Incidence and Prevalence of Microvascular and Macrovascular Diseases and All-cause Mortality in Type 2 Diabetes Mellitus: A 10-year Study in a US Commercially Insured and Medicare Advantage Population

MMP9 Gene Polymorphism (rs3918242) Increases the Risk of Cardiovascular Disease in Type 2 Diabetes Patients

Matrix metalloproteinase 9 (MMP-9) C(-1562)T gene polymorphism has been considered a risk factor for cardiovascular disease (CVD). Our study aimed to evaluate the association between this polymorphism and CVD in diabetes patients. The genotyping was performed in 740 patients with T2DM and 400 healthy subjects. A significant difference in the polymorphism distribution was revealed between patients and controls. The T allele and TT homozygote were associated with increased risk of diabetes (OR 1.88, p < 0.0001 and OR 3.77, p = 0.0002, respectively). The comparison between CVD+ and CVD- subgroups showed a much higher frequency of the T allele in patients with CVD (OR 2.87, 95% CI 2.14-3.85, p < 0.0001). Patients with the TT genotype had a higher prevalence of CVD (OR 3.19, 95% CI 1.55-6.56, p = 0.0015). The carrier genotypes (CT/TT) were correlated with HDL levels in both CVD+ and CVD- subgroups (p < 0.001 for both). In the logistic regression analysis, only C(-1562)T SNP was a significant predictor of CVD in diabetic patients (p < 0.001). In conclusion, our study suggests an association between MMP-9 C(-1562)T polymorphism and an increased risk of CVD in T2DM. If replicated in other studies, it could be considered a genetic marker for predicting risk of T2DM and its cardiovascular comorbidity.

Youth-onset type 2 diabetes mellitus: an urgent challenge

The incidence and prevalence of youth-onset type 2 diabetes mellitus (T2DM) and its complications are increasing worldwide. Youth-onset T2DM has been reported in all racial and ethnic groups, but Indigenous peoples and people of colour are disproportionately affected. People with youth-onset T2DM often have a more aggressive clinical course than those with adult-onset T2DM or those with type 1 diabetes mellitus. Moreover, the available treatment options for children and adolescents with T2DM are more limited than for adult patients. Intermediate complications of youth-onset T2DM, such as increased albuminuria, often develop in late childhood or early adulthood, and end-stage complications, including kidney failure, develop in mid-life. The increasing frequency, earlier onset and greater severity of childhood obesity in the past 50 years together with increasingly sedentary lifestyles and an increasing frequency of intrauterine exposure to diabetes are important drivers of the epidemic of youth-onset T2DM. The particularly high risk of the disease in historically disadvantaged populations suggests an important contribution of social and environmental factors, including limited access to high-quality health care, healthy food choices and opportunities for physical activity as well as exposure to stressors including systemic racism and environmental pollutants. Understanding the mechanisms that underlie the development and aggressive clinical course of youth-onset T2DM is key to identifying successful prevention and management strategies.

TSH levels within the normal range and risk of cardiovascular and all-cause mortality among individuals with diabetes

BACKGROUND

Evidence regarding thyroid-stimulating hormone (TSH) levels within the normal range and mortality in adults with diabetes is scarce. This study aimed to identify the association between TSH levels and cardiovascular disease (CVD) and all-cause mortality among euthyroid patients with diabetes.

METHODS

This prospective cohort study included 1830 adults with diabetes from the Third National Health and Nutrition Examination Survey III. Mortality outcomes were ascertained by linkage to National Death Index records through December 31, 2019. Participants were categorized by tertiles of TSH levels (low-normal, 0.39-1.30 mIU/L; medium-normal, 1.30-2.09 mIU/L; high-normal, 2.09-4.60 mIU/L). Multivariable Cox proportional hazards models were used to explore the association between TSH levels within the normal range and overall and CVD mortality. Furthermore, restricted cubic spline analyses were used to determine the nonlinear relationship between TSH levels and mortality.

RESULTS

During a median follow-up of 17.1 years, 1324 all-cause deaths occurred, including 525 deaths from CVD. After multivariate adjustment, a U-shaped relationship was observed between TSH levels in euthyroid status and all-cause or CVD mortality among patients with diabetes (both P < 0.05 for nonlinearity). Compared with participants with medium-normal TSH levels, those with high-normal TSH levels had a significantly higher risk of all-cause (hazard ratio, 1.31; 95% confidence interval, 1.07-1.61) and CVD (1.52; 1.08-2.12) mortality. Similarly, low-normal TSH levels also increased all-cause (1.39; 1.12-1.73) and CVD (1.69; 1.17-2.44) mortality risk. In stratum-specific analyses, we found that high-normal TSH levels were associated with higher mortality risk in younger (< 60 years) patients with diabetes but not in older (≥ 60 years) participants.

CONCLUSION

Low- and high-normal serum TSH levels were associated with increased all-cause and CVD mortality in euthyroid adults with diabetes. Further studies are needed to confirm the present observation in a wider population.

Distribution and association of visual impairment with myopic maculopathy across age groups among highly myopic eyes - based on the new classification system (ATN)

Purpose

To investigate the percentages and risk factors for visual impairment (VI) across age groups in a highly myopic cohort with a wide range of age (18–93 years).

Methods

A total of 2099 eyes (1220 participants) were enrolled. All participants underwent detailed ocular examinations. Myopic maculopathy (MM) was assessed as myopic atrophy maculopathy (MAM), myopic traction maculopathy (MTM) or myopic neovascular maculopathy (MNM) based on the ATN system.

Results

Most participants younger than 50 years had normal vision, while the cumulative risk of VI and blindness gradually increased after 50–59 years. The percentage of each type of MM increased nonlinearly with ageing (all p < 0.001), with an accelerated period of increase after 45 years for MAM, and after 50 years for MTM and MNM. Axial length (AL) ≥30 mm was the only associated factor for mild VI or worse in participants aged 18–39 years (p < 0.001). Older age, AL ≥30 mm and the presence of MAM were predictors for mild VI or worse in the group aged 40–49 years (all p < 0.05). In participants aged ≥50 years, older age, female sex, longer AL and increased severity of MM were risk factors for VI and blindness (all p < 0.05).

Conclusion

The percentages of MM and related VI increased nonlinearly with older age, with a turning point at 45 years for MAM, preceding that of MTM, MNM and VI by 5 years, warranting future longitudinal studies to confirm. