonstrated a U-shaped pattern, suggesting a potential threshold effect of SUA on the risk of CKD. Additionally, Subgroup analyses revealed significant associations between elevated SUA levels with CKD in postmenopausal women, but not in premenopausal women.

Conclusion

Elevated SUA levels are associated with an increased risk of CKD development and renal function decline in middle-aged and elderly individuals, particularly in postmenopausal women.

The relationship between skeletal muscle mass to visceral fat area ratio and metabolic dysfunction-associated fatty liver disease subtypes in middle-aged and elderly population: a single-center retrospective study

Background

It has been reported that decreased muscle mass combined with excessive visceral adipose tissue are significantly correlated with the risk of non-alcoholic fatty liver disease (NAFLD). However, it has not been explored among populations with metabolic dysfunction-associated fatty liver disease (MAFLD) subtypes. We aimed to investigate whether appendicular skeletal muscle mass to visceral fat area ratio (SVR), an indicator of sarcopenic obesity, influences on the risk of MAFLD subtypes and its hepatic condition in middle-aged and elderly population.

Methods

A total of 4,003 middle-aged and elderly subjects were finally enrolled in this single-center retrospective study. Abdominal ultrasonography was employed for hepatic steatosis diagnosis. Participants were divided into four groups: diabetes-MAFLD, overweight/obese-MAFLD, lean-MAFLD and no MAFLD. Appendicular skeletal muscle mass as well as visceral fat area (VAF) was estimated by bioimpedance analysis measurements. Liver fibrosis was defined as a Fibrosis-4 index (FIB-4) and the NAFLD Fibrosis Score (NFS). Multivariate logistic regression analysis was performed to estimate the odds ratio and 95% confidence interval between SVR and MAFLD subtypes/hepatic condition stratified by sex.

Results

Participants with MAFLD subtypes had a significant lower value of SVR compared with those without MAFLD (P<0.001), while high quartiles of FIB-4 and NFS also showed a decreasing value of SVR in comparison with its lower quartiles (Pfor trend<0.001). The lowest quartile of SVR increased the prevalence of MAFLD subtypes [adjusted OR (95%CI): 2.96 (1.48 ~ 5.93) male /3.30(1.46 ~ 7.46) female for diabetes-MAFLD, 1.91(1.26 ~ 2.88) male /4.48(1.91 ~ 10.49) female for overweight/obese-MAFLD and 4.01(1.46 ~ 10.98) male/2.53(1.19 ~ 5.37) female for lean-MAFLD groups] compared with the highest quartile of SVR (all Pfor trend<0.001). Besides, the interaction effect of gender on the relationship between SVR and MAFLD subtypes was statistically significant (all Pfor interaction<0.001).Restricted cubic spline indicated an inverse association between SVR and the risk of MAFLD subtypes with linearity (all P for non-linearity>0.05). The lowest quartile of SVR also increases the risk of MAFLD fibrosis in both males and females.

Conclusion

Our study concluded that a decrease in SVR (appendicular skeletal muscle mass divided by visceral fat area) is significantly associated with an increased prevalence of developing MAFLD subtypes and liver fibrosis in middle-aged and older persons of both genders.

Aerobic Training Increases Hippocampal Volume and Protects Cognitive Function for Type 2 Diabetes Patients with Normal Cognition

AIM

To evaluate the effects of aerobic training on hippocampal volume and cognitive function in patients with type 2 diabetes mellitus (T2DM) with normal cognition.

MATERIALS AND METHODS

One hundred patients with T2DM aged 60-75 years who met inclusion criteria were randomized into the aerobic training group (n=50) and control group (n=50). The aerobic training group received 1 year of aerobic training, while the control group maintained their lifestyle without additional exercise intervention. The primary outcomes were hippocampal volume measured by MRI and Mini-mental State Examination (MMSE) score or Montreal Cognitive Assessment scale (MoCA) scores.

RESULTS

Eighty-two participants completed the study (aerobic training group, n=40; control group, n=42). There was no significant difference between the two groups at baseline (P>0.05). After one year of moderate aerobic training, increase in total and right hippocampal volume in the aerobic training group were significantly higher than in the control group (P=0.027, P=0.043, respectively). In the aerobic group, total hippocampal volume significantly increased after the intervention compared with baseline (P=0.034). The between-group difference in the change of MMSE and MoCA scores was statistically significant (P=0.015, P=0.027, respectively). Logistic regression showed strong correlations between aerobic training and increase in total hippocampal volume (OR:1.091, [95%CI 0.969, 1.228], P=0.002), improvement of MMSE scores (OR:1.127, [95%CI 1.005, 1.263], P=0.041) or MoCA scores (OR:2.564, [95%CI 2.098.2.973], P=0.045).

CONCLUSIONS

One-year moderate aerobic training increased total and right hippocampal volume and protected cognitive function for T2DM patients with normal cognition. Early intervention focusing on cognition protection should be considered for T2DM patients in clinical settings.

Serum uric acid to creatinine ratio as a risk factor for mortality among patients on continuous ambulatory peritoneal dialysis: a multi-center retrospective study

BACKGROUND

Serum uric acid to serum creatinine ratio (SUA/Scr) has emerged as a new biomarker, which is significantly associated with several metabolic diseases. However, no study has investigated the association between SUA/Scr and mortality among patients on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

In this multicenter retrospective cohort study, we enrolled CAPD patients in eight tertiary hospitals in China from 1 January 2005 to 31 May 2021. Cox proportional hazard models were used to determine the relationship between SUA/Scr and mortality.

RESULTS

A total of 2480 patients were included; the mean age was 48.9 ± 13.9 years and 56.2% were males. During 12648.0 person-years of follow-up, 527 (21.3%) patients died, of which 267 (50.7%) deaths were caused by cardiovascular disease. After multivariable adjustment for covariates, per unit increase in SUA/Scr was associated with a 62.9% (HR, 1.629 (95% confidence interval (CI) 1.420-1.867)) and 73.0% (HR, 1.730 (95% CI 1.467-2.041)) higher risk of all-cause and cardiovascular mortality. Results were similar when categorized individuals by SUA/Scr quartiles. Compared with the lowest quartile of SUA/Scr, the highest and the second highest quartile of SUA/Scr had a 2.361-fold (95% CI 1.810-3.080) and 1.325-fold (95% CI 1.003-1.749) higher risk of all-cause mortality, as well as a 3.701-fold (95% CI 2.496-5.489) and 2.074-fold (95% CI 1.387-3.100) higher risk of cardiovascular mortality. Multivariable-adjusted spline regression models showed nonlinear association of SUA/Scr with mortality in CAPD patients.

CONCLUSIONS

Higher levels of SUA/Scr were associated with higher risk of all-cause and cardiovascular mortality in CAPD patients.

Association of socioeconomic status with metabolic syndrome and its components among adult population: a community-based cross-sectional study in Nanjing Municipality of China

OBJECTIVES

To investigate the association of metabolic syndrome (MetS) and its components with socioeconomic status (SES) among general and gender-specific adult population in Nanjing municipality, China.

DESIGN

Cross-sectional study.

PARTICIPANTS

13287 participants completed the survey. A participant: (1) must be a local registered resident, (2) aged 18+ years, (3) had no literal or physical/mental problems and (4) was not pregnant.

STUDY MEASURES

MetS was the outcome variable, which was defined based on the diagnostic criteria released by the Chinese Diabetes Society. SES was the main explanatory measure, which was indicated with educational attainment and family average income (FAI), separately.

RESULTS

The prevalence of MetS was 19.7% (95% CI=19.0% to 20.4%) among overall participants, and 24.6% (95% CI=23.5% to 25.6%) and 15.5% (95% CI=14.7% to 16.4%) for men and women, respectively. After controlling for potential confounders, participants with either college level (OR=0.51, 95% CI=0.43 to 0.60) or high school level education (OR=0.78, 95% CI=0.70 to 0.90) were at lower odds to experience MetS compared with those with primary education, while only those within upper FAI tertile were at significantly lower risk of MetS relative to their counterparts within lower FAI category (OR=0.85, 95% CI=0.76 to 0.97) among overall participants. Meanwhile, with respect to the five components of MetS, higher educational level predicted lower waist circumference (WC), triglycerides, systolic blood pressure (SBP) and diastolic blood pressure (DBP) and fasting glucose concentration among all participants. And higher FAI was associated with lower WC and SBP and DBP in women, and with lower SBP and DBP in men.

