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Hanna M, Wabnitz A, Grewal P. Sex and stroke risk factors: A review of differences and impact. J Stroke Cerebrovasc Dis 2024; 33:107624. [PMID: 38316283 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/24/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors. METHODS We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review. RESULTS Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels. CONCLUSIONS By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.
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Affiliation(s)
- Mckay Hanna
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Ashley Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Parneet Grewal
- Department of Neurology, Medical University of South Carolina, Charleston, SC 29425, United States.
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Yongpet R, Seangpraw K, Ong-Artborirak P. Association between Perceived Protection Motivation, Preventive Behaviors, and Biomarkers among Diabetic Patients in Rural Areas of Thailand. Clin Pract 2023; 13:1400-1412. [PMID: 37987427 PMCID: PMC10660454 DOI: 10.3390/clinpract13060126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
The prevalence of diabetes mellitus (DM) is increasing rapidly worldwide. Without proper management, DM can have serious complications. We aimed to investigate the association between protection motivation theory (PMT) constructs, self-care behaviors, and biomarkers among diabetic patients in a community in northern Thailand. A cross-sectional study was conducted. Simple random sampling was used to select 422 subjects from patients enrolled in primary care in Chiang Rai Province. Data were collected using questionnaires and blood sampling to measure fasting blood sugar (FBS) and glycated hemoglobin (HbA1c). Pearson's correlation and multiple linear regression were used to analyze the data. The diabetic subjects' age was 62.25 years (standard deviation [SD] = 8.90), and the duration of diabetes was 9.07 years (SD = 7.23). Positive correlations were found between the DM knowledge score and the PMT score (r = 0.812, p < 0.01) and between the PMT score and the preventive behavior score (r = 0.817, p < 0.01). The preventive behavior score was negatively correlated with FBS (r = -0.319, p < 0.01) and HbA1c (r = -0.625, p < 0.01) and significantly associated with income (B = 0.15) and the PMT score (B = 0.71), accounting for 67.0% of the variance. Age (B = -0.73), sleep problems (B = 10.71), and the preventive behavior score (B = -1.15) were statistically significantly associated with FBS (R2 = 14.3%). Four variables, the female gender (B = -0.26), being married (B = -0.24), sleep problems (B = 0.42), and the preventive behavior score (B = -0.09), were statistically significantly associated with HbA1c levels (R2 = 41.6%). Health education programs should primarily target awareness of disease severity, complications, and self-efficacy enhancement to generate intention and behavior change. This may delay or reduce the occurrence of diabetes-related complications in people with type 2 diabetes.
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Affiliation(s)
| | | | - Parichat Ong-Artborirak
- Department of Research and Medical Innovation, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10300, Thailand;
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Kvitkina T, Narres M, Claessen H, Metzendorf MI, Richter B, Icks A. Incidence of Stroke in People With Diabetes Compared to Those Without Diabetes: A Systematic Review. Exp Clin Endocrinol Diabetes 2023; 131:476-490. [PMID: 37279879 PMCID: PMC10506631 DOI: 10.1055/a-2106-4732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND One of the goals of the St. Vincent Declaration was to reduce serious complications of diabetes, including strokes. However, it remains uncertain whether this goal has been achieved. STUDY AIM To evaluate the incidence of stroke in the diabetic population and its differences regarding sex, ethnicity, age, and region, to compare the incidence rate in people with and without diabetes, and to investigate time trends. MATERIALS AND METHODS A systematic review was conducted according to the guidelines for meta-analysis of observational studies in epidemiology (the MOOSE group) and the PRISMA group guidelines. RESULTS Nineteen of the 6.470 studies retrieved were included in the analysis. The incidence of stroke in the population with diabetes ranged from 238 per 100,000 person-years in Germany in 2014 to 1191 during the 1990s in the United Kingdom. The relative risk comparing people with diabetes to those without diabetes varied between 1.0 and 2.84 for total stroke, 1.0 and 3.7 for ischemic stroke, and 0.68 and 1.6 for hemorrhagic stroke. Differences between fatal and non-fatal stroke were significant, depending on the time period and the population. We found decreasing time trends in people with diabetes and stable incidence rates of stroke over time in people without diabetes. CONCLUSION The considerable differences between results can partly be explained by differences in study designs, statistical methods, definitions of stroke, and methods used to identify patients with diabetes. The lack of evidence arising from these differences ought to be rectified by new studies.
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Affiliation(s)
- Tatjana Kvitkina
- Institute for Health Services Research and Health Economics, German
Diabetes Center, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, Centre for
Health and Society, Medical Faculty of the Heinrich-Heine University
Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg,
Germany
| | - Maria Narres
- Institute for Health Services Research and Health Economics, German
Diabetes Center, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, Centre for
Health and Society, Medical Faculty of the Heinrich-Heine University
Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg,
Germany
| | - Heiner Claessen
- Institute for Health Services Research and Health Economics, German
Diabetes Center, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, Centre for
Health and Society, Medical Faculty of the Heinrich-Heine University
Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg,
Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General
Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf,
Germany
| | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General
Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf,
Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German
Diabetes Center, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, Centre for
Health and Society, Medical Faculty of the Heinrich-Heine University
Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg,
Germany
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Diabetes and cardiovascular risk according to sex: An overview of epidemiological data from the early Framingham reports to the cardiovascular outcomes trials. ANNALES D'ENDOCRINOLOGIE 2023; 84:57-68. [PMID: 36183805 DOI: 10.1016/j.ando.2022.09.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/28/2022] [Accepted: 09/05/2022] [Indexed: 11/21/2022]
Abstract
Male sex is a major cardiovascular risk factor in the general population, with men showing higher age-adjusted prevalence of cardiovascular disease than women. Diabetes, another major cardiovascular risk factor, affects cardiovascular risk differentially between men and women. Data from prospective observational studies showed that women with diabetes had greater relative risk of cardiovascular events than men with diabetes, leading to a smaller difference between diabetic men and women than between non-diabetic men and women in terms of cardiovascular disease. This excess relative risk concerns cardiovascular death, coronary heart disease, stroke and heart failure. It is greatest in the youngest age group and decreases gradually with age. Although many mechanisms have been proposed to explain the greater cardiovascular burden in women with diabetes, little is known about the impact of diverse anti-hyperglycemic drugs on cardiovascular events according to sex. Hence, cardiovascular outcomes trials provide a unique opportunity to study the impact of novel anti-hyperglycemic drugs on cardiovascular outcomes in men and women with type-2 diabetes. Here, we present an overview of the epidemiological data concerning sex-related differences in cardiovascular disease in people with diabetes, with a focus on the effects of novel anti-hyperglycemic drugs on cardiovascular outcomes in men and women. In addition, we summarize proposed mechanisms to explain these differences, with relevant references for the interested reader.
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Wan C, Read S, Wu H, Lu S, Zhang X, Wild SH, Liu Y. Prediction of Five-Year Cardiovascular Disease Risk in People with Type 2 Diabetes Mellitus: Derivation in Nanjing, China and External Validation in Scotland, UK. Glob Heart 2022; 17:46. [PMID: 36051323 PMCID: PMC9336685 DOI: 10.5334/gh.1131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/17/2022] [Indexed: 11/20/2022] Open
Abstract
Background To use routinely collected data to develop a five-year cardiovascular disease (CVD) risk prediction model for Chinese adults with type 2 diabetes with validation of its performance in a population of European ancestry. Methods People with incident type 2 diabetes and no history of CVD at diagnosis of diabetes between 2008 and 2017 were included in derivation and validation cohorts. The derivation cohort was identified from a pseudonymized research extract of data from the First Affiliated Hospital of Nanjing Medical University (NMU). Five-year risk of CVD was estimated using basic and extended Cox proportional hazards regression models including 6 and 11 predictors respectively. The risk prediction models were internally validated and externally validated in a Scottish population-based cohort with CVD events identified from linked hospital records. Discrimination and calibration were assessed using Harrell's C-statistic and calibration plots, respectively. Results Mean age of the derivation and validation cohorts were 58.4 and 59.2 years, respectively, with 53.5% and 56.9% men. During a median follow-up time of 4.75 [2.67, 7.42] years, 18,827 (22.25%) of the 84,630 people in the NMU-Diabetes cohort and 8,763 (7.31%) of the Scottish cohort of 119,891 people developed CVD. The extended model had a C-statistic of 0.723 [0.721-0.724] in internal validation and 0.716 [0.713-0.719] in external validation. Conclusions It is possible to generate a risk prediction model with moderate discriminative power in internal and external validation derived from routinely collected Chinese hospital data. The proposed risk score could be used to improve CVD prevention in people with diabetes.
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Affiliation(s)
- Cheng Wan
- Department of Medical Informatic, School of Biomedical Engineering and Informatics, Nanjing Medical University, CN
| | - Stephanie Read
- Women’s College Research Institute, Women’s College Hospital, Toronto, CA
| | - Honghan Wu
- Institute of Health Informatics, University College London, London, UK
| | - Shan Lu
- Outpatient department, the First Affiliated Hospital, Nanjing Medical University, CN
| | - Xin Zhang
- Department of Information, the First Affiliated Hospital, Nanjing Medical University, China
- Department of Medical Informatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, CN
| | | | - Yun Liu
- Department of Medical Informatic, School of Biomedical Engineering and Informatics, Nanjing Medical University, CN
- Department of Information, the First Affiliated Hospital, Nanjing Medical University, No. 300 Guang Zhou Road, Nanjing, Jiangsu, 210029, China
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Gaspar RS, Rezende LFM, Laurindo FRM. Analysing the impact of modifiable risk factors on cardiovascular disease mortality in Brazil. PLoS One 2022; 17:e0269549. [PMID: 35731729 PMCID: PMC9216570 DOI: 10.1371/journal.pone.0269549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/23/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives We have examined the impact of changes in modifiable risk factors on CVD mortality in 26 Brazilian states from 2005 to 2017. Methods Data were acquired from the Global Burden of Diseases study (GBD) and official sources of the Brazilian government, totalling 312 state-year observations. Population attributable fractions (PAFs) were calculated to determine the number of deaths attributed to changes in each risk factor. Fixed-effects multivariable linear regression models were performed, adjusting for income, income inequality, poverty and access to healthcare. Results Between 2005 and 2017, CVD deaths reduced by 21.42%, accompanied by a decrease in smoking (-33%) and increases in hyperglycaemia (+9.5%), obesity (+31%) and dyslipidaemia (+5.2%). Reduction in smoking prevented or postponed almost 20,000 CVD deaths in this period, while increased hyperglycaemia exposure resulted in more than 6,000 CVD deaths. The association between hyperglycaemia and CVD mortality was 5 to 10 times higher than those found for other risk factors, especially in women (11; 95%CI 7 to 14, deaths per 1-point increase in hyperglycaemia exposure). Importantly, the association between hyperglycaemia and CVD mortality was independent of socioeconomic status and access to healthcare, while associations for other risk factors after the same adjustments. Conclusion Reduction in smoking was the risk factor that led to the highest number of CVD deaths prevented or postponed, while hyperglycaemia showed the most deleterious association with CVD mortality. Health policies should aim to directly reduce the prevalence of hyperglycaemia to mitigate the population burden of CVD in Brazil in the future.
