Categories of glucose tolerance and continuous glycemic measures and mortality

Prediabetes as a risk factor for all-cause and cause-specific mortality: a prospective analysis of 115,919 adults without diabetes in Mexico City

BACKGROUND

Prediabetes has been associated with increased all-cause and cardiovascular mortality. However, no large-scale studies have been conducted in Mexico or Latin America examining these associations.

METHODS

We analyzed data from 115,919 adults without diabetes (diagnosed or undiagnosed) aged 35-84 years who participated in the Mexico City Prospective Study between 1998 and 2004. Participants were followed until January 1 st , 2021 for cause-specific mortality. We defined prediabetes according to the American Diabetes Association (ADA, HbA 1c 5.7% to 6.4%) and the International Expert Committee (IEC, HbA 1c 6.0-6.4%) definitions. Cox regression adjusted for confounders was used to estimate all-cause and cause-specific mortality rate ratios (RR) at ages 35-74 years associated with prediabetes.

FINDINGS

During 2,085,392 person-years of follow-up (median in survivors 19 years), there were 6,810 deaths at ages 35-74, including 1,742 from cardiovascular disease, 892 from renal disease and 108 from acute diabetic crises. Of 110,405 participants aged 35-74 years at recruitment, 28,852 (26%) had ADA-defined prediabetes and 7,203 (7%) had IEC-defined prediabetes. Compared with those without prediabetes, individuals with prediabetes had higher risk of all-cause mortality at ages 35-74 years (RR 1.13, 95% CI 1.07-1.19 for ADA-defined prediabetes and RR 1.28, 1.18-1.39 for IEC-defined prediabetes), as well as increased risk of cardiovascular mortality (RR 1.22 [1.10-1.35] and 1.42 [1.22-1.65], respectively), renal mortality (RR 1.35 [1.08-1.68] and 1.69 [1.24-2.31], respectively), and death from an acute diabetic crisis (RR 2.63 [1.76-3.94] and 3.43 [2.09-5.62], respectively). RRs were larger at younger than at older ages, and similar for men compared to women. The absolute excess risk associated with ADA and IEC-defined prediabetes at ages 35-74 accounted for6% and 3% of cardiovascular deaths respectively, 10% and 5% of renal deaths respectively, and 31% and 14% of acute diabetic deaths respectively.

INTERPRETATION

Prediabetes is a significant risk factor for all-cause, cardiovascular, renal, and acute diabetic deaths in Mexican adults. Identification and timely management of individuals with prediabetes for targeted risk reduction could contribute to reducing premature mortality from cardiometabolic causes in this population.

FUNDING

Wellcome Trust, the Mexican Health Ministry, the National Council of Science and Technology for Mexico, Cancer Research UK, British Heart Foundation, UK Medical Research Council. Instituto Nacional de Geriatría (Mexico City).

RESEARCH IN CONTEXT

Evidence before this study: We conducted a literature search in PubMed to identify articles published in English before February 27 th , 2024 that reported on prospective studies examining the association between prediabetes with all-cause or cause-specific mortality or progression to diabetes in a Mexican or Latin American population, using the terms ("prediabetes" OR "impaired fasting glucose" OR "impaired glucose tolerance") AND ("mortality" OR "death") AND ("Mexico" OR "Mexican" OR "Latin America" OR "Latin American"). There were no studies examining risk associated with prediabetes definitions and mortality among adults in Mexico. We identified one study from Peru that included 988 participants and investigated only all-cause mortality for impaired fasting glucose and HbA 1c -based definitions of prediabetes from ADA and IEC; this study reported increased mortality risk related to ADA-defined prediabetes based on HbA 1c measures. Generalizability of these findings to other Latin American countries and regions with distinct cardiometabolic profiles in unclear. Added value of this study: Our study included 115,919 participants without diabetes from Mexico City, of whom (26%) had ADA-defined prediabetes and 7,203 (7%) had IEC-defined prediabetes. We found that prediabetes is associated with higher risks of all-cause and cause-specific mortality (cardiovascular, renal, and acute diabetic causes) than among participants without prediabetes. We found RRs to be larger at younger than at older ages, and largely similar for men compared to women. Among those without previously diagnosed diabetes, we found that the excess risk associated with ADA- and IEC-defined prediabetes at ages 35-74 years accounted for 6% and 3% of cardiovascular deaths, 10% and 5% of renal deaths, and 31% and 14% of acute diabetic deaths, respectively. .Implications of all the available evidence: Our results show that prediabetes is a significant risk factor for cardiovascular, kidney, and acute diabetic deaths among Mexican adults and accounts for a notable fraction of such deaths. Identification of individuals with prediabetes should be prioritized for optimized management to improve cardiometabolic outcomes in Mexican adults.

Glucose tolerance predicts survival in old zebra finches

The capacity to deal with external and internal challenges is thought to affect fitness, and the age-linked impairment of this capacity defines the ageing process. Using a recently developed intra-peritoneal glucose tolerance test (GTT) in zebra finches, we tested for a link between the capacity to regulate glucose levels and survival. We also investigated for the effects of ambient factors, age, sex, and manipulated developmental and adult conditions (i.e. natal brood size and foraging cost, in a full factorial design) on glucose tolerance. Glucose tolerance was quantified using the incremental ‘area under the curve’ (AUC), with lower values indicating higher tolerance. Glucose tolerance predicted survival probability in old birds, above the median age, with individuals with higher glucose tolerance showing better survival than individuals with low or intermediate glucose tolerance. In young birds there was no association between glucose tolerance and survival. Experimentally induced adverse developmental conditions did not affect glucose tolerance, but low ambient temperature at sampling and hard foraging conditions during adulthood induced a fast return to baseline levels (i.e. high glucose tolerance). These findings can be interpreted as an efficient return to baseline glucose levels when energy requirements are high, with glucose presumably being used for energy metabolism or storage. Glucose tolerance was independent of sex. Our main finding that old birds with higher glucose tolerance had better survival supports the hypothesis that the capacity to efficiently cope with a physiological challenge predicts lifespan, at least in old birds.

Combined effects of maximal oxygen uptake and glucose status on mortality: The prospective KIHD cohort study

Objective

To examine the combined effects of cardiorespiratory fitness (CRF) and prediabetes or diabetes on cardiovascular and noncardiovascular mortality.

Patients and methods

This prospective study evaluated a population‐based cohort of 1562 men aged 42–60 years at baseline (1984–1989). We utilized maximal oxygen uptake (VO_2max) for assessing aerobic capacity and CRF in the cohort and stratified participants into six groups according to both their glucose status (diabetes, prediabetes, or no diabetes) and whether they were below‐ or above‐median VO_2max. Deaths in the cohort were recorded till December 31 2016. Cox regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for cardiovascular and noncardiovascular mortality. Smoking, alcohol consumption, BMI, blood pressure, cholesterol, diagnosis of ischemic heart disease, and socioeconomic status served as covariates in the mortality analyses.

Results

During the follow‐up (mean 24.2 years), 341 men died from cardiovascular and 468 men from noncardiovascular causes. When compared to men with no diabetes and above‐median VO_2max, the presence of either diabetes (HR = 4.10, 95% CI: 2.27–7.40) or prediabetes (HR = 2.10, 95% CI: 1.18–3.73) combined with below‐median VO_2max increased the risk of cardiovascular death. Noncardiovascular mortality was increased by low oxygen uptake in men with prediabetes (HR = 2.24, 95% CI: 1.30–3.84), and among men with diabetes, the increase was not statistically significant (HR = 1.99, 95% CI: 0.91–4.32).

Conclusions

Cardiorespiratory fitness modifies the risk of death related to prediabetes and diabetes. This highlights the importance of CRF assessment and interventions to support the uptake of regular physical activity among aging men with disturbed glucose metabolism.

Different Curve Shapes of Fasting Glucose and Various Obesity-Related Indices by Diabetes and Sex

Fasting plasma glucose (FPG) and obesity-related indices are prognostic factors for adverse outcomes in both subjects with and without diabetes. A few studies have investigated sex differences in obesity indices related to the risk of diabetes, however no studies have compared the relationship between FPG and obesity-related indices by diabetes and sex. Therefore, in this study, we compared the curve shapes of FPG and various obesity-related indices by diabetes, and further explored sex differences in these associations. Data were derived from the Taiwan Biobank database, which included 5000 registered individuals. We used an adjusted generalized linear regression model and calculated the difference of least square means (Lsmean; standard error, SE) for males and females with and without diabetes. Associations between obesity-related indices and fasting glucose level by diabetes and sex groups were estimated, and the ORTHOREG procedure was used to construct B-splines. The post-fitting for linear models procedure was used to determine the range at which the trends separated significantly. The diabetes/sex/FPG interaction term was significant for all obesity-related indices, including body mass index, waist circumference, hip circumference, waist-to-hip ratio, waist-to-height ratio, lipid accumulation product, body roundness index, conicity index, body adiposity index and abdominal volume index. B-spline comparisons between males and females did not reach significance. However, FPG affected the trend towards obesity-related indices. As the fasting glucose level increased, the values of obesity-related indices varied more obviously in the participants without diabetes than in those with diabetes mellitus. The current study revealed that there was a different relationship between FPG and obesity-related indices by diabetes and sex. FPG affected the trend towards obesity-related indices more obviously in participants without diabetes than in those with diabetes. Further studies with a longitudinal design would provide a better understanding of the underlying mechanisms for the relationships.

Prediabetes, Diabetes, and the Risk of All-Cause and Cause-Specific Mortality in a Japanese Working Population: Japan Epidemiology Collaboration on Occupational Health Study

OBJECTIVE

Prediabetes has been suggested to increase risk for death; however, the definitions of prediabetes that can predict death remain elusive. We prospectively investigated the association of multiple definitions of prediabetes with the risk of death from all causes, cardiovascular disease (CVD), and cancer in Japanese workers.

RESEARCH DESIGN AND METHODS

The study included 62,785 workers who underwent a health checkup in 2010 or 2011 and were followed up for death from 2012 to March 2019. Prediabetes was defined according to fasting plasma glucose (FPG) or glycated hemoglobin (HbA_1c) values or a combination of both using the American Diabetes Association (ADA) or World Health Organization (WHO)/International Expert Committee (IEC) criteria. The Cox proportional hazards regression model was used to investigate the associations.

RESULTS

Over a 7-year follow-up, 229 deaths were documented. Compared with normoglycemia, prediabetes defined according to ADA criteria was associated with a higher risk of all-cause mortality (hazard ratio [HR] 1.53; 95% CI 1.12-2.09) and death due to cancer (HR 2.37; 95% CI 1.45-3.89) but not with death due to CVD. The results were materially unchanged when prediabetes was defined according to ADA FPG, ADA HbA_1c, WHO FPG, or combined WHO/IEC criteria. Diabetes was associated with the risk of all-cause, CVD, and cancer deaths.

CONCLUSIONS

In a cohort of Japanese workers, FPG- and HbA_1c-defined prediabetes, according to ADA or WHO/IEC, were associated with a significantly increased risk of death from all causes and cancer but not CVD.

Longitudinal factors associated with mortality in older patients with mood disorders

BACKGROUND

To clarify the longitudinal risk factors for mortality in older people with bipolar disorder (BD) and major depressive disorder (MDD).

METHODS

This study is a national cohort study of older patients with mood disorders. Patients were identified from Taiwan's National Health Insurance Research Database and followed from 2008 to 2011. We determined the mortality rates and standardized mortality ratios (SMRs) in this study population. Survival analyses were conducted to examine factors and healthcare utilization patterns associated with mortality during the 3-year follow-up period.

RESULTS

26,570 patients aged ≥ 65 years and diagnosed with and treated for BD or MDD in 2008 were enrolled (5,854 and 20,716 with BD and MDD, respectively). Within the 3-year follow-up period, 15.24% (n=4048) of the enrolled patients died, including 1003 (17.13%) in the BD and 3045 (14.70%) in the MDD groups. The SMRs for BD and MDD were 1.65 (1.56-1.76), and 1.26 (1.21-1.32), respectively. Among the examined comorbidities, dementia, diabetes mellitus and renal diseases each constituted an elevated relative mortality risk. By contrast, hypertension and hyperlipidemia were associated with a lower risk of mortality.

LIMITATION

In Taiwan's National Health Insurance program, specific medications are prescribed for specific diagnoses and confounding by indication should be kept in mind.

CONCLUSION

Older patients with mood disorders had a relatively high mortality risk over the 3-year follow-up period. Early detection, risk prevention, and better management of comorbid physical and mental disorders can improve the health outcomes of older patients with BD and MDD.

Impaired glucose tolerance predicts all-cause mortality among older men at high risk for cardiovascular disease in China

AIMS

To investigate the potential association between impaired glucose tolerance (IGT) and all-cause mortality among older men at high risk for cardiovascular disease (CVD) in China.

METHODS

In this prospective observational study, 460 older men aged ≥60 years were determined to have either IGT or normal glucose tolerance (NGT) based on an oral glucose tolerance test conducted between May 2005 and May 2007. IGT and NGT were diagnosed according to the 1999 WHO diagnostic criteria. All subjects were followed until March 2017. The primary outcome studied was all-cause mortality. Multivariate Cox models were used to estimate relative risk for all-cause mortality.

RESULTS

During a mean follow-up of 11.2 years, forty-three (21.4%) subjects in the IGT group and twenty-nine (11.2%) subjects in the NGT group died (HR 2.05, 95% CI 1.28-3.28, P=0.003). Multivariate Cox proportional-hazards analysis demonstated that IGT was significantly associated with increased risk for all-cause mortality, composite cardiovascular outcome, nonfatal stroke and heart failure after adjusting for potential confounding factors. Logistic regression analysis showed that IGT at baseline (P<0.05) rather than incident type 2 diabetes was a risk factor of all-cause mortality.

CONCLUSIONS

IGT was significantly associated with all-cause mortality in older Chinese men at high risk for CVD.

Natural history of prediabetes in older adults from a population-based longitudinal study

BACKGROUND

The natural history of prediabetes in older adults remains unknown.

OBJECTIVES

To assess the rate at which prediabetes progresses to diabetes, leads to death or reverts to normoglycaemia in older adults and to identify prognostic factors related to different outcomes of prediabetes.

METHODS

In the Swedish National Study on Aging and Care-Kungsholmen, 2575 diabetes-free participants aged ≥60 years were examined at baseline and followed for up to 12 years. At each wave, diabetes was diagnosed via medical examination, antidiabetic drug use, medical records or glycated haemoglobin (HbA1c) ≥6.5%. Prediabetes was defined as HbA1c ≥5.7% and normoglycaemia as HbA1c <5.7% in diabetes-free participants. Data were analysed with multinomial logistic regression.

RESULTS

At baseline, 918 (36%) individuals had prediabetes. Of them, 204 (22%) reverted to normoglycaemia (3.4/100 person-years, 95% CI 5.6-12.3), 119 (13%) developed diabetes (2.0/100 person-years, 95% CI 1.7-2.4) and 215 (23%) died (13.0/100 person-years, 95% CI 11.4-14.9) during the 12-year follow-up. The rates of reversion, progression and mortality were higher in the first 6-year than in the second 6-year follow-up, albeit not statistically significant. Lower systolic blood pressure (SBP), absence of heart diseases and weight loss promoted the reversion from prediabetes to normoglycaemia, whilst obesity accelerated its progression to diabetes.