CONCLUSIONS

Education and FAI each were inversely associated with MetS and its components at the present stage of economic development in Nanjing Municipality of China. It has important public health implications that the tailored prevention strategies for MetS should be put into consideration of the intervention of MetS components and subgroups of people with different SES.

Analysis of Subclinical Thyroid Dysfunction and Metabolic Abnormality in 28568 Healthy People

We analyzed the detection rates of metabolic syndrome (MetS) and subclinical thyroid dysfunction, including subclinical hyperthyroidism (SCHyper) and subclinical hypothyroidism (SCH), in healthy people, as well as their relationship. Clinical data were collected from 28,568 healthy individuals who underwent physical examinations. The detection rates of SCHyper, SCH, and MetS, as well as in different genders and ages, were analyzed. The detection rate of SCHyper and SCH in females was significantly higher than that in males (P < 0.001), but that of MetS in males was significantly higher than that in females (P < 0.001). In each age group, the detection rate of SCH in females was higher than that in males (P < 0.001). The detection rate of SCH was significantly different in different age groups (P < 0.001). The detection rates of hyperlipidemia (P < 0.001), obesity (P = 0.004), hypertension (P = 0.009), and hyperglycemia (P < 0.001) in the female SCH group were significantly higher than those in the normal group. The detection rates of hyperlipidemia (P = 0.006), obesity (P = 0.04), and hypertension (P = 0.04) in the male SCH group were higher than those in the normal group. The males with SCHyper were more prone to hyperlipidemia (P = 0.02) and obesity (P = 0.03). In addition, the female SCHyper group was not significantly different from the normal group (P > 0.05). Conclusively, the detection rate of SCHyper and SCH in females is higher than that in males, which increases with age. Attention should be paid to subclinical thyroid dysfunction in elderly people, especially females. Early individualized screening and early intervention should be carried out for people with abnormal metabolism.

Association between serum LDL-C concentrations and risk of diabetes: A prospective cohort study

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) and diabetes mellitus are both modifiable risk factors for cardiovascular disease; however, whether elevated LDL-C levels confer a risk for diabetes remains unclear.

OBJECTIVE

We aimed to examine the association between serum LDL-C concentrations at baseline and the risk of developing diabetes at follow-up in the general population of Chinese adults.

METHODS

This study included 5274 adults aged ≥ 40 years from a community cohort who were without diabetes and followed for a median of 4.4 years. A standard 75-g oral glucose tolerance test was conducted at baseline and follow-up visits to diagnose diabetes. Logistic regression models and a restricted cubic spline were used to examine the association between baseline serum LDL-C levels and the risk of diabetes development. Subgroup analyses were conducted stratifying on age, sex, body mass index, hypertension, family history of diabetes, and LDL-C levels.

RESULTS

A total of 652 participants (12%) developed diabetes during the follow-up period. Compared to quartile 1 of serum LDL-C, quartiles 2, 3, and 4 were associated with a 30%, 33%, and 30% significantly higher risk of diabetes, respectively after adjustment for confounders including homeostatic model assessment for insulin resistance. The linear relationship between baseline LDL-C down to 30.1 mg/dL and incident diabetes was demonstrated by restricted cubic spline analysis, and each 1-SD increase in LDL-C concentration (28.5 mg/dL) was associated with a 12% increase in the risk of diabetes (odds ratio 1.12, 95% confidence interval 1.03-1.22).

CONCLUSION

In this community-based general population, higher serum LDL-C levels were linearly associated with an elevated risk of incident diabetes.

Associations of serum uric acid with cardiovascular disease risk factors: a retrospective cohort study in southeastern China

OBJECTIVE

To evaluate the associations between serum uric acid (SUA) levels and cardiovascular disease (CVD) risk factors, focusing on potential sex-specific differences.

DESIGN

A retrospective cohort study.

SETTING

A large community-based survey was conducted every two years from 2010 to 2018 in Hangzhou, Zhejiang Province, outheastern China.

PARTICIPANTS

6119 participants aged 40 years and above who underwent at least three times of physical examinations were enrolled.

METHODS

Participants were categorised into four groups (Q1-Q4) based on baseline SUA quartiles within the normal range, with hyperuricaemia (HUA) as the fifth group. The Q1 was the reference. By stratifying participants by gender, the relationships between SUA levels and systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG) and total cholesterol (TC) were investigated using linear regression models in the generalised estimating equation. Additionally, the associations of elevated SUA levels and HUA with hypertension, hyperglycaemia and dyslipidaemia were correspondingly examined using multivariate logistic regression models.

RESULTS

After adjusting for confounding variables, we found positive associations between SUA levels and SBP, DBP, FBG and TC in women, and with TC in men (p<0.01). Likewise, elevated SUA quartiles and HUA were linked to increased dyslipidaemia risk in both sexes, and increased hyperglycaemia risk only in women, with HRs (95% CI) of 1.64 (1.05 to 2.55) and 2.37 (1.47 to 3.81) in the Q4 and HUA group, respectively. Women with HUA had higher hypertension risk (HR=1.45, 95% CI 1.21 to 1.73), while no such association was observed in men. Stratified analyses revealed significant associations between elevated SUA levels and CVD risk factors in postmenopausal and non-obese women.

CONCLUSIONS

Elevated SUA levels increase the risk of dyslipidaemia in both sexes. SUA levels within normal range and HUA are positively associated with hyperglycaemia and hypertension in postmenopausal women, but not in men.

Association of the Clínica Universidad de Navarra-Body Adiposity Estimator With Type 2 Diabetes: A Retrospective Cohort Study

Objectives: Clínica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE) is considered to be a more accurate indicator of body fat estimation. We aimed to investigate the association of CUN-BAE with the risk of type 2 diabetes mellitus (T2DM) and to compare the strength of the association between CUN-BAE, body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR) and T2DM. Methods: The data were obtained from the annual health checkup database of residents in Xinzheng, China. From January 2011 to December 2021, 80,555 subjects aged ≥45 years met the inclusion criteria. Cox proportional hazard regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for CUN-BAE, BMI, WC, and WHtR in T2DM. Results: During a mean follow-up of 6.26 years, T2DM occurred in 12,967 subjects. The multivariable-adjusted HRs (95% CIs) of T2DM (highest vs. reference group) were 1.994 (1.811-2.196) for CUN-BAE, 1.751 (1.665-1.842) for WC, 1.715 (1.631-1.804) for WHtR, and 1.510 (1.436-1.588) for BMI, respectively. In addition, the risk of T2DM increased with baseline CUN-BAE (HR: 1.374; 95% CI: 1.328, 1.421), WC (HR: 1.236; 95% CI: 1.215, 1.256), WHtR (HR: 1.228; 95% CI: 1.208, 1.248), and BMI (HR: 1.175; 95% CI: 1.156, 1.195). Conclusion: Compared to BMI, WC or WHtR, CUN-BAE may more adequately reflect the adverse effects of adiposity on the risk of T2DM.

Fibrinogen is Associated with Clinical Adverse Events in Patients with Psoriasis and Coronary Artery Disease

Purpose

The presence of elevated fibrinogen levels is associated with cardiovascular disease. However, whether fibrinogen level is associated with adverse clinical events in patients with psoriasis and coronary artery disease (CAD) is unknown. This study aimed to investigate the relationship between fibrinogen levels and cardiovascular adverse events in these patients.

Patients and Methods

This retrospective cohort study collected consecutive patients with psoriasis and CAD between January 2017 and May 2022 in our hospital. The clinical records were collected, and comparisons were made between groups. The Cox regression analysis and Kaplan-Meier survival analysis were used to evaluate the association between variables.