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Affiliation(s)
- Renato Simões Gaspar
- Laboratory of Vascular Biology, Health Institute (InCor), University of Sao Paulo School of Medicine, Sao Paulo, Brazil
- * E-mail:
| | - Leandro F. M. Rezende
- Departamento de Medicina Preventiva, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Kezerle L, Haim M, Akriv A, Senderey AB, Bachrach A, Leventer-Roberts M, Tsadok MA. Relation of Hemoglobin A1C Levels to Risk of Ischemic Stroke and Mortality in Patients With Diabetes Mellitus and Atrial Fibrillation. Am J Cardiol 2022; 172:48-53. [PMID: 35361475 DOI: 10.1016/j.amjcard.2022.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
Diabetes mellitus (DM) is associated with an increased risk of complications in atrial fibrillation (AF). This study aimed to assess the incidence and risks of ischemic stroke and mortality according to baseline HbA1c levels in patients with DM and AF. We conducted a cohort study using Clalit Health Services electronic medical records. The study population included all Clalit Health Services members aged ≥25 years, with the first diagnosis of AF between January 1, 2010, and December 31, 2016, who had a diagnosis of DM. The risk of stroke and all-cause death were compared according to HbA1c levels at the time of AF diagnosis: <7.0%, between 7% and 9%, and ≥9%. A total of 44,451 patients with DM and AF were identified. The median age was 75 years (interquartile 65 to 83), and 52.5% were women. During a mean follow-up of 38 months, higher levels of HbA1c were associated with an increased risk of stroke with a dose-dependent response when compared with patients with HbA1c <7% (Adjusted hazard ratio [aHR] =1.30 [95% confidence interval 1.10 to 2.05] for levels between 7% and 9% and 1.60 (95% confidence interval 1.25 to 2.03) for HbA1c >9%, even after adjusting for CHA2DS2-Vasc risk factors and use of oral anticoagulants. The risk for overall mortality was significantly higher in the HBA1C >9% group (aHR = 1.17 [1.07 to 1.28]). In conclusion, in this cohort of patients with AF and DM, HbA1c levels were associated with the risk of stroke in a dose-dependent manner even after accounting for other recognized risk factors for stroke.
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Affiliation(s)
- Louise Kezerle
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Moti Haim
- Cardiac Electrophysiology and Pacing, Cardiology Department, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Amichay Akriv
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Adi Berliner Senderey
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Asaf Bachrach
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Maya Leventer-Roberts
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Meytal Avgil Tsadok
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
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8
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Cui C, Wu Z, Shi Y, Xu Z, Zhao B, Zhou D, Miao X, He C, Xu X. Sex-specific association of BMI change with stroke in middle-aged and older adults with type 2 diabetes. Nutr Metab Cardiovasc Dis 2021; 31:3095-3102. [PMID: 34511289 DOI: 10.1016/j.numecd.2021.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/29/2021] [Accepted: 07/13/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS We aimed to evaluate the association between BMI change and stroke in middle-aged and older adults with type 2 diabetes and identify sex differences. METHODS AND RESULTS The China Health and Retirement Longitudinal Study is an ongoing national population-based cohort study. Participants aged 45 or above with type 2 diabetes were enrolled and followed for stroke incidence. BMI change was defined as BMI at 2013-BMI at 2011. Of 1774 participants (mean [SD] age in 2011, 60.23 [8.88] years), 795 (44.8 %) were men. A total of 112 incident stroke cases were confirmed up to 2018. The incidence rate of stroke was similar between men and women (6.79 % vs 5.92 %, P = 0.516). BMI increase was independently associated with an increased stroke risk (adjusted odds ratio, 1.15; 95 % CI, 1.05-1.31) in men, while this positive association was not significant in women (adjusted odds ratio, 1.12; 95 % CI, 0.98-1.29). In addition, the positive dose-response relationship between BMI increase and stroke was observed only in men. CONCLUSION Among middle-aged and older adults with type 2 diabetes, there is a sex-specific association of BMI change with stroke. An increase in BMI could result in a higher risk of incident stroke in men.
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Affiliation(s)
- Cancan Cui
- China-Japan Union Hospital of Jilin University, Jilin University, China.
| | - Zhiyuan Wu
- School of Public Health, Capital Medical University, China; School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.
| | - Yunke Shi
- School of Public Health, Capital Medical University, China.
| | - Zhonghang Xu
- China-Japan Union Hospital of Jilin University, Jilin University, China.
| | - Bing Zhao
- State Key Laboratory of Supramolecular Structure and Materials, Jilin University, China.
| | - Di Zhou
- School of Public Health, Capital Medical University, China.
| | - Xinlei Miao
- School of Public Health, Capital Medical University, China.
| | - Chengyan He
- China-Japan Union Hospital of Jilin University, Jilin University, China.
| | - Xuesong Xu
- China-Japan Union Hospital of Jilin University, Jilin University, China.
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Madsen TE, Long DL, Carson AP, Howard G, Kleindorfer DO, Furie KL, Manson JE, Liu S, Howard VJ. Sex and Race Differences in the Risk of Ischemic Stroke Associated With Fasting Blood Glucose in REGARDS. Neurology 2021; 97:e684-e694. [PMID: 34045272 DOI: 10.1212/wnl.0000000000012296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To investigate sex and race differences in the association between fasting blood glucose (FBG) and risk of ischemic stroke (IS). METHODS This prospective longitudinal cohort study included adults age ≥45 years at baseline in the Reasons for Geographic And Racial Differences in Stroke Study, followed for a median of 11.4 years. The exposure was baseline FBG (mg/dL); suspected IS events were ascertained by phone every 6 months and were physician-adjudicated. Cox proportional hazards were used to assess the adjusted sex/race-specific associations between FBG (by category and as a restricted cubic spline) and incident IS. RESULTS Of 20,338 participants, mean age was 64.5 (SD 9.3) years, 38.7% were Black, 55.4% were women, 16.2% were using diabetes medications, and 954 IS events occurred. Compared to FBG <100, FBG ≥150 was associated with 59% higher hazards of IS (95% confidence interval [CI] 1.21-2.08) and 61% higher hazards of IS among those on diabetes medications (95% CI 1.12-2.31). The association between FBG and IS varied by race/sex (hazard ratio, FBG ≥150 vs FBG <100: White women 2.05 [95% CI 1.23-3.42], Black women 1.71 [95% CI 1.10-2.66], Black men 1.24 [95% CI 0.75-2.06], White men 1.46 [95% CI 0.93-2.28], p FBG×race/sex = 0.004). Analyses using FBG splines suggest that sex was the major contributor to differences by race/sex subgroups. CONCLUSIONS Sex differences in the strength and shape of the association between FBG and IS are likely driving the significant differences in the association between FBG and IS across race/sex subgroups. These findings should be explored further and may inform tailored stroke prevention guidelines.
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Affiliation(s)
- Tracy E Madsen
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA.
| | - D Leann Long
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - April P Carson
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - George Howard
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Dawn O Kleindorfer
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Karen L Furie
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - JoAnn E Manson
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Simin Liu
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Virginia J Howard
- From the Departments of Emergency Medicine (T.E.M.), Neurology (K.L.F.), Epidemiology (S.L.), Medicine (S.L.), and Surgery (S.L.), and Center for Global Cardiometabolic Health, Brown University School of Public Health (S.L.), Alpert Medical School of Brown University, Providence, RI; Departments of Biostatistics (D.L.L., G.H.) and Epidemiology (A.P.C., V.J.H.), School of Public Health, University of Alabama at Birmingham; Department of Neurology (D.O.K.), University of Michigan Medical School, Ann Arbor; and Department of Medicine, Division of Preventive Medicine (J.E.M.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA
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Practical use of electronic health records among patients with diabetes in scientific research. Chin Med J (Engl) 2021; 133:1224-1230. [PMID: 32433055 PMCID: PMC7249716 DOI: 10.1097/cm9.0000000000000784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Electronic health (medical) records, which are also considered as patients’ information that are routinely collected, provide a great chance for researchers to develop an epidemiological understanding of disease. Electronic health records systems cannot develop without the advance of computer industries. While conducting clinical trials that are always costly, feasible and reasonable analysis of routine patients’ information is more cost-effective and reflective of clinical practice, which is also called real world study. Real world studies can be well supported by big data in healthcare industry. Real world studies become more and more focused and important with the development of evidence-based medicine. These big data will definitely help in making decisions, making policies and guidelines, monitoring of effectiveness and safety on new drugs or technologies. Extracting, cleaning, and analyzing such big data will be a great challenge for clinical researchers. Successful applications and developments of electronic health record in western countries (eg, disease registries, health insurance claims, etc) have provided a clear direction for Chinese researchers. However, it is still at primary stages in China. This review tries to provide a full perspective on how to translate the electronic health records into scientific achievements, for example, among patients with diabetes. As a summary in the end, resource sharing and collaborations are highly recommended among hospitals and healthcare groups.
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Sex-Related Disparities in the Incidence and Outcomes of Ischemic Stroke among Type 2 Diabetes Patients. A Matched-Pair Analysis Using the Spanish National Hospital Discharge Database for Years 2016-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18073659. [PMID: 33915785 PMCID: PMC8037293 DOI: 10.3390/ijerph18073659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
Background: To analyze the incidence, use of therapeutic procedures, and in-hospital outcomes among patients suffering an ischemic stroke (IS) according to the presence of type 2 diabetes mellitus (T2DM) in Spain (2016–2018) and to assess the existence of sex differences. Methods: Matched-pair analysis using the Spanish National Hospital discharge. Results: IS was coded in 92,524 men and 79,731 women (29.53% with T2DM). The adjusted incidence of IS (IRR 2.02; 95% CI 1.99–2.04) was higher in T2DM than non-T2DM subjects, with higher IRRs in both sexes. Men with T2DM had a higher incidence of IS than T2DM women (IRR 1.54; 95% CI 1.51–1.57). After matching patients with T2DM, those with other comorbid conditions, however, significantly less frequently received endovascular thrombectomy and thrombolytic therapy. In-hospital mortality (IHM) was lower among T2DM men than matched non-T2DM men (8.23% vs. 8.71%; p < 0.001). Women with T2DM had a higher IHM rate than T2DM men (11.5% vs. 10.20%; p = 0.004). After adjusting for confounders, women with T2DM had a 12% higher mortality risk than T2DM men (OR 1.12; 95% CI 1.04–1.21). Conclusions: T2DM is associated with higher incidence of IS in both sexes. Men with T2DM have a higher incidence rates of IS than T2DM women. Women with T2DM have a higher risk of dying in the hospital.