CONCLUSIONS

During a 12-year follow-up, most of older adults with prediabetes remained stable or reverted to normoglycaemia, whereas only one-third developed diabetes or died. Lower SBP, no heart diseases and weight management may promote reversion to normoglycaemia, suggesting possible strategies for achieving normoglycaemia in older adults with prediabetes.

Mortality risk in adults according to categories of impaired glucose metabolism after 18 years of follow-up in the North of Spain: The Asturias Study

People who develop type 2 diabetes (T2D) are known to have a higher mortality risk. We estimated all-cause, cardiovascular, and cancer mortality-risks in our patient cohort according to categories of impaired glucose metabolism. This 18-year retrospective analysis included a region-wide, representative sample of a population aged 30-75 years. Age- and sex-stratified hazard ratios (HRs) were calculated for 48 participants with diagnosed T2D, 83 with undiagnosed T2D (HbA1c ≥6.5%, fasting glycemia ≥126 mg/dL, or glycemia after 75 g glucose load ≥200 mg/dL); 296 with prediabetes (HbA1c 5.7%-6.4%, fasting glycemia 100-125 mg/dL, or glycemia after 75 g glucose load 140-199 mg/dL), and 607 with normoglycemia. Over 18,612 person-years, 32 individuals with undiagnosed T2D, 30 with diagnosed T2D, 62 with prediabetes, and 80 with normoglycemia died. Total sample crude mortality rate (MR) was 10.96 deaths per 1,000 person-years of follow-up. MR of the diagnosed T2D group was more than 3-times higher and that of newly diagnosed T2D was 2-times higher (34.72 and 21.42, respectively) than total sample MR. Adjusted HR for all-cause mortality was 2.02 (95% confidence interval 1.29-3.16) and 1.57 (95% CI 1.00-2.28) in the diagnosed T2D group and the newly diagnosed T2D group, respectively. Adjusted HR for cardiovascular mortality in the T2D group was 2.79 (95% CI 1.35-5.75); this risk was greatly increased in women with T2D: 6.72 (95% CI 2.50-18.07). In Asturias, age- and sex-standardized all-cause mortality is more than 2-times higher for adults with T2D than for adults without T2D. The HR for cardiovascular mortality is considerably higher in T2D women than in normoglycemic women.

Excess mortality for people diagnosed with type 2 diabetes in 2012 - Estimates based on claims data from 70 million Germans

BACKGROUND AND AIMS

The hazard ratio (HR) is a meaningful concept for comparing the mortality of people with and without type 2 diabetes (T2D). Nevertheless, there is only one German study estimating age-specific HRs. Thus, this study aimed to provide population-wide age-specific HRs for Germany using a novel method based on aggregated population data.

METHODS AND RESULTS

We used an illness-death model and published data on T2D prevalence and incidence as well as mortality in the German general population to estimate age-specific HRs in the year 2012 for the population aged 65-90 years. For men, the overall HR was 2.3, which decreased from 2.8 between 65 and 69 years old to 1.6 between 85 and 90 years old. For women, the overall HR was 3.0, which decreased from 4.2 to 1.7 in the same age groups, respectively.

CONCLUSION

In Germany, men and women in 2012 with T2D aged 65-90 years experienced a three-to four-fold higher mortality compared to people without T2D, which might indicate that the excess mortality could be higher than in countries with comparable health care systems. Female sex and younger age were associated with higher excess mortality.

All-cause mortality in adults with and without type 2 diabetes: findings from the national health monitoring in Germany

OBJECTIVE

To estimate age-specific and sex-specific all-cause mortality among adults with and without type 2 diabetes (T2D) in Germany.

RESEARCH DESIGN AND METHODS

The German National Health Interview and Examination Survey 1998 (GNHIES98) included a mortality follow-up (median follow-up time 12.0 years) of its nationwide sample representative of the population aged 18-79 years. After exclusion of participants with type 1 diabetes, age- and sex-stratified mortality rates (MR) were calculated for 330 GNHIES98 participants with diagnosed T2D (self-reported diagnosis or antidiabetic medication), 245 with undiagnosed T2D (no diagnosed T2D, glycated hemoglobin A1c ≥6.5% (≥48 mmol/mol)), and 5975 without T2D. Mortality rate ratios (MRR) comparing MR of persons with and without T2D were estimated. Age-/sex-standardized MR and MRR were calculated including persons aged 45 years or older. MRR were used to estimate the number of years of life lost (YLL) due to diagnosed diabetes in 2010.

RESULTS

Over 75 994 person-years, 73 persons with undiagnosed T2D, 103 with diagnosed T2D, and 425 persons without T2D died. MRR were significantly higher in younger age groups, except for analyses limited to women or diagnosed T2D. Age- and sex-standardized MRR (95% CI) among persons aged 45 years or older were 1.96 (1.41 to 2.71) for undiagnosed, 1.68 (1.26 to 2.23) for diagnosed, and 1.82 (1.45 to 2.28) for total (undiagnosed or diagnosed) T2D. Sex-stratified analysis revealed similar age-standardized MRR for undiagnosed (1.56 (0.79 to 3.06)) and diagnosed T2D (1.56 (1.03 to 2.37)) among women, and a higher age-standardized MRR for undiagnosed (2.06 (1.43 to 2.97)) than diagnosed T2D (1.70 (1.10 to 2.63)) among men. YLL due to diagnosed diabetes in Germany in 2010 were 164 600 (35 000 to 279 300) among women and 169 900 (28 300 to 328 300) among men.

CONCLUSIONS

In Germany, age- and sex-standardized all-cause mortality is almost twice as high for adults with T2D as for adults without T2D. The T2D-associated excess risk of mortality appears to be most pronounced in younger adults and among men unaware of their T2D.

Burden of Mortality Attributable to Diagnosed Diabetes: A Nationwide Analysis Based on Claims Data From 65 Million People in Germany

OBJECTIVE

In Germany, as in many other countries, nationwide data on mortality attributable to diagnosed diabetes are not available. This study estimated the absolute number of excess deaths associated with diabetes (all types) and type 2 diabetes in Germany.

RESEARCH DESIGN AND METHODS

A prevalence approach that included nationwide routine data from 64.9 million people insured in the German statutory health insurance system in 2010 was used for the calculation. Because nationwide data on diabetes mortality are lacking in Germany, the mortality rate ratio from the Danish National Diabetes Register was used. The absolute number of excess deaths associated with diabetes was calculated as the number of deaths due to diabetes minus the number of deaths due to diabetes with a mortality that was as high as in the population without diabetes. Furthermore, the mortality population-attributable fraction was calculated.

RESULTS

A total of 174,627 excess deaths were due to diabetes in 2010, including 137,950 due to type 2 diabetes. Overall, 21% of all deaths in Germany were attributable to diabetes and 16% were attributable to type 2 diabetes. Most of the excess deaths (34% each) occurred in the 70- to 89-year-old age-group.

CONCLUSIONS

In this first nationwide calculation of excess deaths related to diabetes in Germany, the results suggest that the official German estimates that rely on information from death certificates are grossly underestimated. Countries without national cohorts or diabetes registries could easily use this method to estimate the number of excess deaths due to diabetes.

Perceived risk of diabetes seriously underestimates actual diabetes risk: The KORA FF4 study

OBJECTIVE

Early detection of diabetes and prediabetic states is beneficial for patients, but may be delayed by patients´ being overly optimistic about their own health. Therefore, we assessed how persons without known diabetes perceive their risk of having or developing diabetes, and we identified factors associated with perception of diabetes risk.