Results

Of the 267 participants, one hundred and forty-seven patients (55.1%) had elevated fibrinogen levels. Compared with patients in low fibrinogen group, white blood cell and platelet counts and high-sensitivity C-reactive protein levels were higher, whereas the left ventricular ejection fraction was lower in patients in high fibrinogen group. After a median follow-up of 35.5 months, the incidence of major adverse cardiovascular events (MACEs) was higher in patients in high fibrinogen group compared with patients in low fibrinogen group (31.4% vs 16.4%, p = 0.013). The Kaplan-Meier survival curves showed the same trend (log rank p = 0.020). Subgroup analysis revealed a positive association between elevated fibrinogen levels and MACEs in patients aged <60 years (log-rank p = 0.013), those with diabetes (log-rank p = 0.027), and those who were not admitted for acute cardiovascular syndrome (log-rank p = 0.015).

Conclusion

Elevated fibrinogen levels were associated with adverse clinical events in patients with psoriasis and CAD, especially among patients aged <60 years, those with diabetes, and those not admitted for acute cardiovascular syndrome.

Effectiveness and cost-effectiveness of six GLP-1RAs for treatment of Chinese type 2 diabetes mellitus patients that inadequately controlled on metformin: a micro-simulation model

Objective

To systematically estimate and compare the effectiveness and cost-effectiveness of the glucagon-like peptide-1 receptor agonists (GLP-1RAs) approved in China and to quantify the relationship between the burden of diabetic comorbidities and glycosylated hemoglobin (HbA1c) or body mass index (BMI).

Methods

To estimate the costs (US dollars, USD) and quality-adjusted life years (QALY) for six GLP-1RAs (exenatide, loxenatide, lixisenatide, dulaglutide, semaglutide, and liraglutide) combined with metformin in the treatment of patients with type 2 diabetes mellitus (T2DM) which is inadequately controlled on metformin from the Chinese healthcare system perspective, a discrete event microsimulation cost-effectiveness model based on the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model was developed. A cohort of 30,000 Chinese patients was established, and one-way sensitivity analysis and probabilistic sensitivity analysis (PSA) with 50,000 iterations were conducted considering parameter uncertainty. Scenario analysis was conducted considering the impacts of research time limits. A network meta-analysis was conducted to compare the effects of six GLP-1RAs on HbA1c, BMI, systolic blood pressure, and diastolic blood pressure. The incremental net monetary benefit (INMB) between therapies was used to evaluate the cost-effectiveness. China's per capita GDP in 2021 was used as the willingness-to-pay threshold. A generalized linear model was used to quantify the relationship between the burden of diabetic comorbidities and HbA1c or BMI.

Results

During a lifetime, the cost for a patient ranged from USD 42,092 with loxenatide to USD 47,026 with liraglutide, while the QALY gained ranged from 12.50 with dulaglutide to 12.65 with loxenatide. Compared to exenatide, the INMB of each drug from highest to lowest were: loxenatide (USD 1,124), dulaglutide (USD -1,418), lixisenatide (USD -1,713), semaglutide (USD -4,298), and liraglutide (USD -4,672). Loxenatide was better than the other GLP-1RAs in the base-case analysis. Sensitivity and scenario analysis results were consistent with the base-case analysis. Overall, the price of GLP-1RAs most affected the results. Medications with effective control of HbA1c or BMI were associated with a significantly smaller disease burden (p < 0.05).

Conclusion

Loxenatide combined with metformin was identified as the most economical choice, while the long-term health benefits of patients taking the six GLP-1RAs are approximate.

Lipoprotein(a) is a new prognostic factor in patients with psoriasis and coronary artery disease: a retrospective cohort study

BACKGROUND

The prognostic value of lipoprotein (Lp) (a) in patients who have suffered from coronary artery disease (CAD) has not been fully studied, and the results are inconsistent. This study was conducted to evaluate whether increased Lp(a) concentrations cause differences in clinical adverse outcomes in patients with psoriasis who have already suffered from CAD.

METHODS

This retrospective cohort study included consecutive patients with psoriasis and CAD between January 2017 and May 2022 in our hospital. The clinical records were collected, and comparisons were made between patients in the low Lp(a) and high Lp(a) groups. Cox proportional hazard analysis and log-rank tests were used to evaluate the association between variables.

RESULTS

Among 295 patients, 148 patients were in the low Lp(a) group, and 147 were in the high Lp(a) group. These two groups did not differ significantly in age, gender or body mass index. Compared with the low Lp(a) group, the levels of platelet counts (P = 0.038) and high sensitivity C reactive protein (P = 0.012) were higher in the high Lp(a) group. Patients in the high Lp(a) group had higher total cholesterol levels (P = 0.029) and lower triglyceride levels (P = 0.037). Among the whole cohort, clinical adverse events were not correlated with Lp(a) concentrations after a median follow-up of 3 years. However, in the subgroup analysis, there were significant differences in all-cause death (log rank P = 0.036) and rehospitalization (log rank P = 0.037) between the two groups in patients with diabetes; a difference in rehospitalization (log rank P = 0.042) was also found between the two groups in men.

CONCLUSIONS

In patients with psoriasis and CAD, high levels of Lp(a) were related to a poor prognosis, especially in patients with diabetes and in men. These results will provide valuable information for the risk stratification of patients with psoriasis and CAD.

Relationships Between Body Composition and Cognitive Impairment in Hospitalised Middle-Aged Type 2 Diabetic Patients

Objective

The aim of this study was to elucidate the relationship between specific body composition and the risk of Cognitive Impairment (CI) in middle-aged Type 2 Diabetes Mellitus (T2DM) patients.

Methods

This cross-sectional study included 504 hospitalized patients with T2DM from the Department of Endocrinology and Metabolism of the Tianjin Union Medical Center. Subjects were grouped by sex, and cognitive status was assessed using the Montreal Cognitive Assessment (MoCA). The relationship between body composition and cognitive ability was investigated with the use of linear regression analysis. The association between body composition and CI risk was determined by logistic regression analysis.

Results

The prevalence of CI was 39.3% in middle-aged T2DM patients. After adjusting for age, education, marriage status, carotid atherosclerosis, cerebrovascular disease and hemoglobin, multiple linear regression analysis showed that lean mass index (LMI), body mass index (BMI) and appendicular skeletal muscle index (SMI) were significant predictors for the MoCA scores in men (p < 0.05). In addition, BMI (OR 0.913, 95% CI 0.840-0.992) and LMI (OR 0.820, 95% CI 0.682-0.916) were independent protective factors for CI in males. After adjusted for age, education, marriage status, dietary control of diabetes and cerebrovascular disease, visceral obesity (VO, OR 1.950, 95% CI 1.033-3.684) and abdominal obesity (AO, OR 2.537, 95% CI 1.191-5.403) were risk factors for CI in female patients.

Conclusion

The results suggest that there may be different mechanisms underlying the relationship of body compositions and cognitive performance between middle-aged male and female patients with T2DM. In addition, our finding of potential determinants of cognitive impairment may facilitate the development of intervention programs for middle-aged type 2 diabetic patients. Nevertheless, more large prospective studies looking at cognition and changes in body composition over time are needed in the future to further support their association.

Inactivation of the antidiabetic drug acarbose by human intestinal microbial-mediated degradation

Drugs can be modified or degraded by the gut microbiota, which needs to be considered in personalized therapy. The clinical efficacy of the antidiabetic drug acarbose, an inhibitor of α-glucosidase, varies greatly among individuals for reasons that are largely unknown. Here we identify in the human gut acarbose-degrading bacteria, termed Klebsiella grimontii TD1, whose presence is associated with acarbose resistance in patients. Metagenomic analyses reveal that the abundance of K. grimontii TD1 is higher in patients with a weak response to acarbose and increases over time with acarbose treatment. In male diabetic mice, co-administration of K. grimontii TD1 reduces the hypoglycaemic effect of acarbose. Using induced transcriptome and protein profiling, we further identify an acarbose preferred glucosidase, Apg, in K. grimontii TD1, which can degrade acarbose into small molecules with loss of inhibitor function and is widely distributed in human intestinal microorganisms, especially in Klebsiella. Our results suggest that a comparatively large group of individuals could be at risk of acarbose resistance due to its degradation by intestinal bacteria, which may represent a clinically relevant example of non-antibiotic drug resistance.

