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Bello-Chavolla OY, Bahena-López JP, Vargas-Vázquez A, Antonio-Villa NE, Márquez-Salinas A, Fermín-Martínez CA, Rojas R, Mehta R, Cruz-Bautista I, Hernández-Jiménez S, García-Ulloa AC, Almeda-Valdes P, Aguilar-Salinas CA. Clinical characterization of data-driven diabetes subgroups in Mexicans using a reproducible machine learning approach. BMJ Open Diabetes Res Care 2020; 8:8/1/e001550. [PMID: 32699108 PMCID: PMC7380860 DOI: 10.1136/bmjdrc-2020-001550] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/05/2020] [Accepted: 06/14/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Previous reports in European populations demonstrated the existence of five data-driven adult-onset diabetes subgroups. Here, we use self-normalizing neural networks (SNNN) to improve reproducibility of these data-driven diabetes subgroups in Mexican cohorts to extend its application to more diverse settings. RESEARCH DESIGN AND METHODS We trained SNNN and compared it with k-means clustering to classify diabetes subgroups in a multiethnic and representative population-based National Health and Nutrition Examination Survey (NHANES) datasets with all available measures (training sample: NHANES-III, n=1132; validation sample: NHANES 1999-2006, n=626). SNNN models were then applied to four Mexican cohorts (SIGMA-UIEM, n=1521; Metabolic Syndrome cohort, n=6144; ENSANUT 2016, n=614 and CAIPaDi, n=1608) to characterize diabetes subgroups in Mexicans according to treatment response, risk for chronic complications and risk factors for the incidence of each subgroup. RESULTS SNNN yielded four reproducible clinical profiles (obesity related, insulin deficient, insulin resistant, age related) in NHANES and Mexican cohorts even without C-peptide measurements. We observed in a population-based survey a high prevalence of the insulin-deficient form (41.25%, 95% CI 41.02% to 41.48%), followed by obesity-related (33.60%, 95% CI 33.40% to 33.79%), age-related (14.72%, 95% CI 14.63% to 14.82%) and severe insulin-resistant groups. A significant association was found between the SLC16A11 diabetes risk variant and the obesity-related subgroup (OR 1.42, 95% CI 1.10 to 1.83, p=0.008). Among incident cases, we observed a greater incidence of mild obesity-related diabetes (n=149, 45.0%). In a diabetes outpatient clinic cohort, we observed increased 1-year risk (HR 1.59, 95% CI 1.01 to 2.51) and 2-year risk (HR 1.94, 95% CI 1.13 to 3.31) for incident retinopathy in the insulin-deficient group and decreased 2-year diabetic retinopathy risk for the obesity-related subgroup (HR 0.49, 95% CI 0.27 to 0.89). CONCLUSIONS Diabetes subgroup phenotypes are reproducible using SNNN; our algorithm is available as web-based tool. Application of these models allowed for better characterization of diabetes subgroups and risk factors in Mexicans that could have clinical applications.
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Affiliation(s)
- Omar Yaxmehen Bello-Chavolla
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
- Division of Research, Instituto Nacional de Geriatría, Mexico City, Mexico
| | | | - Arsenio Vargas-Vázquez
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
- MD/PhD (PECEM) Program, Facultad de Medicina, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Neftali Eduardo Antonio-Villa
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
- MD/PhD (PECEM) Program, Facultad de Medicina, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Alejandro Márquez-Salinas
- MD/PhD (PECEM) Program, Facultad de Medicina, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Carlos A Fermín-Martínez
- MD/PhD (PECEM) Program, Facultad de Medicina, Universidad Nacional Autónoma de México, Coyoacan, Mexico
| | - Rosalba Rojas
- Instituto Nacional de Salud Publica, Cuernavaca, Mexico
| | - Roopa Mehta
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
| | - Ivette Cruz-Bautista
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
| | - Sergio Hernández-Jiménez
- Center of Comprehensive Care for the Patient with Diabetes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ana Cristina García-Ulloa
- Center of Comprehensive Care for the Patient with Diabetes, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Paloma Almeda-Valdes
- Department of Endocrinology and Metabolism, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Tlalpan, Mexico
| | - Carlos Alberto Aguilar-Salinas
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, Tlalpan, Mexico
- Department of Endocrinology and Metabolism, Salvador Zubiran National Institute of Medical Sciences and Nutrition, Tlalpan, Mexico
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Nuevo Leon, Mexico
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Lozano-Esparza S, López-Ridaura R, Ortiz-Panozo E, González-Villalpando C, Aguilar-Salinas C, Hernández-Ávila JE, Hernández-Ávila M, Lajous M. Diabetes is associated with a higher risk of mortality among women in a middle-income country: Results form the Mexican Teacher's cohort study. DIABETES & METABOLISM 2019; 46:304-310. [PMID: 31525457 DOI: 10.1016/j.diabet.2019.101119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/22/2019] [Accepted: 09/04/2019] [Indexed: 01/09/2023]
Abstract
AIMS In Mexico City, the mortality rate among patients with diabetes appears to be four times that of people without diabetes. Our study aimed to refine analyses of the impact of diabetes on mortality in a large cohort of women from different areas in Mexico with healthcare insurance. METHODS Our study followed 111,299 women with comprehensive healthcare coverage from the Mexican Teachers' Cohort. After a median follow-up of 7.8years, 5514 (5%) prevalent self-reported diabetes cases and 4023 incident cases were identified, while deaths were identified through employers' databases and next-of-kin reports, with dates and causes of death for 1121 women obtained from mortality databases. Hazard ratios (HRs) for total and cause-specific mortality were estimated by Cox regression models, using follow-up time as the time scale and allowing for time-variable diabetes status after adjusting for age, socioeconomic status, use of health services, and anthropometric and lifestyle variables. RESULTS In multivariable-adjusted models, the HR for all-cause mortality was 3.28 (95% CI: 2.86-3.75) in women with vs. without diabetes. The impact of diabetes on mortality was higher in rural vs. urban areas (HR: 4.72 vs. 2.98, respectively). HRs were 1.57 and 23.44 for cancer and renal disease mortality, respectively. CONCLUSION In women with healthcare coverage in Mexico, the magnitude of the association between diabetes and all-cause mortality was higher than that observed in high-income countries, but less than what has previously been reported for Mexico. Such elevated mortality suggests a lack of adequate access to quality diabetes care in the population despite comprehensive healthcare coverage.
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Affiliation(s)
- S Lozano-Esparza
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - R López-Ridaura
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - E Ortiz-Panozo
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - C González-Villalpando
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - C Aguilar-Salinas
- Department of Endocrinology and Metabolism, Salvador Zubirán National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | - J E Hernández-Ávila
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico
| | - M Hernández-Ávila
- Mexican Institute of Social Security (IMSS), Avenue Paseo de la Reforma 476, Juárez, 06600 Ciudad de México, CDMX, México
| | - M Lajous
- Center for Population Health Research, National Institute of Public Health, Mexico City, Mexico; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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