RESEARCH DESIGN AND METHODS

1,953 participants without previously known diabetes from the population-based, German KORA FF4 Study (59.1 years, 47.8% men) had an oral glucose tolerance test. They estimated their probability of having undiagnosed diabetes mellitus (UDM) on a six category scale, and assessed whether they were at risk of developing diabetes in the future. We cross-tabulated glycemic status with risk perception, and fitted robust Poisson regression models to identify determinants of diabetes risk perception.

RESULTS

74% (95% CI: 65-82) of persons with UDM believed that their probability of having undetected diabetes was low or very low. 72% (95% CI: 69-75) of persons with prediabetes believed that they were not at risk of developing diabetes. In people with prediabetes, seeing oneself at risk of diabetes was associated with self-rated poor general health (prevalence ratio (PR) = 3.1 (95% CI: 1.4-6.8), parental diabetes (PR = 2.6, 1.9-3.4), high educational level (PR = 1.9 (1.4-2.5)), lower age (PR = 0.7, 0.6-0.8, per 1 standard deviation increase), female sex (PR = 1.2, 0.9-1.5) and obesity (PR = 1.5, 1.2-2.0).

CONCLUSIONS

People with undiagnosed diabetes or prediabetes considerably underestimate their probability of having or developing diabetes. Contrary to associations with actual diabetes risk, perceived diabetes risk was lower in men, lower educated and older persons.

Type 2 Diabetes in the Elderly: Challenges in a Unique Patient Population

In the older patient population, rates of Type 2 Diabetes (T2D) and obesity are reaching epidemic proportions. In fact, older patients will soon constitute the majority of patients with T2D in most developed countries. The higher prevalence of T2D in older individuals is seen in both men and women and across racial and ethnic groups. However, certain ethnic groups are disproportionately affected and successful strategies must account for these fundamental differences. T2D in old age is associated with traditional diabetes-associated complications including micro- and macro vascular disease, but is also closely related to numerous other comorbidities including cognitive impairment, urinary incontinence, sarcopenia, and increased fall risk. An overall state of chronic inflammation and dysregulated immune system may underlie these increased risks; yet our understanding of immunometabolism during the aging process remains incomplete. In addition, optimal recognition and treatment of diabetes in the elderly is hampered by a lack of relevant, high-quality studies, as the majority of clinical trial data establishing risk profiles, glycemic targets, and therapeutic interventions for T2D are not applicable for large segments of the older patient population. Simply acknowledging this gap is inadequate. We need strong evidence-based data upon which to successfully identify diabetic patients and then intervene in ways that are targeted to specific individuals within a heterogeneous group of elderly patients with T2D.

Associations Between the Serum Metabolome and All-Cause Mortality Among African Americans in the Atherosclerosis Risk in Communities (ARIC) Study

Early and accurate identification of people at high risk of premature death may assist in the targeting of preventive therapies in order to improve overall health. To identify novel biomarkers for all-cause mortality, we performed untargeted metabolomics in the Atherosclerosis Risk in Communities (ARIC) Study. We included 1,887 eligible ARIC African Americans, and 671 deaths occurred during a median follow-up period of 22.5 years (1987-2011). Chromatography and mass spectroscopy identified and quantitated 204 serum metabolites, and Cox proportional hazards models were used to analyze the longitudinal associations with all-cause and cardiovascular mortality. Nine metabolites, including cotinine, mannose, glycocholate, pregnendiol disulfate, α-hydroxyisovalerate, N-acetylalanine, andro-steroid monosulfate 2, uridine, and γ-glutamyl-leucine, showed independent associations with all-cause mortality, with an average risk change of 18% per standard-deviation increase in metabolite level (P < 1.23 × 10(-4)). A metabolite risk score, created on the basis of the weighted levels of the identified metabolites, improved the predictive ability of all-cause mortality over traditional risk factors (bias-corrected Harrell's C statistic 0.752 vs. 0.730). Mannose and glycocholate were associated with cardiovascular mortality (P < 1.23 × 10(-4)), but predictive ability was not improved beyond the traditional risk factors. This metabolomic analysis revealed potential novel biomarkers for all-cause mortality beyond the traditional risk factors.

Different glucose tolerance status and incident cardiovascular disease and all-cause mortality among elderly Iranians

AIMS

To determine the effect of different glucose categories on incident cardiovascular disease (CVD) and all-cause mortality in a population-based cohort.

METHODS

A total of 834 individuals aged 65 years and older without a history of CVD at baseline were stratified according to 2-h post-load glucose fasting glucose test into six categories including: (i) normal fasting glucose/normal glucose tolerance; (ii) prediabetes, (iii) isolated fasting hyperglycemia (IFH); (iv) isolated post-challenge hyperglycemia (IPH); (v) IPH and IFH; and (vi) known diabetes mellitus. The prognostic significance of these groups on CVD and total mortality were examined by Cox proportional hazard ratios in a multivariate adjusted model.

RESULTS

Over 9 years of follow up, 186 incidents of CVD and 218 deaths occurred (72 CVD mortality).Of the population, 45.2%, 30.7%, 1.2%, 6.1% 4.7%, and 11.9% were normal fasting glucose/normal glucose tolerance, prediabetes IFH, IPH, IFH and IPH, and known diabetes mellitus, respectively. Multivariate adjusted hazard ratios for CVD were 1.13 (95% CI 0.78-1.64), 1.03 (95% CI 0.25-4.22), 1.17 (95% CI 0.65-2.11), 2.52 (95% CI 1.43-4.42) and 2.39 (95% CI 1.55-3.69), and for CVD mortality were 0.59 (95% CI 0.27-1.30), 2.02 (95% CI 0.27-15.15), 1.26 (95% CI 0.51-3.16), 3.57 (95% CI 1.64-7.75), and 4.70 (95% CI 2.54-8.69) for prediabetes, IFH, IPH, IFH and IPH, and known diabetes mellitus phenotypes, respectively. Corresponding hazard ratios for all-cause mortality in multivariate model adjusted for prevalent CVD were 1.07 (95% CI 0.73-1.57), 0.59 (95% CI 0.08-4.30), 0.92 (95% CI 0.5-1.70), 2.31 (95% CI 1.33-4.01) and 3.88 (95% CI 2.70-5.55), respectively.

CONCLUSION

Among the elderly population with newly diagnosed diabetes, only the combined IFH and IPH phenotype, but not IFH or IPH alone, was a significant predictor of CVD and mortality events. Prediabetes was not associated with any risk. Geriatr Gerontol Int 2016; 16: 1263-1271.

Prevalence, incidence and concomitant co-morbidities of type 2 diabetes mellitus in South Western Germany--a retrospective cohort and case control study in claims data of a large statutory health insurance

Background

Type 2 diabetes mellitus (T2DM) has become a world-wide epidemic. This chronic metabolic disease has a major impact on life expectancy and on quality of life. The burden of this disease includes a number of co-morbidities. However, estimates of prevalence, incidence and associated diseases as well as the current temporal development and regional differences are largely missing for South Western Germany.

Methods

Lifetime diagnosis-based prevalence, incidence and presence of concomitant co-morbidities were examined between the years 2007 and 2010 in the claims data set of all insured persons of the AOK Baden-Wuerttemberg, a large statutory health insurance. The analysis was based on the respective WHO-ICD-10 codes. Data were standardized for age and sex on the residential population of about 10 million inhabitants of South Western Germany.