Changes in body weight and cardiovascular risk factors in a Chinese population with type 2 diabetes mellitus: a longitudinal study

Introduction

The primary care management of blood glucose, blood pressure, lipid profiles, and body weight is important among patients with type 2 diabetes mellitus (T2DM) to prevent disease progression. Information on how weight changes would improve or deteriorate cardiovascular (CV) risk factors is warranted for making primary care recommendations. We aimed to investigate the changes in body weight and CV risk factors and to analyse their association in a Chinese population with T2DM.

Methods

We retrieved longitudinal data between 2020 and 2021 from 1,758 adult primary care patients enrolled in a diabetic retinopathy (DR) screening programme. Linear associations of changes in body weight with CV risk factors were explored. Multivariable logistic regression analysis was performed to examine associations between different weight change categories and the worsening of CV risk factors.

Results

The mean age of all the participants was 63.71 years, and over half of participants were females. During a one-year follow-up period, 24.7% of patients had a weight loss of ≥3%, while 22.2% of patients had a weight gain of ≥3%. Patients who had a weight loss of ≥3% were more likely to prevent the worsening of haemoglobin A1c (HbA1c) and triglycerides, while those who had a weight gain of ≥3% tended to have worsened HbA1c, lipid profiles, and blood pressure.

Conclusion

Results from this real-world investigation suggested the concurrent need for weight loss intervention among patients who are overweight or obese and weight gain prevention among patients whose body weight falls within the normal range in the context of community-based diabetes management.

Efficacy and safety of empagliflozin in combination with insulin in Chinese patients with type 2 diabetes and insufficient glycaemic control: A phase III, randomized, double-blind, placebo-controlled, parallel study

AIM

To evaluate the efficacy and safety of empagliflozin in combination with insulin ± oral antidiabetic drugs (OADs) over 24 weeks, in Chinese patients with type 2 diabetes (T2D) who had insufficient glycaemic control.

MATERIALS AND METHODS

This was a randomized, double-blind, placebo-controlled, parallel group, multicentre phase III study. Adult patients with T2D and insufficient glycaemic control who received insulin ± up to two OADs were randomized (1:1:1) to receive empagliflozin 10 or 25 mg, or placebo for 24 weeks. The primary endpoint was change from baseline in HbA1c at week 24.

RESULTS

Of 219 randomized patients, 73 patients were in each treatment group; baseline characteristics were comparable among the groups. There was a significantly larger decrease from baseline in HbA1c (adjusted mean treatment difference -0.99 and -0.98 for in the empagliflozin 10 and 25 mg groups, respectively; P < .0001) with both doses of empagliflozin than with placebo. There were also significantly larger decreases from baseline in fasting plasma glucose, 2-hour postprandial glucose and body weight with both empagliflozin doses than with placebo. Among patients in the empagliflozin 10 mg, 25 mg and placebo groups, 17.8%, 9.6% and 11.0% reported confirmed hypoglycaemic events, respectively (nominal P = .2422 and .7661 in the empagliflozin 10 and 25 mg groups, respectively), and no Clinical Events Committee-confirmed diabetic ketoacidosis events were reported.

CONCLUSIONS

In Chinese patients with T2D, empagliflozin combined with insulin ± OADs improved glycaemic control and was well tolerated, without an increased risk of hypoglycaemia.

Mitochondrial DNA Copy Number Is a Potential Biomarker for Treatment Choice Between Metformin and Acarbose

Metformin is the first-line drug for type 2 diabetes (T2D) while acarbose is suggested as a viable alternative in Chinese patients with newly diagnosed T2D. However, few biomarkers have been established to guide the choice between these two agents. Mitochondrial DNA (mtDNA) copy number (mtDNA-CN) is a biomarker of mitochondrial function, which is associated with various metabolic outcomes. Using data from the trial of Metformin and Acarbose in Chinese as the Initial Hypoglycaemic Treatment (MARCH) (metformin n = 214; acarbose n = 198), we examined whether mtDNA-CN was associated with response to the drugs in terms of glycemic response and β-cell function protection response. The glycemic response is defined as the maximum glucose reduction of glycated hemoglobin A_1c , fasting plasma glucose, or postprandial blood glucose during 48 weeks. β-cell function protection response is defined as the maximum increment of insulinogenic index (IGI) or disposition index (DI). For all three glycemic responses, mtDNA-CN was not significantly associated with either metformin or acarbose. Importantly, for β-cell function protection response, we found the increased mtDNA-CN was significantly associated with more IGI increment (beta: 0.84; 95% confidence interval (CI), 0.02 to 1.66) in the metformin group, but less IGI increment (beta: -1.38; 95% CI, -2.52 to -0.23) in the acarbose group. A significant interaction (P = 0.008) between mtDNA-CN and the treatment group was observed. Consistent results were also obtained when DI increment was used as a measure of β-cell function response. This study demonstrated the potential application of mtDNA-CN in guiding the treatment choice between metformin and acarbose based on β-cell protection.

Elevated remnant cholesterol increase 6-year type 2 diabetes mellitus onset risk

AIM

To investigate the association of remnant cholesterol (RC) with future type 2 diabetes mellitus (T2DM) risk, and to assess the underlying impact of some recognized risk factors on it.

METHODS

A total of 11468 nondiabetic adults in rural China were recruited in 2007-2008 and followed up in 2013-2014. Logistic regression was used to assess the risk of incident T2DM by quartiles of baseline RC, estimating odds ratios (ORs) and 95% confidence intervals (CIs). Association of the combinations of RC and low-density lipoprotein cholesterol (LDL-C) with T2DM risk were further evaluated.

RESULTS

Multivariable adjusted OR (95% CI) for incident T2DM associated with quartile 4 versus quartile 1 of RC was 2.72 (2.05-3.62). Per 1-standard deviation (SD) increases in RC levels was associated with a 34% higher T2DM risk. However, gender modified the specific association (P_interaction < 0.05), with the association stronger among females. When combining the low LDL-C and low RC groups as reference, individuals with RC levels ≥ 0.56 mmol/L had more than a 2-fold T2DM risk, regardless of LDL-C level.

CONCLUSIONS

Elevated RC levels increase T2DM risk in rural Chinese populations. In those who cannot control their risk by lowering LDL-C levels, the goal of lipid-lowering therapy can be shifted to RC.

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.

Development and External Validation of Nomogram to Identify Risk Factors for CHD in T2DM in the Population of Northwestern China

Purpose

Cardiovascular disease is the leading cause of mortality in patients with type 2 diabetes mellitus (T2DM). This study aimed to develop and validate a nomogram for predicting the risk factors for coronary heart disease (CHD) in T2DM in the population of northwestern China.

Patients and Methods

The records of 2357 T2DM patients who were treated in the First Affiliated Hospital of Xinjiang Medical University from July 2021 to July 2022 were reviewed. After some data (n =239) were excluded, 2118 participants were included in the study and randomly divided into a training set (n =1483) and a validation set (n = 635) at a ratio of 3:1. Univariate and stepwise regression analysis was performed to screen risk factors and develop predictive models. The results of logistic regression are presented through a nomogram. The C-index, receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were employed to verify the distinction, calibration, and clinical practicality of the model.

Results

The stepwise logistic regression analysis suggested that independent factors in patients with T2DM combined with CHD were age, gender, hypertension (HTN), glycated hemoglobin (HbA1c), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and Uygur, which were associated with the occurrence of CHD. The nomogram demonstrated good discrimination with a C-index of 0.771 (95% CI, 0.741, 0.800) in the training set and 0.785 (95% CI, 0.743, 0.828) in the validation set. The area under curve (AUC) of the ROC curves were 0.771 (95% CI, 0.741, 0.800) and 0.785 (95% CI, 0.743, 0.828) in the training and validation sets, respectively. The nomogram was well-calibrated. The DCA revealed that the nomogram was clinically valuable.

Conclusion

A nomogram based on 7 clinical characteristics was developed to predict CHD in patients with T2DM.