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Seng JJB, Monteiro AY, Kwan YH, Zainudin SB, Tan CS, Thumboo J, Low LL. Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review. BMC Med Res Methodol 2021; 21:49. [PMID: 33706717 PMCID: PMC7953703 DOI: 10.1186/s12874-021-01209-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/13/2021] [Indexed: 12/25/2022] Open
Abstract
Background Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients. Methods The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed. Results Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies. Conclusions Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01209-w.
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Affiliation(s)
- Jun Jie Benjamin Seng
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore
| | | | - Yu Heng Kwan
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore.,Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Sueziani Binte Zainudin
- Department of General Medicine (Endocrinology), Sengkang General Hospital, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
| | - Julian Thumboo
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore.,Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore
| | - Lian Leng Low
- SingHealth Regional Health System PULSES Centre, Singapore Health Services, Outram Rd, Singapore, 169608, Singapore. .,SingHealth Regional Health System, Singapore Health Services, Singapore, Singapore. .,Department of Family Medicine and Continuing Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore. .,SingHealth Duke-NUS Family Medicine Academic Clinical Program, Singapore, Singapore. .,Outram Community Hospital, SingHealth Community Hospitals, 10 Hospital Boulevard, Singapore, 168582, Singapore.
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13
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Shen Y, Shi L, Nauman E, Katzmarzyk P, Price-Haywood E, Bazzano A, Nigam S, Hu G. Association between Hemoglobin A1c and Stroke Risk in Patients with Type 2 Diabetes. J Stroke 2020; 22:87-98. [PMID: 32027794 PMCID: PMC7005352 DOI: 10.5853/jos.2019.01704] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 10/10/2019] [Indexed: 01/01/2023] Open
Abstract
Background and Purpose The association between hemoglobin A1c (HbA1c) and stroke risk along with its subtypes is rarely reported. We aimed to investigate the association between HbA1c and the risk of incident stroke in patients with type 2 diabetes based on real world data from three healthcare systems.
Methods We performed a retrospective cohort study of 27,113 African Americans and 40,431 whites with type 2 diabetes. Demographic, anthropometric, laboratory, and medication information were abstracted from the National Patient-Centered Clinical Research Network common data model. Incident stroke events including both ischemic and hemorrhagic stroke were defined.
Results During a mean follow-up period of 3.79±1.68 years, 7,735 patients developed stroke (6,862 ischemic and 873 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HbA1c at baseline (<6.0%, 6.0% to 6.9% [reference group], 7.0% to 7.9%, 8.0% to 8.9%, 9.0% to 9.9%, and ≥10%) were 1.07, 1.00, 1.13, 1.23, 1.27, and 1.37 (Ptrend <0.001) for total stroke, 1.02, 1.00, 1.13, 1.20, 1.24, and 1.35 (Ptrend <0.001) for ischemic stroke, and 1.40, 1.00, 1.14, 1.47, 1.47, and 1.51 (Ptrend=0.002) for hemorrhagic stroke. When we used an updated mean value of HbA1c, the U-shaped association of HbA1c with stroke risk did not change. This U-shaped association was consistent among patients of different subgroups. The U-shaped association was more pronounced among patients taking antidiabetic, lipid-lowering, and antihypertensive medications compared with those without these medications.
Conclusions These data suggest that diabetes management may have to be individualized according to the guideline recommendations rather than intensively attempting to lower HbA1c.
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Affiliation(s)
- Yun Shen
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - Lizheng Shi
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | | | | | - Eboni Price-Haywood
- Ochsner Health System Center for Outcomes and Health Services Research, New Orleans, LA, USA
| | - Alessandra Bazzano
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Somesh Nigam
- Blue Cross and Blue Shield of Louisiana, Baton Rouge, LA, USA
| | - Gang Hu
- Pennington Biomedical Research Center, Baton Rouge, LA, USA
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Wang YL, Leng XY, Dong Y, Hou XH, Tong L, Ma YH, Xu W, Cui M, Dong Q, Tan L, Yu JT. Fasting glucose and HbA 1c levels as risk factors for the presence of intracranial atherosclerotic stenosis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:804. [PMID: 32042820 DOI: 10.21037/atm.2019.12.56] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Intracranial atherosclerotic stenosis (ICAS) is the most common cause of stroke, but the relationship of ICAS with fasting blood glucose (FBG) and glycated hemoglobin A1c (HbA1c) is unclear. This study aimed to investigate the effects of increased FBG and HbA1c concentration on ICAS. Methods A total of 4,012 patients aged over 40 years who underwent cerebral magnetic resonance angiography (MRA) were enrolled in this study, including 1,434 non-stroke controls and 2,578 patients with ischemic stroke. Participants were classified into four groups according to stroke and ICAS status. ICAS was defined as the presence of ≥50% stenosis in any intracranial artery. Multivariate regression analysis was used to evaluate the associations of FBG and HbA1c with ICAS. Results Levels of fasting glucose and HbA1c in patients with ICAS were significantly higher than those in patients without ICAS among both stroke and non-stroke groups. Multivariate regression analysis showed that elevated levels of fasting glucose (OR 1.14, 95% CI, 1.11-1.18, P<0.001) and HbA1c (OR 1.22, 95% CI, 1.16-1.28, P<0.001) were independent risk factors for ICAS. In addition, patients with the DM (FBG ≥7.0 mmol/L) were at the high risk of ICAS in both non-stroke (OR 2.90, 95% CI, 2.11-3.99, P<0.001) and stroke (OR 1.99, 95% CI, 1.67-2.39, P<0.001) groups. Besides, subjects with the high risk of ICAS were found in the fourth HbA1c quartile in both non-stroke (OR 3.50, 95% CI, 2.23-5.61, P<0.001) and stroke (OR 1.98, 95% CI, 1.50-2.63, P<0.001) groups. Conclusions The results suggest that elevated fasting glucose and HbA1c levels are associated with high risk for ICAS.
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Affiliation(s)
- Yan-Li Wang
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Xin-Yi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi Dong
- Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Xiao-He Hou
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Lin Tong
- Department of Neurology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai 264100, China
| | - Ya-Hui Ma
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Wei Xu
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Mei Cui
- Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Qiang Dong
- Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Lan Tan
- Department of Neurology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Jin-Tai Yu
- Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
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15
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Howard VJ, Madsen TE, Kleindorfer DO, Judd SE, Rhodes JD, Soliman EZ, Kissela BM, Safford MM, Moy CS, McClure LA, Howard G, Cushman M. Sex and Race Differences in the Association of Incident Ischemic Stroke With Risk Factors. JAMA Neurol 2019; 76:179-186. [PMID: 30535250 DOI: 10.1001/jamaneurol.2018.3862] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Race-specific and sex-specific stroke risk varies across the lifespan, yet few reports describe sex differences in stroke risk separately in black individuals and white individuals. Objective To examine incidence and risk factors for ischemic stroke by sex for black and white individuals. Design, Setting, and Participants This prospective cohort study included participants 45 years and older who were stroke-free from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, enrolled from the continental United States 2003 through 2007 with follow-up through October 2016. Data were analyzed from March 2018 to September 2018. Exposures Sex and race. Main Outcomes and Measures Physician-adjudicated incident ischemic stroke, self-reported race/ethnicity, and measured and self-reported risk factors. Results A total of 25 789 participants (14 170 women [54.9%]; 10 301 black individuals [39.9%]) were included. Over 222 120 person-years of follow-up, 939 ischemic strokes occurred: 159 (16.9%) in black men, 326 in white men (34.7%), 217 in black women (23.1%), and 237 in white women (25.2%). Between 45 and 64 years of age, white women had 32% lower stroke risk than white men (incidence rate ratio [IRR], 0.68 [95% CI, 0.49-0.94]), and black women had a 28% lower risk than black men (IRR, 0.72 [95% CI, 0.52-0.99]). Lower stroke risk in women than men persisted at age 65 through 74 years in white individuals (IRR, 0.71 [95% CI, 0.55-0.94]) but not in black individuals (IRR, 0.94 [95% CI, 0.68-1.30]); however, the race-sex interaction was not significant. At 75 years and older, there was no sex difference in stroke risk for either race. For white individuals, associations of systolic blood pressure (women: hazard ratio [HR], 1.13 [95% CI, 1.05-1.22]; men: 1.04 [95% CI, 0.97-1.11]; P = .099), diabetes (women: HR, 1.84 [95% CI, 1.35-2.52]; men: 1.13 [95% CI, 0.86-1.49]; P = .02), and heart disease (women: HR, 1.76 [95% CI, 1.30-2.39]; men, 1.26 [95% CI, 0.99-1.60]; P = .09) with stroke risk were larger for women than men, while antihypertensive medication use had a smaller association in women than men (women: HR, 1.17 [95% CI, 0.89-1.54]; men: 1.61 [95% CI, 1.29-2.03]; P = .08). In black individuals, there was no evidence of a sex difference for any risk factors. Conclusions and Relevance For both races, at age 45 through 64 years, women were at lower stroke risk than men, and there was no sex difference at 75 years or older; however, the sex difference pattern may differ by race from age 65 through 74 years. The association of risk factors on stroke risk differed by race-sex groups. While the need for primordial prevention, optimal management, and control of risk factors is universal across all age, racial/ethnic, and sex groups, some demographic subgroups may require earlier and more aggressive strategies.