Results

The total study cohort involved approximately 3.5 million persons each year. The standardized diagnosis-based prevalence (SDP) of T2DM rose from 6.6 %, 7.4 %, 8.0 %, up to 8.6 % in the years 2007 to 2010. Yearly SDP was between 14.0 % and 18.9 % at an age range of 60 to 64 years and between 26.7 % and 31.8 % at an age of 75 years or older. In the year 2010 the regional distributions of standardized diagnosis-based prevalence were between 7.6 % and 11.6 %, respectively. Incidence rates were 8.3 in 2008, 7.8 in 2009, and 8.7 in 2010 (all rates per 1000). The excess disease risk (odds ratio) of T2DM was for adiposity 2.8 to 3.0, hypertension 2.4 to 3.7, coronary heart disease 1.8 to 1.9, stroke 1.7 to 1.8, renal insufficiency 2.8 to 3.4, and retinopathy 2.8 to 2.9 in the years 2007 to 2010. These co-morbidities appeared several years earlier compared to the non-diabetic population.

Conclusions

T2DM is common and increasing in South Western Germany. In particular a quarter of the population in higher ages was afflicted by T2DM. Interestingly a region-specific pattern was observed as well as an increase in numbers during earlier years in life. Our data underline the need for diabetes awareness programmes including early diagnosis measures as well as structured and timely health surveys for major diseases such as T2DM and its concomitant co-morbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2188-1) contains supplementary material, which is available to authorized users.

Impact of glucose level on morbidity and mortality in elderly with diabetes and pre-diabetes

The prevalence of type 2 diabetes mellitus (DM) increases with age and reaches 25% in those older than age 65 years. Pre-diabetes status is also very common in the elderly, and is present in about half of those age 75 years and older. Many physicians care for elderly patients with diabetes and pre-diabetes, dealing with the challenge of controlling glucose levels and improving health with minimal adverse events. Over the last decade, research on diabetes among the elderly population has proliferated, adding new information on this topic. This review summarizes the updated medical literature on diabetes and pre-diabetes in the elderly, including the significance of pre-diabetic conditions, new-onset DM in the elderly and long-standing DM. The role of therapeutic intervention and the level of glycemic control for this population are discussed in particular.

Prediabetes and associated disorders

Prediabetes represents an elevation of plasma glucose above the normal range but below that of clinical diabetes. Prediabetes includes individuals with IFG, IGT, IFG with IGT and elevated HbA1c levels. Insulin resistance and β-cell dysfunction are characteristic of this disorder. The diagnosis of prediabetesis is vital as both IFG and IGT are indeed well-known risk factors for type 2 diabetes with a greater risk in the presence of combined IFG and IGT. Furthermore, as will be illustrated in this review, prediabetes is associated with associated disorders typically only considered in with established diabetes. These include cardiovascular disease, periodontal disease, cognitive dysfunction, microvascular disease, blood pressure abnormalities, obstructive sleep apnea, low testosterone, metabolic syndrome, various biomarkers, fatty liver disease, and cancer. As the vast majority of individuals with prediabetes are unaware of their diagnosis, it is therefore vital that the associated conditions are identified, particularly in the presence of mild hyperglycemia, so they may benefit from early intervention.

Association between hemoglobin A1c and all-cause mortality: results of the mortality follow-up of the German National Health Interview and Examination Survey 1998

OBJECTIVE

This study examined the association of HbA1c-defined glycemic status and continuous HbA1c with all-cause mortality.

RESEARCH DESIGN AND METHODS

The study population comprised 6,299 participants (aged 18-79 years) of the German National Health Interview and Examination Survey 1998, who were followed up for mortality for an average of 11.6 years. Glycemic status was defined as known diabetes (self-reported diagnosis or intake of antidiabetic medication) and based on HbA1c levels according to American Diabetes Association diagnostic criteria as undiagnosed diabetes (≥6.5% [≥48 mmol/mol]), prediabetes with very high (6.0-6.4% [42-46 mmol/mol]) or high diabetes risk (5.7-5.9% [39-41 mmol/mol]), and normoglycemia (<5.7% [<39 mmol/mol]). Associations between glycemic status and mortality were examined by Cox regression adjusting for age, sex, education, lifestyle factors, anthropometric measures, and history of chronic diseases (reference: normoglycemia). Spline models were fitted to investigate associations between continuous HbA1c and mortality among participants without known diabetes.

RESULTS

Excess mortality risk was observed for participants with known diabetes (hazard ratio 1.41 [95% CI 1.08-1.84]) and undiagnosed diabetes (1.63 [1.23-2.17]) but not for those with high (1.02 [0.80-1.30]) or very high diabetes risk (0.87 [0.67-1.13]). Spline models revealed a U-shaped association, with lowest risk at HbA1c levels 5.4-5.6% (36-38 mmol/mol) and a significantly increased risk at ≤5.0% (≤31 mmol/mol) and ≥6.4% (≥46 mmol/mol).

CONCLUSIONS

Unlike known and undiagnosed diabetes, HbA1c levels in the prediabetic range were not associated with an increased mortality risk. The observed U-shaped relationship adds to existing evidence that not only high but also low HbA1c levels might be associated with all-cause mortality.

The risk of total mortality and cardiovascular mortality associated with impaired glucose regulation in Tayside, Scotland, UK: a record-linkage study in 214 094 people

OBJECTIVE

Mortality among adults of all ages diagnosed with impaired glucose regulation (IGR) in Tayside, Scotland, UK, was evaluated using routinely collected healthcare data sets.

RESEARCH DESIGN AND METHODS

Using record-linked data in 2003-2008, all instances of blood glucose testing in the population defined 2 cohorts of patients aged 18+years: those with IGR (whether impaired fasting glucose or impaired glucose tolerance (IGT)) according to the WHO criteria, and those who were normoglycemic. They were followed in survival analyses for mortality or cardiovascular mortality (censoring deaths that occurred within a 30-day period of testing), to derive HRs (with 95% CI) for IGR status using Cox regression, adjusted for age, sex, and an area measure of deprivation.

RESULTS

There were 2 372 712 tests for 214 094 patients, with 196 799 patients in the non-IGR cohort and 50 080 in the IGR cohort. During follow-up, 19 147 (9.7%) and 8397 (16.8%) patients died in 2 cohorts, respectively, with mortality rates of 33.2/1000 patient-years and 70.7/1000 patient-years. In multivariable analyses, the overall adjusted risk of mortality for IGR was 1.16 (95% CI 1.13 to 1.20). However, it was 2.59 (95% CI 2.17 to 3.10) for people aged <45 years, decreasing to 0.94 (95% CI 0.85 to 1.00) in those aged 85+years. The HRs for cardiovascular mortality were lower overall, but they followed the same pattern, with statistically significant increased risks for patients aged <64 years only. The mortality risk was highest among patients with IGT.

CONCLUSIONS

IGR is associated with an increased mortality risk which declines with age. It is therefore important to prioritize young people with IGR for prevention; but less important to be aggressive about risk factor modification in older people.

Prediabetes, elevated iron and all-cause mortality: a cohort study

OBJECTIVES

Data have indicated low to non-existent increased mortality risk for individuals with prediabetes, but it is unclear if the risk is increased when the patient has elevated iron markers. Our purpose was to examine the mortality risk among adults with prediabetes in the context of coexisting elevated transferrin saturation (TS) or serum ferritin.

SETTING

Data collected by the third National Health and Nutrition Examination Survey 1988-1994 (NHANES III) in the USA and by the National Center for Health Statistics for the National Death Index from 1988 to 2006.

PARTICIPANTS

Individuals age 40 and older who participated in the NHANES and provided a blood sample.

PRIMARY OUTCOME VARIABLE

Mortality was measured as all-cause mortality.