Association between age at diabetes onset or diabetes duration and subsequent risk of pancreatic cancer: Results from a longitudinal cohort and mendelian randomization study

BACKGROUND

The aim of the study is to estimate the incidence of pancreatic cancer among individuals with new-onset type 2 Diabetes (T2DM) and evaluate the relationship of pancreatic cancer risk with age at diabetes onset and diabetes duration.

METHODS

This longitudinal cohort study included 428,362 new-onset T2DM patients in Shanghai and Mendelian randomization (MR) in the east-Asian population were used to investigate the association. Incidence rates of pancreatic cancer in all patients and by subgroups were calculated and compared to the general population.

FINDINGS

A total of 1056 incident pancreatic cancer cases were identified during eight consecutive years of follow-up. The overall pancreatic cancer annual incidence rate was 55·28/100,000 person years in T2DM patients, higher than that in the general population, with a standardized incidence ratio (SIR) of 1·54 (95% confidence interval [CI], 1·45-1·64). The incidence of pancreatic cancer increased with age and a significantly higher incidence was observed in the older groups with T2DM. However, the relative pancreatic cancer risk was inversely related to age of T2DM onset, and a higher SIR of 5·73 (95%CI, 4·49-7·22) was observed in the 20-54 years old group. The risk of pancreatic cancer was elevated at any diabetes duration. Fasting blood glucose ≥10·0 mmol/L was associated with increased risk of pancreatic cancer. MR analysis indicated a positive association between T2DM and pancreatic cancer risk.

INTERPRETATION

Efforts toward early and close follow-up programs, especially in individuals with young-onset T2DM, and the improvement of glucose control might represent effective strategies for improving the detection and results of treatment of pancreatic cancer.

FUNDING

Chinese National Natural Science Foundation.

Predictors of HbA1c reduction and hypoglycemia in type 2 diabetes mellitus individuals switching from premixed to basal insulin: an exploratory analysis of optimization study

OBJECTIVE

To identify population with type 2 diabetes mellitus (T2DM) who are more likely to benefit from switching to basal insulin (BI) treatment from premixed insulin.

METHODS

This secondary analysis included data from a previously published study (Optimization: NCT00693771) which was a single-arm, multicenter, 16 weeks, phase IV study. The analysis included participants with T2DM inadequately controlled with premixed insulin plus oral hypoglycemic drugs (OADs) who switched to BI plus OADs.

RESULTS

Among the 297 participants included for analysis, subjects with fasting C-peptide (FCP)>1.2 nmol/L group showed a trend for greater reduction in HbA1c [Least square mean difference (LSMD), -0.59; 95% confidence interval (CI), -0.98 to -0.21; p = 0.003] and FPG (LSMD, -1.36; 95% CI, -2.20 to -0.53; p = 0.002) than those with FCP ≤ 0.4 nmol/L. The baseline insulin glargine 100 U/mL (Gla-100) dose increased significantly in 0.4 to ≤ 1.2 nmol/L group with LS mean difference (SE) of 0.16 (0.01) U/kg/day (p = 0.008) compared to FCP ≤ 0.4 nmol/L group. When combined with Diabetes Treatment Satisfaction Questionnaire (DTSQ) score, participants with a C-peptide level of 0.4 to ≤1.2 nmol/L (OR, 4.05; 95% CI, 1.08 to 15.22; p = 0.039) had significantly higher odds of achieving HbA1c <7%. The number of participants experiencing documented symptomatic hypoglycaemia (≤3.9 mmol/L) was higher in the FCP ≤0.4 nmol/L group compared to those in 0.4 to ≤1.2 nmol/L FCP group at any time of the day (31.6 vs. 17.1%) and during night (00:00 ∼ 05:59) (17.1 vs. 7.5%).

CONCLUSION

The findings from this study proposed that FCP is an important biomarker to identify T2DM participants who experience improved glucose control without compromising on hypoglycemia levels during switch from premixed insulin to BI. Participants especially with FCP levels >1.2 nmol/L may respond better in terms of HbA1c reduction without increased hypoglycemia risk compared to those with lower FCP values.

What is the best anthropometry index to evaluate the risk of metabolic abnormalities in Chinese adults?

AIMS

Obesity, defined by body mass index (BMI), is a heterogeneous condition with varying metabolic manifestations, and the best index for predicting metabolic abnormalities remains unclear. This study aimed to explore the most suitable anthropometry index for predicting metabolic abnormalities in Chinese adults.

METHODS

A cross-sectional study was conducted using the data obtained from 9517 Chinese adults who underwent physical examination, bioelectrical impedance analysis, and laboratory examinations between March 2018 and March 2022. Participants were further divided into eight subgroups according to age, BMI, and sex. Descriptive statistics were calculated, and the area under the receiver operating characteristic curve and Youden index values were calculated to identify the best predictor of metabolic abnormalities in Chinese adults.

RESULTS

The waist-to-height ratio (WHtR) had the largest area under the curve for predicting metabolic abnormalities in men of any age and women aged 18-49 years. However, BMI showed the highest accuracy in predicting metabolic abnormalities in women aged 50 years and older. Based on the highest Youden index, the optimal WHtR threshold was 0.51 in women and 0.53 in men.

CONCLUSIONS

The WHtR was the most effective index for predicting metabolic abnormalities in most Chinese adults, whereas BMI showed a higher accuracy only in elderly women. This observation supports WHtR as a novel adiposity marker for screening metabolic abnormalities and shows value for public health practice.

Frequency of Follow-Up Attendance and Blood Glucose Monitoring in Type 2 Diabetic Patients at Moderate to High Cardiovascular Risk: A Cross-Sectional Study in Primary Care

Regular follow-up attendance in primary care and routine blood glucose monitoring are essential in diabetes management, particularly for patients at higher cardiovascular (CV) risk. We sought to examine the regularity of follow-up attendance and blood glucose monitoring in a primary care sample of type 2 diabetic patients at moderate-to-high CV risk, and to explore factors associated with poor engagement. Cross-sectional data were collected from 2130 patients enrolled in a diabetic retinopathy screening programme in Guangdong province, China. Approximately one-third of patients (35.9%) attended clinical follow-up <4 times in the past year. Over half of patients (56.9%) failed to have blood glucose monitored at least once per month. Multivariable logistic regression analysis showed that rural residents (adjusted odds ratio [aOR] = 0.420, 95% confidence interval [CI] = 0.338-0.522, p < 0.001, for follow-up attendance; aOR = 0.580, 95%CI: 0.472-0.712, p < 0.001, for blood glucose monitoring) and subjects with poor awareness of adverse consequences of diabetes complications (aOR = 0.648, 95%CI = 0.527-0.796, p < 0.001, for follow-up attendance; aOR = 0.770, 95%CI = 0.633-0.937, p = 0.009, for blood glucose monitoring) were both less likely to achieve active engagement. Our results revealed an urban-rural divide in patients' engagement in follow-up attendance and blood glucose monitoring, which suggested the need for different educational approaches tailored to the local context to enhance diabetes care.

Cost-effectiveness of insulin degludec/insulin aspart versus biphasic insulin aspart in Chinese population with type 2 diabetes

Objective

To evaluate the long-term cost effectiveness of insulin degludec/insulin aspart (IDegAsp) vs. biphasic insulin aspart 30 (BIAsp 30) for the treatment of people with type 2 diabetes mellitus (T2DM) inadequately managed on basal insulin in China.

Methods

The CORE (the Center for Outcomes Research) Diabetes Model, which has been published and verified, was used to simulate disease progression and calculate the total direct medical costs, life years (LYs) and quality-adjusted life years (QALYs) over 30 years, from the perspective of Chinese healthcare system. The patient demographic information and clinical data needed for the model were gathered from a phase III treat-to-target clinical trial (NCT02762578) and other Chinese cohort studies. Medical costs on treating diabetes were calculated based on clinical trial and local sources. The diabetes management and complications costs were derived from published literature. A discounting rate of 5% was applied to both health and cost outcomes. And one-way and probabilistic sensitivity analyses were carried out to test the reliability of the results.