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Affiliation(s)
- Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston Salem, North Carolina.,Department of Internal Medicine, Cardiology Section, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Monika M Safford
- Department of Medicine, Weill-Cornell Medicine, New York, New York
| | - Claudia S Moy
- Department of Health and Human Services, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, Colchester, Vermont
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16
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Fan W, Song Y, Inzucchi SE, Sperling L, Cannon CP, Arnold SV, Kosiborod M, Wong ND. Composite cardiovascular risk factor target achievement and its predictors in US adults with diabetes: The Diabetes Collaborative Registry. Diabetes Obes Metab 2019; 21:1121-1127. [PMID: 30609214 DOI: 10.1111/dom.13625] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 12/20/2022]
Abstract
AIM To investigate multiple risk factor target attainment in adults with diabetes mellitus (DM) for atherosclerotic cardiovascular disease (ASCVD) prevention and the predictors of such attainment in a contemporary DM registry. METHODS In the US Diabetes Collaborative Registry we identified patients who were at target for glycated haemoglobin (HbA1c; < 53 mmol/mol (7%) or < 64 mmol/mol (8%) if with ASCVD), LDL cholesterol (< 2.6 mmol/L (100 mg/dL) or < 1.8 mmol/L (70 mg/dL) 1.8 if with ASCVD) and blood pressure (BP; <140/90 mmHg and < 130/80 mmHg as an alternate), and who had non-smoking status, by sex, race and history of ASCVD. Multiple logistic regression was used to examine predictors of target attainment. RESULTS In 74 393 patients with DM who had available data (mean age 69.0 years, 41.0% women), overall target attainment for HbA1c, BP, LDL cholesterol and non-smoking status was 73.6%, 69.0% (40.3% for BP <130/80 mmHg), 48.6% and 85.2%, respectively. Only 21.6% (13.0% with BP <130/80 mmHg) were at target for all four measures, and the proportions were higher in men (23.6%) versus women (18.6%) and in white people (22.5%) versus African-American people (14.7%) and people of other races (20.8%; P < 0.01). A total of 62.4% were on a moderate-/high-intensity statin. Age (≥65 years: odds ratio [OR] 1.9, 95% confidence interval [CI] 1.7-2.0; and 55-64 years: OR 1.3, 95% CI 1.2-1.4 vs. <55 years), male sex (OR 1.3, 95% CI 1.3-1.4), white race (OR 1.4, 95% CI 1.3-1.5), middle or high income (ORs 1.1, 95% CI 1.1-1.2 or 1.4, 95% CI 1.4-1.5, respectively) were associated, and depression (OR 0.9, 95% CI 0.8-1.0) was inversely associated with meeting all four targets (all P = 0.01 to P < 0.001). CONCLUSIONS In our US registry of patients with DM, only one in five patients were achieving comprehensive risk factor control. Multifactorial interventions will be necessary to optimize ASCVD risk factor control.
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Affiliation(s)
- Wenjun Fan
- University of California, Irvine School of Medicine, Irvine, California
| | - Yang Song
- Baim Institute, Boston, Massachusetts
| | | | | | - Christopher P Cannon
- Baim Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | | | | | - Nathan D Wong
- University of California, Irvine School of Medicine, Irvine, California
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17
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Haghighatpanah M, Nejad ASM, Haghighatpanah M, Thunga G, Mallayasamy S. Factors that Correlate with Poor Glycemic Control in Type 2 Diabetes Mellitus Patients with Complications. Osong Public Health Res Perspect 2018; 9:167-174. [PMID: 30159222 PMCID: PMC6110332 DOI: 10.24171/j.phrp.2018.9.4.05] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objectives Inadequate glycemic control amongst patients with Type 2 diabetes mellitus (T2DM) indicates a major public health problem and a significant risk factor for the progression and complications caused by diabetes. Glycemic control is the main therapeutic objective for the prevention of organ damage and other complications arising from diabetes. Methods This was a retrospective observational study of T2DM patients with complications, who were aged 40 years and older. The study was conducted retrospectively on medical records (in-patient and out-patient) obtained from a South Indian teaching hospital, Manipal, India. The patients included in the study had fasting blood sugar, postprandial blood sugar and HbA1c measured at least twice during follow-ups the previous year. Patients' HbA1c levels were categorized into good control ≤7% (≤53mmol/mol), and poor control >7% (>53mmol/mol), and patients' characteristics were analyzed. Results A total of 657 patients were included in the study. The mean age was 59.67 (SD = 9.617) years, with 152 (23.1%) females and 505 (76.9%) males, and 514 (78.2%) patients had poor glycemic control. Most of the patients were on insulin mono-therapy [n = 271 (42.1%)], about a third of the patients were on combination therapy that included an oral hypoglycemic agent and insulin [n = 236 (36.6%)]. Patients with a history of more than 10 years of diabetes [n = 293 (44.6%)], had a family history of diabetes [n = 256 (39%)] and obesity [n = 95 (14.5%)], all had poor glycemic control. Conclusion This present study indicated a significant association of gender (female), age, high-density lipoprotein level, duration of diabetes and type of medication, with poor glycemic control in T2DM patients that had secondary medical complications.
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Affiliation(s)
- Mohammad Haghighatpanah
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, India
| | - Amir Sasan Mozaffari Nejad
- Nutrition Health Research Center, Student Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Girish Thunga
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, India
| | - Surulivelrajan Mallayasamy
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal University, Manipal, India
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18
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Investigating the Association between Chronic Kidney Disease and Ischaemic Stroke from a Health Examination Database. Sci Rep 2018; 8:10903. [PMID: 30026538 PMCID: PMC6053403 DOI: 10.1038/s41598-018-29161-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 06/07/2018] [Indexed: 01/07/2023] Open
Abstract
Stroke has become one of the leading causes of death, with ischaemic stroke as the most common type of stroke occurrence compared to haemorrhagic stroke. Chronic kidney disease(CKD), another important cause of death, shares several traditional cardiovascular riskfactors with ischaemic stroke. Therefore, it is important to examine the existence of shared risk factors in the association between CKD and ischaemic stroke. This study used a health examination database from a medical centre in Taiwan. A generalized linear regression analysis was used to determine the association between CKD and ischaemic stroke. The Maentel-Haenszel test was performed to analyse the effect of possible confounding factors on the association between CKD and ischaemic stroke. A prevalence rate study showed that more subjects with CKD suffered from ischaemic stroke than subjects without CKD. Diabetes, hypertension, hypertriglyceridemia, and hypercholesterolemia were associated with increased risks of ischaemic stroke in CKD subjects. There was an inverse association of the odds ratio of ischaemic stroke between CKD and non-CKD patients, which implied that younger subjects with CKD should be made aware of ischaemic stroke prevention.
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19
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Relation between HbA 1c and incident cardiovascular disease over a period of 6 years in the Hong Kong population. DIABETES & METABOLISM 2018; 44:415-423. [PMID: 29449147 DOI: 10.1016/j.diabet.2018.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/18/2018] [Accepted: 01/21/2018] [Indexed: 10/18/2022]
Abstract
AIM The current trend on diabetes management advocates replacing the paradigm from a uniform to an individualized patient-centered haemoglobin A1c (HbA1c) target, but there is no consensus on the optimal HbA1c level. The study aimed at examining the association between HbA1c and the risk of cardiovascular diseases (CVD) for diabetic patients with different characteristics, in order to identify patient-centered treatment targets. METHODS A retrospective cohort study was conducted on 115,782 Chinese adult primary care patients with type 2 diabetes mellitus (DM) but no known CVD history, who were prescribed antidiabetic medications in 2010-2011. The cumulative mean HbA1c over a median follow-up period of 5.8 years was used to evaluate the relationship between HbA1c and CVD incidence using Cox analysis. Subgroup analyses were conducted by stratifying different baseline characteristics including gender, age, smoking status, diabetes duration, body mass index, Charlson's comorbidity index and DM treatment modalities. RESULTS For patients with a DM duration of<2years, an exponential relationship between HbA1c and risk of CVD was identified, suggesting that there was no threshold HbA1c level for CVD risk. For other diabetic patients, an HbA1c level of 6.8-7.2% was associated with a minimum risk for CVD and a J-shaped curvilinear association between HbA1c. The risk of CVD increased in patients with HbA1c<6.5% or ≥7.5%. CONCLUSION Among Chinese primary care patients at the early (<2years) disease stage, lower HbA1c targets (<6.5%) may be warranted to prevent CVD events whilst for all others, excessively lower HbA1c levels may not necessarily better and can potentially be harmful.
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20
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Read SH, McAllister DA, Colhoun HM, Farran B, Fischbacher C, Kerssens JJ, Leese GP, Lindsay RS, McCrimmon RJ, McGurnaghan S, Philip S, Sattar N, Wild SH. Incident ischaemic stroke and Type 2 diabetes: trends in incidence and case fatality in Scotland 2004-2013. Diabet Med 2018; 35:99-106. [PMID: 29044687 DOI: 10.1111/dme.13528] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/27/2022]
Abstract
AIM To describe trends in first ischaemic stroke incidence and case fatality in adults with and without a diagnosis of Type 2 diabetes prior to their ischaemic stroke event in Scotland between 2004 and 2013. METHODS Using population-wide hospital admission, death and diabetes datasets, we conducted a retrospective cohort study. Negative binomial and logistic regression models were used to calculate year-specific incidence and case-fatality rates for people with Type 2 diabetes and for people without diabetes. RESULTS During 41.0 million person-years of follow-up there were 69 757 ischaemic stroke events. Type 2 diabetes prevalence among patients who experienced ischaemic stroke increased from 13.5% to 20.3% between 2004 and 2013. Stroke incidence rates declined by 2.7% (95% CI 2.4, 3.0) annually for people with and without diabetes [diabetes/year interaction: rate ratio 0.99 (95% CI 0.98, 1.01)]. Type 2 diabetes was associated with an increased risk of ischaemic stroke in men [rate ratio 1.23 (95% CI 1.17, 1.30)] and women [rate ratio 1.41 (95% CI 1.35, 1.48)]. Case-fatality rates were 14.2% and 12.7% in people with Type 2 diabetes and without diabetes, respectively. Case fatality declined by 3.5% (95% CI 2.7, 4.5) annually [diabetes/year interaction: odds ratio 1.01 (95% CI 0.98, 1.02)]. CONCLUSIONS Ischaemic stroke incidence declined no faster in people with a diagnosis of Type 2 diabetes than in people without diabetes. Increasing prevalence of Type 2 diabetes among stroke patients may mean that declines in case fatality over time will be less marked in the future.
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Affiliation(s)
- S H Read
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - D A McAllister
- Institutes of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - H M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - B Farran
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - C Fischbacher
- Information Services Division, NHS National Services, Edinburgh, UK
| | - J J Kerssens
- Information Services Division, NHS National Services, Edinburgh, UK
| | - G P Leese
- Department of Diabetes and Endocrinology, University of Dundee, Dundee, UK
| | - R S Lindsay
- Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - R J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - S McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - S Philip
- Department of Diabetes and Endocrinology, NHS Grampian, Aberdeen, UK
| | - N Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - S H Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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21
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Lum-Naihe K, Toedebusch R, Mahmood A, Bajwa J, Carmack T, Kumar SA, Ardhanari S, DeMarco VG, Emter CA, Pulakat L. Cardiovascular disease progression in female Zucker Diabetic Fatty rats occurs via unique mechanisms compared to males. Sci Rep 2017; 7:17823. [PMID: 29259233 PMCID: PMC5736602 DOI: 10.1038/s41598-017-18003-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/30/2017] [Indexed: 02/08/2023] Open
Abstract
Population studies have shown that compared to diabetic men, diabetic women are at a higher risk of cardiovascular disease. However, the mechanisms underlying this gender disparity are unclear. Our studies in young murine models of type 2 diabetes mellitus (T2DM) and cardiovascular disease show that diabetic male rats develop increased cardiac fibrosis and suppression of intracardiac anti-fibrotic cytokines, while premenopausal diabetic female rats do not. This protection from cardiac fibrosis in female rats can be an estrogen-related effect. However, diabetic female rats develop early subclinical myocardial deformation, cardiac hypertrophy via elevated expression of pro-hypertrophic miR-208a, myocardial damage, and suppression of cardio-reparative Angiotensin II receptor 2 (Agtr2). Diabetic rats of both sexes exhibit a reduction in cardiac capillary density. However, diabetic female rats have reduced expression of neuropilin 1 that attenuates cardiomyopathy compared to diabetic male rats. A combination of cardiac hypertrophy and reduced capillary density likely contributed to increased myocardial structural damage in diabetic female rats. We propose expansion of existing cardiac assessments in diabetic female patients to detect myocardial deformation, cardiac hypertrophy and capillary density via non-invasive imaging, as well as suggest miR-208a, AT2R and neuropilin 1 as potential therapeutic targets and mechanistic biomarkers for cardiac disease in females.
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Affiliation(s)
- Kelly Lum-Naihe
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA.,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Ryan Toedebusch
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA.,Dalton Cardiovascular Research Center, University of Missouri, 134 Research Park Drive, Columbia, MO, 65201, USA.,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Abuzar Mahmood
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA.,Dalton Cardiovascular Research Center, University of Missouri, 134 Research Park Drive, Columbia, MO, 65201, USA.,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Jamal Bajwa
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA.,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Terry Carmack
- Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Senthil A Kumar
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA
| | - Sivakumar Ardhanari
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA
| | - Vincent G DeMarco
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA.,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA
| | - Craig A Emter
- Department of Biomedical Sciences, University of Missouri, 1600 E Rollins, Columbia, MO, 65201, USA.,Dalton Cardiovascular Research Center, University of Missouri, 134 Research Park Drive, Columbia, MO, 65201, USA
| | - Lakshmi Pulakat
- Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, USA. .,Department of Nutrition and Exercise Physiology, Universtiy of Missouri, 204 Gwynn Hall, Columbia, MO, 65211, USA. .,Dalton Cardiovascular Research Center, University of Missouri, 134 Research Park Drive, Columbia, MO, 65201, USA. .,Harry S. Truman Memorial Veterans' Hospital, Columbia, MO, 65201, USA.
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22
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Carrère P, Fagour C, Sportouch D, Gane-Troplent F, Hélène-Pelage J, Lang T, Inamo J. Diabetes mellitus and obesity in the French Caribbean: A special vulnerability for women? Women Health 2017; 58:145-159. [PMID: 28095137 DOI: 10.1080/03630242.2017.1282396] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The objective of this study was to analyze the prevalence, awareness, treatment, and control of diabetes and its risk factors among French Caribbean adults. This cross-sectional study included 18-74-year olds (N = 2252; 56.5 percent women) who underwent a heath examination in Guadeloupe during July-December 2014. Diabetes was defined as using antidiabetic treatment, or fasting glucose ≥7 mmol/l, and glycated hemoglobin (HbA1c) ≥6.5 percent; diabetes control was defined as HbA1c < 7 percent. Multilevel logistic regression was used. Diabetes prevalence was 8.2 percent for women and 5 percent for men (age-adjusted odds ratio [aOR] for women = 2.0; 95 percent confidence interval [CI]: 1.4-2.9). The proportion of women with diabetes who were aware of it was 84.5 versus 67.3 percent in men (aOR = 2.7; 95 percent CI: 1.2-6.2). Nearly, all diagnosed participants were being treated. In less than a third of diabetics in both sexes was diabetes control obtained. Most women (55.3 percent) had a waist circumference at or above the National Cholesterol Education Program thresholds versus 14 percent of men (aOR = 9.3; 95 percent CI: 7.5-11.7), which wholly accounted for excess diabetes in women. In women, obesity and diabetes were associated with low education and income. In this French Caribbean sample, abdominal obesity and diabetes affected more women. Diabetes was rarely controlled. A comprehensive women's health policy for the prevention of abdominal obesity and diabetes is needed.
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Affiliation(s)
- Philippe Carrère
- a Department of General Medicine , University of the French West Indies and Guiana , Pointe-à-Pitre , Guadeloupe , France.,b Laboratory of Epidemiology and Analysis in Public Health , UMR1027 INSERM, University of Toulouse III Paul Sabatier , Toulouse , France.,c Guadeloupean Association for the Management and Conduct of Health Examinations and the Promotion of Health (AGREXAM) , Pointe-à-Pitre , Guadeloupe , France
| | - Cédric Fagour
- d Endocrinology-Diabetology-Nutrition Unit , University Hospital, Fort-de-France , Martinique , France.,e Clinical Epidemiology and Medicine Research Team , EA4540 LAMIA, University of the French West Indies and Guiana , Pointe-à-Pitre , Guadeloupe , France
| | - Dan Sportouch
- a Department of General Medicine , University of the French West Indies and Guiana , Pointe-à-Pitre , Guadeloupe , France.,b Laboratory of Epidemiology and Analysis in Public Health , UMR1027 INSERM, University of Toulouse III Paul Sabatier , Toulouse , France
| | - Franciane Gane-Troplent
- a Department of General Medicine , University of the French West Indies and Guiana , Pointe-à-Pitre , Guadeloupe , France
| | - Jeannie Hélène-Pelage
- a Department of General Medicine , University of the French West Indies and Guiana , Pointe-à-Pitre , Guadeloupe , France
| | - Thierry Lang
- b Laboratory of Epidemiology and Analysis in Public Health , UMR1027 INSERM, University of Toulouse III Paul Sabatier , Toulouse , France
| | - Jocelyn Inamo
- b Laboratory of Epidemiology and Analysis in Public Health , UMR1027 INSERM, University of Toulouse III Paul Sabatier , Toulouse , France.,f Department of Cardiology , University of the French West Indies and Guiana , Fort-de-France , Martinique , France
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23
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Yashkin AP, Sloan F. Adherence to Guidelines for Screening and Medication Use: Mortality and Onset of Major Macrovascular Complications in Elderly Persons With Diabetes Mellitus. J Aging Health 2016; 30:503-520. [PMID: 28553792 DOI: 10.1177/0898264316684270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study is to investigate relationships between adherence to recommended screening and medication use and severe macrovascular complications and all-cause mortality among persons aged above 68 years with diabetes mellitus (DM). METHOD Data came from a 5% Medicare claims sample of beneficiaries initially diagnosed with DM during 2006-2008; follow-up was up to 7 years. RESULTS Adherence to screening guidelines led to reduced mortality-hazard ratio (HR) = 0.57, 95% confidence interval [CI] = [0.56, 0.58]; congestive heart failure [CHF], HR = 0.89, CI = [0.87, 0.91]; acute myocardial infarction [AMI], HR = 0.90, CI = [0.85, 0.95]; and stroke/transient ischemic attack [Stroke/TIA], HR = 0.92, CI = [0.87, 0.97]-during follow-up. Recommended medication use led to lower mortality: HR = 0.72, CI = [0.70, 0.73]; CHF, HR = 0.67, CI = [0.66, 0.69]; AMI, HR = 0.68, CI = [0.65, 0.71]; and Stroke/TIA, HR = 0.79, CI = [0.76, 0.83]. DISCUSSION Elderly persons newly diagnosed with diabetes who adhered to recommended care experienced reduced risk of mortality and severe macrovascular complications.
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24
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Nomani AZ, Nabi S, Ahmed S, Iqbal M, Rajput HM, Rao S. High HbA1c is associated with higher risk of ischaemic stroke in Pakistani population without diabetes. Stroke Vasc Neurol 2016; 1:133-139. [PMID: 28959475 PMCID: PMC5435196 DOI: 10.1136/svn-2016-000018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/23/2016] [Accepted: 07/20/2016] [Indexed: 11/04/2022] Open
Abstract
CONTEXT The role of glycated haemoglobin (HbA1c) in the prediction of ischaemic stroke in individuals without diabetes is underestimated. AIMS We performed a study to analyse the role of HbA1c in the risk prediction of ischaemic stroke in Pakistani population without diabetes. We further studied the difference between HbA1c values of individuals with diabetes and without diabetes with stroke. SETTINGS AND DESIGN Single centre, case-control. MATERIALS AND METHODS In phase I, a total of 233 patients without diabetes with ischaemic stroke and 245 as controls were enrolled. Association of HbA1c levels, lipid profiles and blood pressure recordings with ischaemic stroke was analysed. In phase II, comparison was done between diabetics and non-diabetics with stroke. STATISTICAL ANALYSIS Comparison of the mean variables was performed with Student's t-tests. Logistic regression analysis with ischaemic stroke as the dependent variable was performed for phase I. RESULTS In phase I, the ischaemic stroke group had significantly higher HbA1c levels (5.9±2.9% vs 5.5±1.6%) compared with controls (p<0.05). Triglyceride cholesterol, high-density lipoprotein cholesterol, systolic blood pressure, diastolic blood pressure and HbA1c were the significant determinants of stroke (p<0.05). In phase II, mean HbA1c values were significantly higher in the diabetes group (7.6±2.1 vs 6.1±2.3) (p<0.05) but other parameters were not statistically significantly different (p>0.05). CONCLUSIONS Higher HbA1c indicated a significantly increased risk for ischaemic stroke. An HbA1c value above 5.6% (prediabetic range) predicted future risk of stroke and efforts to maintain glucose level within the normal range (≤5.6%) in individuals with high cardiovascular risk are important.