RESULTS

Adjusted analyses show that prediabetes has a small increased mortality risk (HR=1.04; 95% CI 1.00 to 1.08). Persons who had prediabetes and elevated serum ferritin had an increased HR for death (HR=1.14; 95% CI 1.04 to 1.24) compared with those who had normal ferritin and normal glucose. Among persons with prediabetes who had elevated TS, they had an increased mortality risk (HR=1.88; 95% CI 1.06 to 3.30) compared with those with normal TS levels and normal glucose.

CONCLUSIONS

The mortality risk of prediabetes is low. However, among individuals who have coexisting elevated iron markers, particularly TS, the risk rises substantially.

Associations of prediabetes with all-cause and cardiovascular mortality: a meta-analysis

BACKGROUND

Reports on the association of prediabetes with all-cause mortality and cardiovascular mortality are inconsistent. Objective. To evaluate the risk of all-cause and cardiovascular mortality in association with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT).

METHODS

Prospective cohort studies with data on prediabetes and mortality were included. The relative risks (RRs) of all-cause and cardiovascular mortality were calculated and reported with 95% confidence intervals (95% CIs).

RESULTS

Twenty-six studies were included. The risks of all-cause and cardiovascular mortality were increased in participants with prediabetes defined as IFG of 110-125 mg/dL (IFG 110) (RR 1.12, 95% CI 1.05-1.20; and RR 1.19, 95% CI 1.05-1.35, respectively), IGT (RR 1.33, 95% CI 1.24-1.42; RR 1.23, 95% CI 1.11-1.36, respectively), or combined IFG 110 and/or IGT (RR 1.21, 95% CI 1.11-1.32; RR 1.21, 95% CI 1.07-1.36, respectively), but not when IFG was defined as 100-125 mg/dL (RR 1.07, 95% CI 0.92-1.26; and RR 1.16, 95% CI 0.94-1.42, respectively).

CONCLUSIONS

Prediabetes, defined as IFG 110, IGT, or combined IFG 110 and/or IGT, was associated with increased all-cause and cardiovascular mortality.

Regional differences of undiagnosed type 2 diabetes and prediabetes prevalence are not explained by known risk factors

Background

We have previously found regional differences in the prevalence of known type 2 diabetes between northeastern and southern Germany. We aim to also provide prevalence estimates for prediabetes (isolated impaired fasting glucose (i-IFG), isolated glucose intolerance (i-IGT), combined IFG and IGT) and unknown type 2 diabetes for both regions.

Methods

Prevalence (95%CI) of prediabetes (i-IFG: fasting glucose 5.6–6.9 mmol/l; i-IGT: 2 h postchallenge gluose 7.8–11.0 mmol/l, oral glucose tolerance test (OGTT), ≥8 h overnight fasting) and unknown diabetes were analyzed in two regional population-based surveys (age group 35–79 years): SHIP-TREND (Study of Health in Pomerania (northeast), 2008–2012) and KORA F4 (Cooperative Health Research in the region of Augsburg (south), 2006–2008). Both studies used similar methods, questionnaires, and identical protocols for OGTT. Overall, 1,980 participants from SHIP-TREND and 2,617 participants from KORA F4 were included.

Results

Age-sex-standardized prevalence estimates (95%CI) of prediabetes and unknown diabetes were considerably higher in the northeast (SHIP-TREND: 43.1%; 40.9–45.3% and 7.1%; 5.9–8.2%) than in the south of Germany (KORA F4: 30.1%; 28.4–31.7% and 3.9%; 3.2–4.6%), respectively. In particular, i-IFG (26.4%; 24.5–28.3% vs. 17.2%; 15.7–18.6%) and IFG+IGT (11.2%; 9.8–12.6% vs. 6.6%; 5.7–7.5%) were more frequent in SHIP-TREND than in KORA. In comparison to normal glucose tolerance, the odds of having unknown diabetes (OR, 95%CI: 2.59; 1.84–3.65) or prediabetes (1.98; 1.70–2.31) was higher in the northeast than in the south after adjustment for known risk factors (obesity, lifestyle).

Conclusions

The regional differences of prediabetes and unknown diabetes are in line with the geographical pattern of known diabetes in Germany. The higher prevalences in the northeast were not explained by traditional risk factors.

Prediabetes and the risk of cancer: a meta-analysis

AIMS/HYPOTHESIS

The results from prospective cohort studies of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) and risk of cancer are controversial. We conducted a meta-analysis to evaluate the risk of cancer in association with impaired fasting glucose and impaired glucose tolerance.

METHODS

The PubMed, EMBASE and Cochrane Library databases were searched for prospective cohort studies with data on prediabetes and cancer. Two independent reviewers assessed the reports and extracted the data. Prospective studies were included if they reported adjusted RRs with 95% CIs for the association between cancer and prediabetes. Subgroup analyses were conducted according to endpoint, age, sex, ethnicity, duration of follow-up and study characteristics.

RESULTS

Data from 891,426 participants were derived from 16 prospective cohort studies. Prediabetes was associated with an increased risk of cancer overall (RR 1.15; 95% CI 1.06, 1.23). The results were consistent across cancer endpoint, age, duration of follow-up and ethnicity. There was no significant difference for the risk of cancer with different definitions of prediabetes. In a site-specific cancer analysis, prediabetes was significantly associated with increased risks of cancer of the stomach/colorectum, liver, pancreas, breast and endometrium (all p < 0.05), but not associated with cancer of the bronchus/lung, prostate, ovary, kidney or bladder. The risks of site-specific cancer were significantly different (p = 0.01) and were highest for liver, endometrial and stomach/colorectal cancer.

CONCLUSIONS/INTERPRETATION

Overall, prediabetes was associated with an increased risk of cancer, especially liver, endometrial and stomach/colorectal cancer.

Definition of intervention points in prediabetes

With respect to clinical phenotype and pathophysiology, prediabetes is akin to diabetes. Prediabetes is prevalent in the global population, and those affected are at high risk of progression to overt diabetes, and also at risk of cardiovascular disease (CVD). Progression to diabetes can occur because of worsening insulin resistance, β-cell dysfunction, or both, but the timecourse can be non-linear and, therefore, unpredictable. Intervention-by lifestyle modification, glucose-lowering drugs, or a combination-can postpone deterioration of glucose control, but effects of intervention are variable and can be transient. Furthermore, to what extent interventions can reduce cardiovascular risk is uncertain. Lifestyle intervention mainly hinges on weight loss; as such, risk of failure in the long-term is high, and implementation at the community level is difficult. The ideal candidate for intervention is an individual with prediabetes-identified by targeted screening-with many well documented cardiovascular risk factors, and who is highly motivated to initiate and maintain multifactorial risk-control using a personalised mix of lifestyle-adaptation and pharmacological treatment.

PLA1A2 platelet polymorphism predicts mortality in prediabetic subjects of the population based KORA S4-Cohort

OBJECTIVE

The genetic polymorphism concerning the ß3-subunit of platelet integrin receptor glycoprotein IIIa is held responsible for enhanced binding of adhesive proteins resulting in increased thrombogenic potential. Whether it is associated with mortality, HbA1c or platelet volume is tested prospectively in an epidemiological cohort.

RESEARCH DESIGN AND METHODS

Population-based Cooperative Health Research in the Region of Augsburg (KORA) S4-Survey (N = 4,028) was investigated for prognostic value of PLA1A2-polymorphism regarding all-cause mortality, correlation with HbA1c, and mean platelet volume. Multivariate analysis was performed to investigate association between genotype and key variables.