Results

Compared with BIAsp 30, treatment with IDegAsp was associated with an incremental benefit of 0.001 LYs (12.439 vs. 12.438) and 0.280 QALYs (9.522 vs. 9.242) over a 30-year time horizon, and increased CNY (Chinese Yuan) 3,888 (390,152 vs. 386,264) for total costs. IDegAsp was cost-effective vs. BIAsp 30 therapy with an incremental cost-effectiveness ratio of CNY 13,886 per QALY gained. Results were robust across a range of sensitivity analyses.

Conclusion

Compared with BIAsp 30, IDegAsp was a cost-effective treatment option for people with T2DM with inadequate glycemic management on basal insulin in China.

Evaluation of the performance and usability of a novel continuous glucose monitoring system

Background

Continuous glucose monitoring (CGM) can help manage diabetes mellitus (DM) and prevent hypoglycemia. This study aimed to evaluate the performance and usability of a novel SiJoy GS1 CGM system.

Methods

This multicenter trial enrolled participants with DM. Based on the comparison of glucose values measured by SiJoy GS1 CGM and venous blood glucose test, the 20/20% consistency and mean absolute relative difference (MARD%) were calculated, as well as Clarke and consensus error grid analysis. Product usability was evaluated by questionnaire completed by participants. Any occurrence of adverse events (AE) was documented.

Results

Seventy participants were included in the study. The mean age of participants was 41.5 ± 13.2 years, among which 29 (42.0%) were male, with the DM course of 8.6 ± 7.5 years. A total of 39 (56.5%) of them had type 1 DM, 24 (34.8%) had type 2 DM, and 6 (8.7%) were others for DM. The 20/20% consistency achieved 91.82%, which was higher than the target 65%. The percentage of A + B zones of Clarke and consensus error grid was 99.22% and 99.90%, respectively. The MARD value was 8.83% ± 4.03%. The mean score of usability questionnaire was 86.59 ± 5.17 out of 90. AE were observed in only one participant (mild fever), and no severe AEs occurred.

Conclusions

The SiJoy GS1 CGM system achieved satisfactory performance and usability. No severe AEs occurred and mild AE was reported in only one case.

Associations of BMI with all-cause mortality in normoglycemia, impaired fasting glucose and type 2 diabetes mellitus among an elderly Chinese population: a cohort study

Aim

To explore the associations of body mass index (BMI) and mortality among people with normal fasting glucose (NFG), impaired fasting glucose (IFG), and type 2 diabetes mellitus (T2DM) in an elderly Chinese population. 

Methods

A retrospective cohort study was conducted that included 59,874 elderly people who were aged 60 and older at baseline. Data for the study came from a health check-up program in China between 2011 and 2019. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using multivariable Cox proportional hazard models of BMI categories by glycemic status.

Results

During the median of 5.96 years of follow-up, 7928 participants died (6457/49057 with NFG, 712/5898 with IFG and 759/4919 with T2DM). In adjusted Cox models, risk of mortality showed a decreasing trend with BMI < 18.5 kg/m², 24 ≤ BMI < 28 kg/m², and BMI ≥ 28 kg/m² compared to 18.5 ≤ BMI < 24 kg/m²: HR (95% CI): 1.33 (1.18 to 1.49), 0.88 (0.83 to 0.93), and 0.90 (0.82 to 0.98), respectively, for NFG; 0.89 (0.55 to 1.46), 0.84 (0.71 to 0.99), and 0.88 (0.70 to 1.11), respectively, for IFG; and 1.42 (0.88 to 2.29), 0.75 (0.64 to 0.89), and 0.76 (0.62 to 0.93), respectively, for T2DM. There were curvilinear-shaped associations between BMI and mortality in the NFG and T2DM groups (P overall < 0.001 and P overall < 0.001, respectively; P nonlinearity < 0.001 and P nonlinearity = 0.027, respectively) and no significantly association between BMI and all-cause mortality was observed in the IFG group (P overall = 0.170).

Conclusion

High BMI compared to normal BMI was associated with decreased mortality, especially in the old populations with NFG and T2DM. Future studies are needed to explain the obesity paradox in elderly patients with T2DM.

The Impact of a Family Doctor Contract Service on Outcomes for Type 2 Diabetes Patients in Zhejiang Province

This study evaluated the effect of family doctor contract service on the health management in Chinese type 2 diabetes mellitus (T2DM) patients over a 24-month period. According to whether patients signing contracts with family doctors or not, the contracting status was divided into contracted and noncontracted. The analysis of covariance was used to examine changes in weight, body mass index, waist circumference, systolic blood pressure, fasting plasma glucose, and lipid parameters between the two groups. The hazard ratios for incident diabetes-related complications were calculated using a Cox proportional hazard model. Of the 2310 patients, 1155 were contracted. The contracted patients displayed the improved fasting blood glucose control and lower low-density lipoprotein cholesterol level than the noncontracted group. Patients signed up with family doctors had a lower risk of diabetes-related complications than those who did not. The data suggested that family doctor contract service might help to achieve better T2DM control.

The predictive value of Thromboelastography (TEG) parameters in vascular complications in patients with type 2 diabetes mellitus

AIMS

The purpose of this research was to explore the association of TEG parameters (Reaction time, R; Clot kinetics, K; Alpha angle, α-angle; Maximum amplitude, MA) with vascular complications of type 2 diabetes mellitus (T2DM), and assess whether TEG parameters could predict T2DM patients with vascular complications.

METHODS

A total of 68 healthy controls (HC), 57 T2DM patients without vascular complications (NC), 18 T2DM patients with only microvascular complications (MIC), 196 T2DM patients with only macrovascular complications (MAC), and 94 T2DM patients with both microvascular and macrovascular complications (MIC+MAC) were recruited in this study. Participants' clinical information and TEG parameters were recorded. TEG parameters were analyzed by the Jonckheere-Terpstra trend test, assuming the vascular complication was progressing from HC → NC → MIC → MIC+MAC or HC → NC → MAC → MIC+MAC. Receiver operating characteristic (ROC) was performed to explore the diagnostic accuracy of TEG parameters in T2DM with vascular complications.

RESULTS

Shorter TEGK, higher TEG-α-angle, and higher TEG-MA were found in T2DM patients with both microvascular and macrovascular complications (MIC+MAC) group compared with healthy controls (HC) group and T2DM patients without vascular complications (NC) group (P < 0.05). Trend analysis showed that TEG-R/K decreased, but TEG-α-angle/MA increased gradually as the vascular complication progressed (P < 0.001). With stratification of urine microalbumin/creatinine ratio (UACR), diabetic nephropathy with macroalbuminuria (grade A3) behaves shorter TEGK, higher TEG-α-angle/MA compared with normal to mildly increased albuminuria (grade A1) and microalbuminuria (grade A2) (P < 0.05). ROC curves implied that TEGK, TEG-α-angle, and TEG-MA have moderate diagnostic values in T2DM without vascular complications (K-AUC: 0.780, α-angle-AUC: 0.773, and MA-AUC: 0.740) as well as T2DM with both microvascular and macrovascular complications (K-AUC: 0.778, α-angle-AUC: 0.757, and MA-AUC: 0.800).

CONCLUSION

TEG parameters are associated with the progression of vascular complications in T2DM, and it could be a diagnostic indicator for T2DM without vascular complications or with advanced vascular complications.

Association between cardiorespiratory fitness and risk of all-cause and cause-specific mortality

OBJECTIVE

The association of cardiorespiratory fitness (CRF) with all-cause and cause-specific mortality remains unclear in Chinese population. This study aimed to evaluate the risk of all-cause, cardiovascular disease (CVD), cancer and other-cause mortality in Chinese adults using estimated CRF (eCRF).

PATIENTS AND METHODS

We analysed data for 15,566 participants aged ≥20 years recruited in The Rural Chinese Cohort Study during 2007 to 2008 and followed for mortality during 2013 to 2014. eCRF was calculated with sex-specific longitudinal non-exercise algorithms. Cox proportional-hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality risk according to baseline eCRF.