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Affiliation(s)
- Ali Zohair Nomani
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
| | - Sumaira Nabi
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
| | - Shahzad Ahmed
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
| | - Mansoor Iqbal
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
| | - Haris Majid Rajput
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
| | - Suhail Rao
- Department of Neurology, Pakistan institute of Medical Sciences, Islamabad, Pakistan
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25
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Holwerda SW, Vianna LC, Restaino RM, Chaudhary K, Young CN, Fadel PJ. Arterial baroreflex control of sympathetic nerve activity and heart rate in patients with type 2 diabetes. Am J Physiol Heart Circ Physiol 2016; 311:H1170-H1179. [PMID: 27591221 DOI: 10.1152/ajpheart.00384.2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/24/2016] [Indexed: 02/08/2023]
Abstract
Despite greater blood pressure reactivity to acute cardiovascular stressors and a higher prevalence of hypertension in type 2 diabetes (T2D) patients, limited information is available regarding arterial baroreflex (ABR) control in T2D. We hypothesized that ABR control of muscle sympathetic nerve activity (MSNA) and heart rate (HR) are attenuated in T2D patients. Seventeen T2D patients (50 ± 2 yr; 31 ± 1 kg/m2), 9 weight-matched controls (WM-CON, 46 ± 2 yr; 32 ± 2 kg/m2) and 10 lean controls (Lean-CON, 49 ± 3 yr; 23 ± 1 kg/m2), underwent bolus infusions of sodium nitroprusside (100 μg) followed 60 s later by phenylephrine (150 μg) and weighted linear regression performed. No group differences in overall sympathetic baroreflex gain were observed (T2D: -2.5 ± 0.3 vs. WM-CON: -2.6 ± 0.2 vs. Lean-CON: -2.7 ± 0.4 arbitrary units·beat·mmHg-1, P > 0.05) or in sympathetic baroreflex gain when derived separately during blood pressure (BP) falls (nitroprusside) and BP rises (phenylephrine). In contrast, overall cardiac baroreflex gain was reduced in T2D patients compared with Lean-CON (T2D: 8.2 ± 1.5 vs. Lean-CON: 15.6 ± 2.9 ms·mmHg-1, P < 0.05) and also tended to be reduced in WM-CON (9.3 ± 1.9 ms·mmHg-1) compared with Lean-CON (P = 0.059). Likewise, during BP rises, cardiac baroreflex gain was reduced in T2D patients and weight-matched controls compared with lean controls (P < 0.05), whereas no group differences were found during BP falls (P > 0.05). Sympathetic and cardiac ABR gains were comparable between normotensive and hypertensive T2D patients (P > 0.05). These findings suggest preserved ABR control of MSNA in T2D patients compared with both obese and lean age-matched counterparts, with a selective impairment in ABR HR control in T2D that may be related to obesity.
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Affiliation(s)
- Seth W Holwerda
- Department of Health and Human Physiology, University of Iowa, Iowa City, Iowa
| | - Lauro C Vianna
- Faculty of Physical Education, University of Brasilia, Distrito Federal, Brazil
| | - Robert M Restaino
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Kunal Chaudhary
- Department of Internal Medicine, University of Missouri, Columbia, Missouri
| | - Colin N Young
- Department of Pharmacology and Physiology, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia; and
| | - Paul J Fadel
- Department of Kinesiology, University of Texas at Arlington, Arlington, Texas
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26
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Panzica G, Melcangi RC. Structural and molecular brain sexual differences: A tool to understand sex differences in health and disease. Neurosci Biobehav Rev 2016; 67:2-8. [DOI: 10.1016/j.neubiorev.2016.04.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 02/07/2023]
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Herman WH. Are There Clinical Implications of Racial Differences in HbA1c? Yes, to Not Consider Can Do Great Harm! Diabetes Care 2016; 39:1458-61. [PMID: 27457636 PMCID: PMC4955925 DOI: 10.2337/dc15-2686] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Studies that have compared HbA1c levels by race have consistently demonstrated higher HbA1c levels in African Americans than in whites. These racial differences in HbA1c have not been explained by measured differences in glycemia, sociodemographic factors, clinical factors, access to care, or quality of care. Recently, a number of nonglycemic factors and several genetic polymorphisms that operate through nonglycemic mechanisms have been associated with HbA1c Their distributions across racial groups and their impact on hemoglobin glycation need to be systematically explored. Thus, on the basis of evidence for racial differences in HbA1c, current clinical guidelines from the American Diabetes Association state: "It is important to take…race/ethnicity…into consideration when using the A1C to diagnose diabetes." However, it is not clear from the guidelines how this recommendation might be actualized. So, the critical question is not whether racial differences in HbA1c exist between African Americans and whites; the important question is whether the observed differences in HbA1c level are clinically meaningful. Therefore, given the current controversy, we provide a Point-Counterpoint debate on this issue. In the point narrative below, Dr. Herman provides his argument that the failure to acknowledge that HbA1c might be a biased measure of average glycemia and an unwillingness to rigorously investigate this hypothesis will slow scientific progress and has the potential to do great harm. In the counterpoint narrative that follows Dr. Herman's contribution, Dr. Selvin argues that there is no compelling evidence for racial differences in the validity of HbA1c as a measure of hyperglycemia and that race is a poor surrogate for differences in underlying causes of disease risk.-William T. CefaluEditor in Chief, Diabetes Care.
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Affiliation(s)
- William H Herman
- Department of Internal Medicine and Department of Epidemiology, University of Michigan, Ann Arbor, MI
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28
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Wan EYF, Fong DYT, Fung CSC, Lam CLK. Incidence and predictors for cardiovascular disease in Chinese patients with type 2 diabetes mellitus - a population-based retrospective cohort study. J Diabetes Complications 2016; 30:444-50. [PMID: 26774791 DOI: 10.1016/j.jdiacomp.2015.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/02/2015] [Accepted: 12/13/2015] [Indexed: 01/15/2023]
Abstract
AIMS This study aimed to estimate the 5-year incidence rate of cardiovascular disease (CVD) and determine predictive factors of new CVD in Chinese patients with type 2 diabetes mellitus (T2DM). METHODS A retrospective cohort study was conducted on 115,470 T2DM patients aged ≥18 years without any history of CVD. Cox Proportional Hazard regression stratified by gender was performed to explore predictive factors of CVD. RESULTS For 5.3 years median follow-up, the overall incidence rate of CVD per 1,000 person-years was 17.2 (95% CI: 16.9-17.6), without significant gender difference. Predictors of higher risk of CVD were older age, current smoking, longer duration of T2DM, more severe stage of chronic kidney disease, anti-hypertensive and oral anti-diabetic drugs needed, and higher body mass index (BMI), systolic and diastolic blood pressure (SBP and DBP), total cholesterol/high-density lipoprotein-cholesterol ratio (TC/HDL-C ratio) and urine albumin/creatinine ratio (ACR). Lipid-lowering agents needed in men, and ex-smoking and higher hemoglobin A1c (HbA1c) in female were the additional predictive factors of increased CVD risk. CONCLUSIONS Smoking, BMI, HbA1c, SBP, DBP, TC/HDL-C ratio and ACR were found to be modifiable risk factors of new CVD in Chinese T2DM patients, which should be targeted as tertiary preventive interventions. The lack of association between HbA1c and CVD in men found in this study deserves further investigation.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong; School of Nursing, the University of Hong Kong, 4/F, William M. W., Mong Block 21 Sassoon Road, Pokfulam, Hong Kong.
| | - Daniel Yee Tak Fong
- School of Nursing, the University of Hong Kong, 4/F, William M. W., Mong Block 21 Sassoon Road, Pokfulam, Hong Kong.
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, the University of Hong Kong, 3/F Ap Lei Chau Clinic, 161 Main Street, Ap Lei Chau, Hong Kong.
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Krag MØ, Hasselbalch L, Siersma V, Nielsen ABS, Reventlow S, Malterud K, de Fine Olivarius N. The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 2016; 59:275-85. [PMID: 26607637 DOI: 10.1007/s00125-015-3804-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/19/2015] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus. METHODS In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease. RESULTS In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005). CONCLUSIONS/INTERPRETATION Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.
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Affiliation(s)
- Marlene Ø Krag
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark.
| | - Lotte Hasselbalch
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Anni B S Nielsen
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Susanne Reventlow
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
| | - Kirsti Malterud
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
- Research Unit for General Practice, Uni Health Research, Bergen, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Niels de Fine Olivarius
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, P.O. Box 2099, DK-1014, Copenhagen K, Denmark
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30
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Al-Rubeaan K, Al-Hussain F, Youssef AM, Subhani SN, Al-Sharqawi AH, Ibrahim HM. Ischemic Stroke and Its Risk Factors in a Registry-Based Large Cross-Sectional Diabetic Cohort in a Country Facing a Diabetes Epidemic. J Diabetes Res 2016; 2016:4132589. [PMID: 26989695 PMCID: PMC4771899 DOI: 10.1155/2016/4132589] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/08/2015] [Accepted: 01/14/2016] [Indexed: 11/25/2022] Open
Abstract
The main aim of this study is to determine the prevalence and risk factors of ischemic stroke among diabetic patients registered in the Saudi National Diabetes Registry (SNDR) database. A cross-sectional sample of 62,681 diabetic patients aged ≥25 years was used to calculate ischemic stroke prevalence and its risk factors. Univariate and multivariate logistic regression analyses were used to assess the roles of different risk factors. The prevalence of ischemic stroke was 4.42% and was higher in the older age group with longer diabetes duration. Poor glycemic control and the presence of chronic diabetes complications were associated with a high risk of ischemic stroke. History of smoking and type 2 diabetes were more frequent among stroke patients. Obesity significantly decreased the risk for ischemic stroke. Regression analysis for ischemic stroke risk factors proved that age ≥45 years, male gender, hypertension, coronary artery disease (CAD), diabetes duration ≥10 years, insulin use, and hyperlipidemia were significant independent risk factors for ischemic stroke. We conclude that ischemic stroke is prevalent among diabetic individuals, particularly among those with type 2 diabetes. Good glycemic, hypertension, and hyperlipidemia control, in addition to smoking cessation, are the cornerstones to achieve a significant reduction in ischemic stroke risk.