RESULTS

Prevalence of thrombogenic allele variant PLA2 was 15.0%. Multivariate analysis revealed no association between PLA1A2 polymorphism and mortality in the KORA-cohort. HbA1c was a prognostic marker of mortality in non-diabetic persons resulting in J-shaped risk curve with dip at HbA1c = 5.5% (37 mmol/mol), confirming previous findings regarding aged KORA-S4 participants (55-75 years). PLA1A2 was significantly associated with elevated HbA1c levels in diabetic patients (N = 209) and reduced mean platelet volume in general population. In non-diabetic participants (N = 3,819), carriers of PLA2 allele variant presenting with HbA1c > 5.5% (37 mmol/mol) showed higher relative risk of mortality with increasing HbA1c.

CONCLUSION

PLA1A2 polymorphism is associated with mortality in participants with HbA1c ranging from 5.5% (37 mmol/mol) to 6.5% (48 mmol/mol). Maintenance of euglycemic control and antiplatelet therapy are therefore regarded as effective primary prevention in this group.

Is particle pollution in outdoor air associated with metabolic control in type 2 diabetes?

BACKGROUND

There is growing evidence that air pollutants are associated with the risk of type 2 diabetes. Subclinical inflammation may be a mechanism linking air pollution with diabetes. Information is lacking whether air pollution also contributes to worse metabolic control in newly diagnosed type 2 diabetes. We examined the hypothesis that residential particulate matter (PM10) is associated with HbA1c concentration in newly diagnosed type 2 diabetes.

METHODS

Nationwide regional levels of particulate matter with a diameter of ≤ 10 µm (PM10) were obtained in 2009 from background monitoring stations in Germany (Federal Environmental Agency) and assigned to place of residency of 9,102 newly diagnosed diabetes patients registered in the DPV database throughout Germany (age 65.5 ± 13.5 yrs; males: 52.1%). Mean HbA1c (%) levels stratified for air pollution quartiles (PM10 in µg/m(3)) were estimated using linear regression models adjusting for age, sex, BMI, diabetes duration, geographic region, year of ascertainment, and social indicators.

FINDINGS

In both men and women, adjusted HbA1c was significantly lower in the lowest quartile of PM10 exposure in comparison to quartiles Q2-Q4. Largest differences in adjusted HbA1c (95% CI) were seen comparing lowest quartiles of exposure with highest quartiles (men %: -0.42 (-0.62; -0.23)/mmol/mol: -28.11 (-30.30; -26.04), women, %: -0.28 (-0.47; -0.09)/mmol/mol: -0.28 (-0.47; -0.09)).

INTERPRETATION

Air pollution may be associated with higher HbA1c levels in newly diagnosed type 2 diabetes patients. Further studies are warranted to examine this association.

Diabetes in Europe: an update

Diabetes is among the leading causes of death in the IDF Europe Region (EUR), continues to increase in prevalence with diabetic macro- and microvascular complications resulting in increased disability and enormous healthcare costs. In 2013, the number of people with diabetes is estimated to be 56 million in EUR with an overall estimated prevalence of 8.5%. However, estimates of diabetes prevalence in 2013 vary widely in the 56 diverse countries in EUR from 2.4% in Moldova to 14.9% in Turkey. Trends in diabetes prevalence also vary between countries with stable prevalence since 2002 for many countries but a doubling of diabetes prevalence in Turkey. For 2035, a further increase of nearly 10 million people with diabetes is projected for the EUR. Prevalence of type 1 has also increased over the past 20 years in EUR and there was estimated to be 129,350 cases in children aged 0-14 years in 2013. Registries provide valid information on incidence of type 1 diabetes with more complete data available for children than for adults. There are large differences in distribution of risk factors for diabetes at the population level in EUR. Modifiable risk factors such as obesity, physical inactivity, smoking behaviour (including secondhand smoking), environmental pollutants, psychosocial factors and socioeconomic deprivation could be tackled to reduce the incidence of type 2 diabetes in Europe. In addition, diabetes management is a major challenge to health services in the European countries. Improved networking practices of health professionals and other stakeholders in combination with empowerment of people with diabetes and continuous quality monitoring need to be further developed in Europe.

[Prevalence and temporal trend of known diabetes mellitus: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

The first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1, 2008-2011) allows for up-to-date, representative prevalence estimates of known diabetes amongst the 18- to 79-year-old resident population of Germany. Temporal trends can be shown by comparing the survey findings with those of the "German National Health Interview and Examination Survey 1998" (GNHIES98). The definition of known diabetes was based on self-reports in physician-administered interviews that asked respondents if they had ever been diagnosed with diabetes by a doctor or were on anti-diabetic medication. Overall, diabetes had been diagnosed in 7.2 % of the adults (7.4 % of the women; 7.0 % of the men). The prevalence increased substantially with advancing age and was higher in persons of low than of high socioeconomic status. Prevalence varied depending on the type of health insurance held and was highest amongst those insured with AOK health insurance funds. In comparison with GNHIES98, there was a 38 % increase in prevalence, of which approximately one third is to be attributed to demographic ageing. In the context of other nationwide studies, the results indicate a figure of at least 4.6 million 18- to 79-year-olds having been diagnosed with diabetes at some point. Planned analyses of undiagnosed diabetes will contribute to the interpretation of the observed increase in the prevalence of known diabetes. An English full-text version of this article is available at SpringerLink as supplemental.

The Rotterdam Study: 2014 objectives and design update

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, oncological, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over a 1,000 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.

Glucose metabolism after renal transplantation

OBJECTIVE

We determined prevalence, risk factors, phenotype, and pathophysiological mechanism of new-onset diabetes after transplantation (NODAT) to generate strategies for optimal pharmacological management of hyperglycemia in NODAT patients.

RESEARCH DESIGN AND METHODS

Retrospective cohort study comparing demographics, laboratory data, and oral glucose tolerance test (OGTT)-derived metabolic parameters from kidney transplant recipients versus subjects not receiving transplants.

RESULTS

Among 1,064 stable kidney transplant recipients (≥ 6 months posttransplantation), 113 (11%) had a history of NODAT and 132 (12%) had pretransplant diabetes. In the remaining patients, randomly assigned OGTTs showed a high prevalence of abnormal glucose metabolism (11% diabetes; 32% impaired fasting glucose, impaired glucose tolerance, or both), predominantly in older patients who received tacrolimus as the primary immunosuppressant. Compared with 1,357 nontransplant subjects, stable kidney transplant recipients had lower basal glucose, higher glycated hemoglobin, lower insulin secretion, and greater insulin sensitivity in each of the three subgroups, defined by OGTT 2-h glucose (<140, 140-199, ≥ 200 mg/dL). These findings were reinforced in linear spline interpolation models of insulin secretion and sensitivity (all P < 0.001) and in another regression model in which the estimated oral glucose insulin sensitivity index was substantially higher (by 79-112 mL/min m(2)) for transplant versus nontransplant subjects despite adjustments for age, sex, and BMI (all P < 0.001).

CONCLUSIONS

Glucose metabolism differs substantially between kidney transplant recipients and nontransplant controls. Because impaired insulin secretion appears to be the predominant pathophysiological feature after renal transplantation, early therapeutic interventions that preserve, maintain, or improve β-cell function are potentially beneficial in this population.

Projection of the burden of type 2 diabetes mellitus in Germany: a demographic modelling approach to estimate the direct medical excess costs from 2010 to 2040

AIM

To model the future costs of Type 2 diabetes in Germany, taking into account demographic changes, disease dynamics and undiagnosed cases.

METHODS

Using a time-discrete Markov model, the prevalence of diabetes (diagnosed/undiagnosed) between 2010 and 2040 was estimated and linked with cost weights. Demographic, epidemiological and economic scenarios were modelled. Inputs to the model included the official population forecasts, prevalence, incidence and mortality rates, proportions of undiagnosed cases, health expenditure and cost ratios of an individual with (diagnosed/undiagnosed) diabetes to an individual without diabetes. The outcomes were the case numbers and associated annual direct medical excess costs of Type 2 diabetes from a societal perspective in 2010€.