RESULTS

During a median of 6.01 years of follow-up, 859 deaths occurred, including 359 from CVD, 221 from cancer, and 279 from other causes. Each 1 metabolic equivalent increment in eCRF was associated with decreased risk of all-cause mortality (men: HR 0.70, 95% CI [0.66-0.74]; women: 0.59, [0.54-0.64]); CVD mortality (men: 0.70 [0.64-0.77]; women: 0.55, [0.48-0.62]); and other-cause mortality (men: 0.68 [0.62-0.75]; women: 0.57, [0.49-0.66]). The area under receiver operating characteristic curve was significantly higher for eCRF than its modifiable components (waist circumference, body mass index and resting heart rate) in predicting all-cause and cause-specific mortality incidence (all p < .001).

CONCLUSION

eCRF was inversely associated with all-cause, CVD and other-cause mortality.

Association of body mass index and waist circumference with type 2 diabetes mellitus in older adults: a cross-sectional study

BACKGROUND

The prevalence of obesity and diabetes is rising. The aim of this study was to determine the association of body mass index (BMI) and waist circumference (WC) with type 2 diabetes mellitus (T2DM) in the elderly and to compare the discriminatory abilities of BMI, WC and other anthropometric indicators, including waist-to-height ratio (WHtR), body adiposity estimator (BAE) and body roundness index (BRI) for T2DM.

METHODS

This cross-sectional study included 69,388 subjects aged ≥ 60 years living in Xinzheng, Henan Province, from January to December 2020. The data came from the residents' electronic health records of the Xinzheng Hospital Information System. Logistic regression was used to examine the relationships. Fully adjusted models adjusted for age, sex, place of residence, alcohol consumption, smoking, physical exercise, SBP and RHR. The area under the receiver operating characteristic curve (AUC) was used to compare the discriminatory ability of different anthropometric indicators for T2DM under the influence of potential risk factors.

RESULTS

After adjusting for multiple covariates, compared with the first BMI quintile, the odds ratios (ORs) and 95% confidence intervals (CIs) from the second to fifth quintile for T2DM were 1.416 (1.335-1.502), 1.664 (1.570-1.764), 1.879 (1.774-1.990) and 2.156 (2.037-2.283), respectively. Compared with the first WC quintile, the ORs and 95% CIs from the second to fifth quintiles for T2DM were 1.322 (1.244-1.404), 1.549 (1.459-1.643), 1.705 (1.609-1.807) and 2.169 (2.048-2.297), respectively. Among men, compared with other anthropometric indicators (BMI, WHtR, BAE and BRI), WC showed the highest AUC (AUC: 0.629; 95% CI: 0.622-0.636). Among women, the AUCs of BMI (AUC: 0.600; 95% CI: 0.594-0.606), WC (AUC: 0.600; 95% CI: 0.593-0.606) and BAE (AUC: 0.600; 95% CI: 0.594-0.607) were similar, and the AUCs of BMI, WC and BAE were higher than WHtR, BRI.

CONCLUSIONS

All anthropometric indicators were positively associated with T2DM. In men, WC with the strongest positive association with T2DM was the best predictor of T2DM. In women, BMI was most strongly associated with T2DM, and the predictive powers of BMI, WC and BAE were similar. After adjusting the potential confounding factors including age, sex, place of residence, alcohol consumption, smoking, physical exercise, SBP and RHR, the effect of these factors was eliminated, the findings were independent of the covariates considered.

Associations of Long-Term Visit-to-Visit Blood Pressure Variability With Subclinical Kidney Damage and Albuminuria in Adulthood: a 30-Year Prospective Cohort Study

BACKGROUND

Recent evidence indicates that long-term visit-to-visit blood pressure variability (BPV) may be associated with risk of cardiovascular disease. We, therefore, aimed to determine the potential associations of long-term BPV from childhood to middle age with subclinical kidney damage (SKD) and albuminuria in adulthood.

METHODS

Using data from the ongoing cohort of Hanzhong Adolescent Hypertension study, which recruited children and adolescents aged 6 to 18 years at baseline, we assessed BPV by SD and average real variability (ARV) for 30 years (6 visits). Presence of SKD was defined as estimated glomerular filtration rate between 30 and 60 mL/min per 1.73 m² or elevated urinary albumin-to creatinine ratio at least 30 mg/g. Albuminuria was defined as urinary albumin-to creatinine ratio ≥30 mg/g.

RESULTS

During 30 years of follow-up, of the 1771 participants, 204 SKD events occurred. After adjustment for demographic, clinical characteristics, and mean BP during 30 years, higher SD_SBP , ARV_SBP , SD_DBP , ARV_DBP , SD_MAP , ARV_MAP , and ARV_PP were significantly associated with higher risk of SKD. When we used cumulative exposure to BP from childhood to adulthood instead of mean BP as adjustment factors, results were similar. In addition, greater long-term BPV was also associated with the risk of albuminuria. Long-term BPV from childhood to middle age was associated with higher risk of SKD and albuminuria in adulthood, independent of mean BP or cumulative exposure to BP during follow-up.

CONCLUSIONS

Identifying long-term BPV from early age may assist in predicting kidney disease and cardiovascular disease in later life.

C-peptide, glycaemic control, and diabetic complications in type 2 diabetes mellitus: A real-world study

OBJECTIVE

To explore the relationship between C-peptide and glycaemic control rate and diabetic complications (microvascular complication and cerebral infarction) and provide evidence for stratified treatment of type 2 diabetes mellitus (T2DM)-based C-peptide.

METHOD

This is a cross-sectional real-world observational study. According to the inclusion and exclusion criteria, we studied 1377 patients with T2DM, grouped by fasting C-peptide and HOMA-IR. Blood samples were collected after fasting overnight. Logistic regression was used to analyse the relationship among fasting C-peptide, HOMA-IR, C2/C0 ratio (the ratio of 2 h postprandial C-peptide to fasting C-peptide), glycaemic control rate, and occurrence of diabetic complications. Restricted cubic spline (RCS) curves based on logistic regression were used to evaluate the relationship between C-peptide, glycaemic control rate, and diabetic kidney disease (DKD).

RESULTS

Patients were subdivided according to their fasting C-peptide in 4 groups (Q1,Q2,Q3,Q4). Patients of group Q3 (1.71 ≤ C-peptide < 2.51 ng/ml) showed the lowest incidence of DKD, diabetic retinopathy (DR), and rate of insulin absorption as welll as higher glycaemic control rate. Logistic regression shows that the probability of reaching glycemic control increased with higher levels of C-peptide, compared with group Q1, after adjusting for age, gender, duration of diabetes, body mass index, systolic blood pressure, diastolic blood pressure, creatinine, low-density lipoprotein, triglyceride, total cholesterol, and high-density lipoprotein. RCS curve shows that, when C-peptide is ≤2.68 ng/ml, the incidence of not reaching glycaemic control decreases with increasing C-peptide. The possibility of not reaching glycaemic control decreased with increasing C2/C0, when C-peptide is ≥1.71 ng/ml. RCS curve shows that the relationship between C-peptide and DKD follows a U-style curve. When C-peptide is <2.84 ng/ml, the incidence of DKD decreased with increasing C-peptide. With the increase in the C2/C0 ratio, the incidence of DKD, DR, and fatty liver did not decrease.

CONCLUSION

When C-peptide is ≥ 1.71 and < 2.51 ng/ml, patients with T2DM had a higher glycemic control rate. Excessive C-peptide plays different roles in DKD and DR; C-peptide may promote the incidence of DKD but protects patients from DR. Higher C2/C0 ratio is important for reaching glycaemic control but cannot reduce the risk of DKD, DR, and fatty liver.

Normalized Creatinine-to-Cystatin C Ratio and Risk of Diabetes in Middle-Aged and Older Adults: The China Health and Retirement Longitudinal Study

BACKGROUND

Creatinine-to-cystatin C ratio is recently suggested to be a surrogate marker for sarcopenia. However, little is known about its association with diabetes. This study aimed to fill in this gap based on a large-scale prospective cohort.