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Affiliation(s)
- Khalid Al-Rubeaan
- University Diabetes Center, College of Medicine, King Saud University, P.O. Box 18397, Riyadh 11415, Saudi Arabia
- *Khalid Al-Rubeaan:
| | - Fawaz Al-Hussain
- Department of Medicine, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia
| | - Amira M. Youssef
- Registry Department, University Diabetes Center, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia
| | - Shazia N. Subhani
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Center, P.O. Box 3345, Riyadh 11211, Saudi Arabia
| | - Ahmad H. Al-Sharqawi
- Biostatistics Department, University Diabetes Center, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia
| | - Heba M. Ibrahim
- Registry Department, University Diabetes Center, King Saud University, P.O. Box 245, Riyadh 11411, Saudi Arabia
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Regensteiner JG, Golden S, Huebschmann AG, Barrett-Connor E, Chang AY, Chyun D, Fox CS, Kim C, Mehta N, Reckelhoff JF, Reusch JEB, Rexrode KM, Sumner AE, Welty FK, Wenger NK, Anton B. Sex Differences in the Cardiovascular Consequences of Diabetes Mellitus: A Scientific Statement From the American Heart Association. Circulation 2015; 132:2424-47. [PMID: 26644329 DOI: 10.1161/cir.0000000000000343] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Holwerda SW, Restaino RM, Manrique C, Lastra G, Fisher JP, Fadel PJ. Augmented pressor and sympathetic responses to skeletal muscle metaboreflex activation in type 2 diabetes patients. Am J Physiol Heart Circ Physiol 2015; 310:H300-9. [PMID: 26566729 DOI: 10.1152/ajpheart.00636.2015] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 11/06/2015] [Indexed: 11/22/2022]
Abstract
Previous studies have reported exaggerated increases in arterial blood pressure during exercise in type 2 diabetes (T2D) patients. However, little is known regarding the underlying neural mechanism(s) involved. We hypothesized that T2D patients would exhibit an augmented muscle metaboreflex activation and this contributes to greater pressor and sympathetic responses during exercise. Mean arterial pressure (MAP), heart rate (HR), and muscle sympathetic nerve activity (MSNA) were measured in 16 patients with T2D (8 normotensive and 8 hypertensive) and 10 healthy controls. Graded isolation of the muscle metaboreflex was achieved by postexercise ischemia (PEI) following static handgrip performed at 30% and 40% maximal voluntary contraction (MVC). A cold pressor test (CPT) was also performed as a generalized sympathoexcitatory stimulus. Increases in MAP and MSNA during 30 and 40% MVC handgrip were augmented in T2D patients compared with controls (P < 0.05), and these differences were maintained during PEI (MAP: 30% MVC PEI: T2D, Δ16 ± 2 mmHg vs. controls, Δ8 ± 1 mmHg; 40% MVC PEI: T2D, Δ26 ± 3 mmHg vs. controls, Δ16 ± 2 mmHg, both P < 0.05). MAP and MSNA responses to handgrip and PEI were not different between normotensive and hypertensive T2D patients (P > 0.05). Interestingly, MSNA responses were also greater in T2D patients compared with controls during the CPT (P < 0.05). Collectively, these findings indicate that muscle metaboreflex activation is augmented in T2D patients and this contributes, in part, to augmented pressor and sympathetic responses to exercise in this patient group. Greater CPT responses suggest that a heightened central sympathetic reactivity may be involved.
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Affiliation(s)
- Seth W Holwerda
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Robert M Restaino
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Camila Manrique
- Department of Medicine, University of Missouri, Columbia, Missouri
| | - Guido Lastra
- Department of Medicine, University of Missouri, Columbia, Missouri
| | - James P Fisher
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul J Fadel
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri; Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and
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Abstract
Reports from recent studies suggest that diabetes confers a higher risk of cardiovascular disease in women compared to men. Larger studies, including meta-analyses, report that women with diabetes have a 44 % greater risk of incident coronary heart disease and a 27 % greater risk of incident stroke compared to men with diabetes. In this article, we summarize results from longitudinal studies that examine sex differences in risk factors for and rates of macrovascular complications from diabetes. We also discuss possible mechanisms for increased cardiovascular risk associated with diabetes in women compared to men, including the clustering of hypertension, obesity, and elevated triglycerides, the possible contribution of hormonal differences, and sex differences in the prescription of and adherence to pharmacologic treatment. In conclusion, diabetes is associated with a slightly higher risk of cardiovascular disease in women compared to men. Future studies should further explore the reasons underlying imperfect use of medications that lower cardiovascular risk in both women and men with diabetes.
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Affiliation(s)
- Amanda Lyon
- Department of Medicine, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Elizabeth A Jackson
- Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | - Rita R Kalyani
- Department of Medicine, Johns Hopkins University, 1830 E Monument St # 333, Baltimore, MD, 21287, USA.
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University, 1830 E Monument St # 333, Baltimore, MD, 21287, USA.
| | - Catherine Kim
- Departments of Medicine, Obstetrics & Gynecology, and Epidemiology, University of Michigan, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI, 48109, USA.
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Seghieri C, Policardo L, Francesconi P, Seghieri G. Gender differences in the relationship between diabetes process of care indicators and cardiovascular outcomes. Eur J Public Health 2015; 26:219-24. [DOI: 10.1093/eurpub/ckv159] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Dunn CR, Martin-Schild S. Mitigating diabetes associated ischemic stroke risk: High-risk patient identification. J Diabetes Complications 2015; 29:615-6. [PMID: 25953404 DOI: 10.1016/j.jdiacomp.2015.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/13/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Casey R Dunn
- Tulane University Stroke Program, Department of Neurology, Tulane University School of Medicine.
| | - Sheryl Martin-Schild
- Tulane University Stroke Program, Department of Neurology, Tulane University School of Medicine.
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Policardo L, Seghieri G, Francesconi P, Anichini R, Franconi F, Seghieri C, Del Prato S. Gender difference in diabetes-associated risk of first-ever and recurrent ischemic stroke. J Diabetes Complications 2015; 29:713-7. [PMID: 25660138 DOI: 10.1016/j.jdiacomp.2014.12.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/25/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the effect of diabetes by gender on the peak-risk of first-ever-ischemic stroke and its recurrence. METHODS Administrative datasets including all hospital discharges for ischemic stroke (N = 43,332) in the diabetic (N = 207,568) and non-diabetic (N = 2,808,554) population of the Tuscany region, Italy were used to calculate Hazard ratios (HR) after Cox-regression, of first-ever and recurrent ischemic strokes, between 2005 and 2011. RESULTS Overall, diabetes increased the HR of first-ever ischemic stroke by about 50% in both genders. However, this risk significantly declined with age and was higher in women aged 55-74 yr than in men of the same age (HR; 95% CI: 1.392; 1.228-1.579 in age-class 55-64 yr and 1.203; 1.110-1.304 in age class 65-74 yr; p < 0.001). Diabetes also increased the adjusted risk of three-year-stroke recurrence (N = 5,998) in women, independently of age, whereas this was the case in men < 70 yr. CONCLUSIONS Diabetes is associated with increased risk of ischemic stroke although it declines with age though at lower rate among women than men. Moreover, diabetic women have greater risk of recurrence than in men > 70 yrs old, supporting a high-risk "time-window" in postmenopausal-elderly diabetic women.
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Affiliation(s)
| | - Giuseppe Seghieri
- Agenzia Regionale Sanità Toscana, Florence, Italy; Centre of Study for Gender Health Azienda USL 3, Pistoia, Italy.
| | | | | | - Flavia Franconi
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy and Laboratory of Gender Medicine, National Institute of Biostructures and Biosystems, Osilo, Sassari, Italy
| | - Chiara Seghieri
- Laboratorio Management e Sanità, Istituto di Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, Italy
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Sex Differences in the Excess Risk of Cardiovascular Diseases Associated with Type 2 Diabetes: Potential Explanations and Clinical Implications. CURRENT CARDIOVASCULAR RISK REPORTS 2015; 9:36. [PMID: 26029318 PMCID: PMC4442131 DOI: 10.1007/s12170-015-0462-5] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Strong evidence suggests that type 2 diabetes confers a stronger excess risk of cardiovascular diseases in women than in men; with women having a 27 % higher relative risk of stroke and a 44 % higher relative risk of coronary heart disease compared with men. The mechanisms that underpin these sex differences in the associations between diabetes and cardiovascular disease risk are not fully understood. Some of the excess risk may be the result of a sex disparity in the management and treatment of diabetes, to the detriment of women. However, accruing evidence suggests that real biological differences between men and women underpin the excess risk of diabetes-related cardiovascular risk in women such that there is a greater decline in risk factor status in women than in men in the transition from normoglycemia to overt diabetes. This greater risk factor decline appears to be associated with women having to put on more weight than men, and thus attain a higher body mass index, to develop diabetes. Further studies addressing the mechanisms responsible for sex differences in the excess risk of cardiovascular diseases associated with diabetes are needed to improve the prevention and management of diabetes in clinical practise.
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38
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Policardo L, Seghieri G, Anichini R, De Bellis A, Franconi F, Francesconi P, Del Prato S, Mannucci E. Effect of diabetes on hospitalization for ischemic stroke and related in-hospital mortality: a study in Tuscany, Italy, over years 2004-2011. Diabetes Metab Res Rev 2015; 31:280-6. [PMID: 25255901 DOI: 10.1002/dmrr.2607] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/25/2014] [Accepted: 09/02/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Incidence of ischemic stroke and associated in-hospital mortality is decreasing in Western populations, while the prevalence of diabetes, a well-known risk factor for ischemic stroke, is progressively rising. This study was aimed at evaluating the effect of diabetes on ischemic stroke hospitalization and in-hospital mortality after ischemic stroke. METHODS Discharges with diagnosis of ischemic stroke were identified in a database containing all hospitalizations of resident population of Tuscany, Italy, over years 2004-2011. Cases with diabetes were identified through specific drug prescriptions, official certifications or previous hospital diagnosis. Rates of annual ischemic stroke incidence and related in-hospital mortality were separately calculated for gender and age class, in subjects with and without diabetes. RESULTS Sixty-five thousand one hundred sixty-five hospital discharges with ischemic stroke diagnosis were identified. Diabetes was associated with increased risk of stroke odds ratio(95% confidence interval):1.31(1.28-1.34) in men and 1.24(1.21-1.37) in women. Diabetic women, compared with men, had a higher in-hospital mortality risk after ischemic stroke (odds ratio:1.32; 1.06-1.64), whereas in non-diabetic subjects, there was no difference between genders. Incidence of ischemic stroke has declined in non-diabetic subjects, except for women aged ≤70 years; a similar reduction was observed for in-hospital mortality. Among diabetic patients, conversely, annual incidence of ischemic stroke rose by 3% in the elderly people (>70 years), and annual mortality trend remained unchanged. CONCLUSIONS In the last decade, the incidence of ischemic stroke and of related in-hospital mortality declined in persons without diabetes, while increasing among diabetic patients of advanced age. Women with diabetes, compared with men, had a higher in-hospital mortality risk.