RESULTS

In the base case, the case numbers of diabetes will grow from 5 million (2.8 million diagnosed) in 2010 to a maximum of 7.9 million (4.6 million diagnosed) in 2037. From 2010 to 2040, the prevalence rate amonf individuals ≥40 years old will increase from 10.5 to 16.3%. The annual costs of diabetes will increase by 79% from €11.8 billion in 2010 to €21.1 billion in 2040 (€9.5 billion to €17.6 billion for diagnosed cases).

CONCLUSIONS

The projected increase in costs will be attributable to demographic changes and disease dynamics, and will be enhanced by higher per capita costs with advancing age. Better epidemiological and economic data regarding diabetes care in Germany would improve the forecasting accuracy. The method used in the present study can anticipate the effects of alternative policy scenarios and can easily be adapted to other chronic diseases.

Recent HbA1c values and mortality risk in type 2 diabetes. population-based case-control study

This study aimed to evaluate mortality within 365 days of HbA1c values of <6.5% or >9.0% in participants with clinical type 2 diabetes mellitus. A matched nested case-control study was implemented, within a cohort of participants with type 2 diabetes from 2000 to 2008. Conditional logistic regression was used to model the odds ratio for mortality adjusting for comorbidity and drug utilisation. There were 97,450 participants with type 2 diabetes; 16,585 cases that died during follow up were matched to 16,585 controls. The most recent HbA1c value was <6.5% (48 mmol/mol) for 22.2% of cases and 24.2% of controls, the HbA1c was >9.0% for 9.0% of cases and 7.7% of controls. In a complete case analysis, the adjusted odds ratio (AOR) for mortality associated with most recent HbA1c <6.5% was 1.31 (95% confidence interval (CI): 1.21,1.42). After multiple imputation of missing HbA1c values the AOR was 1.20 (CI: 1.12,1.28). The complete case analysis gave an AOR for HbA1c >9.0% of 1.51 (CI: 1.33, 1.70), in the multiple imputation analysis this was 1.29 (1.17,1.41). The risk associated with HbA1c <6.5% was age dependent. In the multiple imputation analysis the AOR was 1.53 (CI: 0.84 to 2.79) at age<55 years but 1.04 (CI: 0.92, 1.17) at age 85 years and over. In non-randomised data, values of HbA1c that are either <6.5% or >9.0% may be associated with increased mortality within one year in clinical type 2 diabetes. Relative risks may be higher at younger ages.

Type 2 diabetes: prevalence and relevance of genetic and acquired factors for its prediction

BACKGROUND

The epidemiology of type 2 diabetes in Germany is of major societal interest, as is the question of the predictive value of genetic and acquired risk factors.

METHODS

We present clinically relevant aspects of these topics on the basis of a selective review of pertinent literature retrieved by a PubMed search that centered on population-based studies.

RESULTS

The German Health Interview and Examination Survey for Adults (Studie zur Gesundheit Erwachsener in Deutschland [DEGS1], 2008-2011) revealed that diabetes was diagnosed in 7.2% of the population aged 18 to 79 years (women 7.4%, men 7.0%). These figures are two percentage points higher than those found in the preceding national survey (1998). The percentage of cases that were not captured by these surveys is estimated at 2% to 7% depending on the method. Independently of personal factors (the individual's life style), it seems that living in a disadvantaged region characterized by high unemployment, air pollution, and poor infrastructure raises the risk of diabetes. Moreover, type 2 diabetes has a substantial hereditary component. More than 60 genetic regions have been identified to date that affect the risk of type 2 diabetes, yet all of them together account for only 10% to 15% of the genetic background of the disease.

CONCLUSION

The prevalence of type 2 diabetes in Germany has risen in recent years. The discovery of new genetic variants that confer a higher risk of developing the disease has improved our understanding of insulin secretion in diabetes pathogenesis rather than the prediction of individual diabetes risk ("personalized medicine").

The Generation R Study: design and cohort update 2012

The Generation R Study is a population-based prospective cohort study from fetal life until adulthood. The study is designed to identify early environmental and genetic causes and causal pathways leading to normal and abnormal growth, development and health during fetal life, childhood and adulthood. The study focuses on six areas of research: (1) maternal health; (2) growth and physical development; (3) behavioural and cognitive development; (4) respiratory health and allergies; (5) diseases in childhood; and (6) health and healthcare for children and their parents. Main exposures of interest include environmental, endocrine, genetic and epigenetic, lifestyle related, nutritional and socio-demographic determinants. In total, n = 9,778 mothers with a delivery date from April 2002 until January 2006 were enrolled in the study. Response at baseline was 61 %, and general follow-up rates until the age of 6 years exceed 80 %. Data collection in mothers, fathers and children include questionnaires, detailed physical and ultrasound examinations, behavioural observations, and biological samples. A genome and epigenome wide association screen is available in the participating children. From the age of 5 years, regular detailed hands-on assessments are performed in a dedicated research center including advanced imaging facilities such as Magnetic Resonance Imaging. Eventually, results forthcoming from the Generation R Study contribute to the development of strategies for optimizing health and healthcare for pregnant women and children.

Postchallenge hyperglycemia is positively associated with diabetic polyneuropathy: the KORA F4 study

OBJECTIVE

To assess the prevalence of distal sensorimotor polyneuropathy (DSPN) in an older population and to examine its relationship with prediabetes.

RESEARCH DESIGN AND METHODS

Glucose tolerance status was determined in 61- to 82-year-old participants (n = 1,100) of the population-based Cooperative Health Research in the Region of Augsburg (KORA) F4 Survey (2006-2008). Clinical DSPN was defined as bilaterally impaired foot-vibration perception and/or foot-pressure sensation.

RESULTS

Prevalence of clinical DSPN was similar in subjects with known diabetes (22.0%) and subjects with combined impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) (23.9%). Among prediabetic subgroups, IFG-IGT, but not isolated-IFG and -IGT, was associated with a higher risk of clinical DSPN, compared with normal glucose tolerance. A J-shaped association was observed between clinical DSPN and quartiles of 2-h postchallenge glucose, but not with fasting glucose and HbA(1c) levels.

CONCLUSIONS

Subjects with IFG-IGT and known diabetes had a similar prevalence of clinical DSPN. Elevated 2-h postload glucose levels appeared important for disease risk.

Prevalence of type 2 diabetes in Germany in 2040: estimates from an epidemiological model

To estimate the number of persons in the age-group 55-74 years with type 2 diabetes in Germany until 2040 and to analyze the impact of an intervention in a high risk group. A Markov model is used to generate forecasts by age and sex in each year using inputs of estimated diabetes prevalence, incidence and mortality based on actual national data. Projections about future demographics stem from the German Federal Office of Statistics. In a slightly modified model a state for persons with prediabetes is included to study the interplay of effect-size and participation quote on the number of persons with diabetes. The projected number of people with type 2 diabetes aged 55-74 years rises from 2.4 million in 2010 to 3.9 million in 2030. From 2030 on this number will decrease slightly to 3.3 million in 2040. If every second person aged 55-74 with prediabetes took part in a prevention program with the effect size of the Finnish Diabetes Prevention Program, 0.4 million cases could be prevented until 2030. To prevent 1.0 million cases in 2030, 90 % of all persons with prediabetes had to take part in an intervention that reduces the transition rate from prediabetes to diabetes by 55 %. Unless enormous efforts are spent into prevention programs, the number of persons with type 2 diabetes will increase tremendously in the next two decades.