METHODS

A population-based representative sample of 5,055 participants aged ≥45 years from the China Health and Retirement Longitudinal Study was enrolled between 2011 and 2012 and followed at least once during the subsequent surveys at 2013, 2015, or 2018. Creatinine-to-cystatin C ratio was calculated and normalized by body weight. Incident diabetes was ascertained by plasma glucose, glycosylated hemoglobin, self-reported history, or use of anti-diabetic drugs. Logistic regression analysis and mediation analysis were employed.

RESULTS

During follow-up, 634 participants developed diabetes. The risk of diabetes was gradually and significantly decreased with increased normalized creatinine-cystatin C ratio. The multivariable-adjusted odds ratio for diabetes was 0.91 (95% confidence interval, 0.83 to 0.99) per 1 standard deviation higher of normalized creatinine-to-cystatin C ratio, and this relationship remained significant after controlling for muscle strength. The risk reduction in diabetes was significantly larger in participants with normal-weight and high normalized creatinine-to-cystatin C ratio compared with those with overweight/obesity and high normalized creatinine-to-cystatin C ratio (Pinteraction=0.01). Insulin resistance and inflammation appeared to be key mediators accounting for the observed relationship between normalized creatinine-to-cystatin C ratio and risk of diabetes, with their mediating effect being 93.1% and 22.0%, respectively.

CONCLUSION

High normalized creatinine-to-cystatin C ratio is associated with reduced risk of diabetes in middle-aged and older adults.

Patient Preferences for Diabetes Treatment Among People With Type 2 Diabetes Mellitus in China: A Discrete Choice Experiment

Introduction

Preferences for diabetes treatment-related attributes may be significant in diabetes management. However, there is a lack of evidence on patient preferences for diabetes in China.

Methods

A large-scale questionnaire survey was conducted in the hospitals of mainland China. Participants' preferences for six attributes were evaluated via a discrete choice experiment (DCE) using the conditional logit model. Patients' willingness to pay (WTP) for each attribute was calculated based on the cost attribute.

Results

The sample consisted of 709 patients (male 51.9%; female 48.1%). The results of the model indicated that patients' preference weight (PW) of days on which the blood glucose level is under control per week was the highest (1.41), and the PW of blood glucose monitoring frequency was the lowest (0.642). Patients were generally willing to pay for improvements in their type 2 diabetes mellitus (T2DM) treatment, and they had relatively higher WTP to avoid the blood glucose level within a normal value of 1 day/week (¥176.01) and also to avoid the frequency of hypoglycemic events within the range of 1–2/month (¥144.53).

Conclusion

The number of days on which the blood glucose level is under control per week is the most important attribute in the treatment choice for patients with T2DM in China, followed by the frequency of hypoglycemic events, medication regimen, weight change, and blood glucose monitoring.

The use of complex marketing analysis and QSPR methodology for the necessity of a drug development grounding for the treatment of type 2 diabetes mellitus with increased bioavailability

In order to guarantee qualitative medical and pharmaceutical care it is necessary for all participants of the process to provide consistent interconnected actions, including the use of modern approaches in pharmacotherapy, assessment of the urgent needs of the population in medicines (drugs), development and introduction of modern qualitative, safe and effective drugs into the market. Today, one of the key indicators in determining the population‘s need for drugs is the epidemiological indicators in a particular region and their dynamics.

In recent years, the actuality of optimal and effective approaches developing in the prevention and treatment of socially significant diseases, including diabetes mellitus (DM), has been increasingly emphasized at the global level. All actions that are proposed for the development of standardized guidelines, treatment protocols, programs for on-time detection and prevention of diabetes are aimed at forming a system of measures are patient-oriented, based on understanding the patient‘s problems, lifestyle, habits, income and expenses for treatment, as well as other components associated with achieving optimal results for patients.

Muscle strength and prediabetes progression and regression in middle-aged and older adults: a prospective cohort study

BACKGROUND

Prediabetes progression is associated with increased mortality while its regression decreases it. It is unclear whether muscle strength is related to prediabetes progression or regression. This study investigated the associations of muscle strength, assessed by grip strength and chair-rising time, with prediabetes progression and regression based on the China Health and Retirement Longitudinal Study (CHARLS) enrolling middle-aged and older adults.

METHODS

We included 2623 participants with prediabetes from CHARLS, who were followed up 4 years later with blood samples collected for measuring fasting plasma glucose and haemoglobin A1c. Grip strength (normalized by body weight) and chair-rising time were assessed at baseline and categorized into tertiles (low, middle, and high groups). Prediabetes at baseline and follow-up was defined primarily using the American Diabetes Association (ADA) criteria and secondarily using the World Health Organization (WHO) and International Expert Committee (IEC) criteria. Multinomial logistic regression analysis was applied to obtain the odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

The mean age of included participants was 59.0 ± 8.6 years, and 46.6% of them were males. During follow-up, 1646 participants remained as prediabetes, 379 progressed to diabetes, and 598 regressed to normoglycaemia based on ADA criteria. Participants who progressed to diabetes had lower normalized grip strength than those who remained as prediabetes (0.49 ± 0.15 vs. 0.53 ± 0.15, P < 0.001), but participants who regressed to normoglycaemia showed the opposite (0.55 ± 0.16 vs. 0.53 ± 0.15, P = 0.003). However, chair-rising time was comparable across different groups (P_overall  = 0.17). Compared with participants in low normalized grip strength or high chair-rising time group, those in high normalized grip strength or low chair-rising time group had decreased odds of progression to diabetes (OR 0.62, 95% CI 0.44 to 0.87; and OR 0.69, 95% CI 0.51 to 0.93, respectively) after multivariable adjustment. However, both were unrelated to the odds of regression to normoglycaemia (OR 0.94, 95% CI 0.71 to 1.25; and OR 0.84, 95% CI 0.65 to 1.07, respectively). These outcomes remained generally comparable when prediabetes was defined by WHO or IEC criteria. Higher normalized grip strength but not lower chair-rising time was prospectively associated with lower blood pressure, better glycaemic condition, and lower inflammation (all P ≤ 0.04).

CONCLUSIONS

High muscle strength is associated with reduced odds of progression to diabetes but does not predict regression to normoglycaemia in prediabetes. Future studies are warranted to assess whether increases in muscle strength promote prediabetes regression.

Comparison of obesity indices and triglyceride glucose-related parameters to predict type 2 diabetes mellitus among normal-weight elderly in China

PURPOSE

Although a significant proportion of type 2 diabetes mellitus (T2DM) cases arose from normal-weight individuals, studies on indicators of T2DM in normal-weight people are limited. Accordingly, this study aims to investigate the predictive value of obesity indices and triglyceride glucose-related parameters (TyG-related parameters) in T2DM among normal-weight Chinese elderly.

METHODS

A total of 24,215 normal-weight Chinese elderly (age ≥ 60 years) [body mass index-BMI (18.5-23.9 kg/m²)] were included. Obesity indices and triglyceride glucose-related parameters (TyG-related parameters) included waist circumference (WC), waist-to-height ratio (WHtR), visceral adiposity index (VAI), lipid accumulation product (LAP), and TyG-related parameters (TyG, TyG-BMI, TyG-WC, and TyG-WHtR). Multivariate logistic regression analysis was performed to examine the associations between obesity- and TyG-related indices and T2DM. The areas under the curve (AUC) of the receiver-operating characteristic (ROC) curve analyses were used to evaluate and compare the predictive value of the different indices.

RESULTS

The prevalence of T2DM was 14.2% in normal-weight individuals. Among the indices, TyG was significantly associated with T2DM among men and women, respectively, (adjusted odds ratio-aOR per SD 3.46; 95% CI 3.23-3.71) and (aOR per SD 3.64; 95% CI 3.43-3.86). Compared with other indices, TyG had the highest AUC value for T2DM in men (AUC: 0.818, 95% CI 0.810-0.825) and women (AUC: 0.824, 95% CI 0.814-0.833).

CONCLUSIONS

TyG is an effective marker and outperforms other indices when predicting T2DM in the normal-weight Chinese elderly population.

LEVEL OF EVIDENCE

Level V: Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.