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Vianna LC, Deo SH, Jensen AK, Holwerda SW, Zimmerman MC, Fadel PJ. Impaired dynamic cerebral autoregulation at rest and during isometric exercise in type 2 diabetes patients. Am J Physiol Heart Circ Physiol 2015; 308:H681-7. [PMID: 25599569 DOI: 10.1152/ajpheart.00343.2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 01/15/2015] [Indexed: 12/21/2022]
Abstract
Type 2 diabetes mellitus patients (T2D) have elevated risk of stroke, suggesting that cerebrovascular function is impaired. Herein, we examined dynamic cerebral autoregulation (CA) at rest and during exercise in T2D patients and determined whether underlying systemic oxidative stress is associated with impairments in CA. Middle cerebral artery blood velocity and arterial blood pressure (BP) were measured at rest and during 2-min bouts of low- and high-intensity isometric handgrip performed at 20% and 40% maximum voluntary contraction, respectively, in seven normotensive and eight hypertensive T2D patients and eight healthy controls. Dynamic CA was estimated using the rate of regulation (RoR). Total reactive oxygen species (ROS) and superoxide levels were measured at rest. There were no differences in RoR at rest or during exercise between normotensive and hypertensive T2D patients. However, when compared with controls, T2D patients exhibited lower RoR at rest and during low-intensity handgrip indicating impaired dynamic CA. Moreover, the RoR was further reduced by 29 ± 4% during high-intensity handgrip in T2D patients (0.307 ± 0.012/s rest vs. 0.220 ± 0.014/s high intensity; P < 0.01), although well maintained in controls. T2D patients demonstrated greater baseline total ROS and superoxide compared with controls, both of which were negatively related to RoR during handgrip (e.g., total ROS: r = -0.71, P < 0.05; 40% maximum voluntary contraction). Collectively, these data demonstrate impaired dynamic CA at rest and during isometric handgrip in T2D patients, which may be, in part, related to greater underlying systemic oxidative stress. Additionally, dynamic CA is blunted further with high intensity isometric contractions potentially placing T2D patients at greater risk for cerebral events during such activities.
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Affiliation(s)
- Lauro C Vianna
- Faculty of Physical Education, University of Brasília, DF, Brazil; Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Shekhar H Deo
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Areum K Jensen
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Seth W Holwerda
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri
| | - Matthew C Zimmerman
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Paul J Fadel
- Department of Medical Pharmacology and Physiology, University of Missouri, Columbia, Missouri; Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri; and
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Strand MA, Will T, Gu X, Perry J. A Descriptive Study of the Progression of the Metabolic Syndrome in Middle-Aged Chinese Population. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2015; 35:163-76. [DOI: 10.1177/0272684x15569490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This longitudinal study investigated the prevalence of the Metabolic Syndrome (MetS) in middle-aged (44–56 years) men and women in China. The presence of the components of the MetS was determined in a cohort of 643 persons born in 1956, 1960–1961, and 1964 in Shanxi Province China in 2008 and 2012. The rate of MetS in 2008 was 51.63% (95% CI [44.73, 58.48]) and 37.15% (95% CI [32.56, 41.92]) and in 2012 was 50.23% (95% CI [43.35, 57.10]) and 46.26% (95% CI [41.46, 51.11]) for men and women, respectively. Increased blood glucose and triglycerides and decreased high-density lipoprotein for women, and blood glucose and triglycerides for men were the components responsible for the development of MetS from 2008 to 2012. MetS develops differently between men and women. From age 44 to 56, the rate is unchanged among men and increasing among women.
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Affiliation(s)
- Mark A. Strand
- Public Health Program, North Dakota State University, Fargo, ND, USA
| | - Theresa Will
- City and County Public Health Department, Valley City, ND, USA
| | - Xiaoxue Gu
- Statistics Department, North Dakota State University, Fargo, ND, USA
| | - Judith Perry
- Medical Department, Shanxi Evergreen Service, Taiyuan, China
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41
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Anagnostis P, Majeed A, Johnston DG, Godsland IF. Cardiovascular risk in women with type 2 diabetes mellitus and prediabetes: is it indeed higher than men? Eur J Endocrinol 2014; 171:R245-55. [PMID: 25117464 DOI: 10.1530/eje-14-0401] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The relative risk for cardiovascular disease (CVD) events and mortality in diabetic women (in comparison with non-diabetic women) is believed to be greater than that in diabetic men. However, the absolute risk for CVD mortality and morbidity does not appear to be higher in women. In general, there is heterogeneity between studies, and whether there is any definite difference in the CVD risk between sexes at any level of glycaemia is not known. The same arguments also apply when comparing the CVD risk factors, such as lipid profiles and systemic inflammation indices, which seem to be worse in women than in men with diabetes mellitus (DM). The same questions emerge at any given glycaemic state: are women at worse risk and do they have a worse risk factor profile than men? These issues have yet to be resolved. Similar, though less extensive, data have been reported for prediabetes. Furthermore, women with DM are suboptimally treated compared with men regarding lipid and blood pressure targets. Large prospective studies representative of the general population are therefore needed to define the differences between sexes regarding CVD events and mortality at a given glucose level and after adjusting for any other confounders.
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Affiliation(s)
- Panagiotis Anagnostis
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Azeem Majeed
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Desmond G Johnston
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
| | - Ian F Godsland
- Division of DiabetesEndocrinology and Metabolism, Department of Medicine, Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, Room G1, Norfolk Place, St Mary's Campus, London W2 1NH, UKDepartment of Primary Care and Public HealthFaculty of Medicine, Imperial College London, London, UK
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Zhao W, Guan J, Horswell R, Li W, Wang Y, Wu X, Hu G. HDL cholesterol and cancer risk among patients with type 2 diabetes. Diabetes Care 2014; 37:3196-203. [PMID: 25216507 PMCID: PMC4237978 DOI: 10.2337/dc14-0523] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the relationship between HDL cholesterol (HDL-C) and cancer risk among type 2 diabetic patients. RESEARCH DESIGN AND METHODS We performed a retrospective cohort study of 14,169 men and 23,176 women with type 2 diabetes. Cox proportional hazards regression models were used to estimate the association of various levels of HDL cholesterol (HDL-C) with cancer risk. RESULTS During a mean follow-up period of 6.4 years, 3,711 type 2 diabetic patients had a cancer diagnosis. A significant inverse association between HDL-C and the risk of cancer was found among men and women. The multivariable-adjusted hazard ratios (HRs) of cancer at various levels of HDL-C at baseline (<30, 30-39.9, 40-49.9, 50-59.9, 60-69.9, 70-79.9, and ≥80 mg/dL) were 1.00, 0.87, 0.95, 1.01, 0.61, 0.45, and 0.37, respectively, in men (Ptrend = 0.027) and 1.00, 0.98, 0.88, 0.85, 0.84, 0.86, and 0.84, respectively, in women (Ptrend = 0.025). When stratified by race, BMI, smoking status, or medication use, the inverse association was still present. With an updated mean of HDL-C used in the analysis, the inverse association of HDL-C with cancer risk did not change. The inverse association substantially attenuated after excluding patients who died of or were diagnosed with cancer during the first 2 years of follow-up. CONCLUSIONS The study suggests an inverse association of HDL-C with cancer risk among men and women with type 2 diabetes, whereas the effect of HDL-C was partially mediated by reverse causation.
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Affiliation(s)
- Wenhui Zhao
- Pennington Biomedical Research Center, Baton Rouge, LA Department of Endocrinology, China Japan Friendship Hospital, Beijing, China
| | - Jing Guan
- Pennington Biomedical Research Center, Baton Rouge, LA Beijing University of Traditional Chinese Medicine, Beijing, China
| | | | - Weiqin Li
- Pennington Biomedical Research Center, Baton Rouge, LA Tianjin Women's and Children's Health Center, Tianjin, China
| | - Yujie Wang
- Pennington Biomedical Research Center, Baton Rouge, LA
| | - Xiaocheng Wu
- Louisiana Tumor Registry, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Gang Hu
- Pennington Biomedical Research Center, Baton Rouge, LA
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Zhao W, Katzmarzyk PT, Horswell R, Wang Y, Li W, Johnson J, Heymsfield SB, Cefalu WT, Ryan DH, Hu G. Body mass index and the risk of all-cause mortality among patients with type 2 diabetes mellitus. Circulation 2014; 130:2143-51. [PMID: 25378546 DOI: 10.1161/circulationaha.114.009098] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several prospective studies have evaluated the association between body mass index (BMI) and death risk among patients with diabetes mellitus; however, the results have been inconsistent. METHODS AND RESULTS We performed a prospective cohort study of 19 478 black and 15 354 white patients with type 2 diabetes mellitus. Cox proportional hazards regression models were used to estimate the association of different levels of BMI stratification with all-cause mortality. During a mean follow-up of 8.7 years, 4042 deaths were identified. The multivariable-adjusted (age, sex, smoking, income, and type of insurance) hazard ratios for all-cause mortality associated with BMI levels (18.5-22.9, 23-24.9, 25-29.9, 30-34.9 [reference group], 35-39.9, and ≥40 kg/m(2)) at baseline were 2.12 (95% confidence interval [CI], 1.80-2.49), 1.74 (95% CI, 1.46-2.07), 1.23 (95% CI, 1.08-1.41), 1.00, 1.19 (95% CI, 1.03-1.39), and 1.23 (95% CI, 1.05-1.43) for blacks and 1.70 (95% CI, 1.42-2.04), 1.51 (95% CI, 1.27-1.80), 1.07 (95% CI, 0.94-1.21), 1.00, 1.07 (95% CI, 0.93-1.23), and 1.20 (95% CI, 1.05-1.38) for whites, respectively. When stratified by age, smoking status, patient type, or the use of antidiabetic drugs, a U-shaped association was still present. When BMI was included in the Cox model as a time-dependent variable, the U-shaped association of BMI with all-cause mortality risk did not change. CONCLUSIONS The present study indicated a U-shaped association of BMI with all-cause mortality risk among black and white patients with type 2 diabetes mellitus. A significantly increased risk of all-cause mortality was observed among blacks with BMI <30 kg/m(2) and ≥35 kg/m(2) and among whites with BMI <25 kg/m(2) and ≥40 kg/m(2) compared with patients with BMI of 30 to 34.9 kg/m(2).
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Affiliation(s)
- Wenhui Zhao
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Peter T Katzmarzyk
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Ronald Horswell
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Yujie Wang
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Weiqin Li
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Jolene Johnson
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Steven B Heymsfield
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - William T Cefalu
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Donna H Ryan
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.)
| | - Gang Hu
- From the Pennington Biomedical Research Center, Baton Rouge, LA (W.Z., PT.K., R.H., Y.W., W.L., S.B.H., W.T.C., D.H.R., G.H.); China Japan Friendship Hospital, Beijing, China (W.Z.); Tianjin Women's and Children's Health Center, Tianjin, China (W.L.); and LSU Health Baton Rouge, Baton Rouge, LA (J.J.).
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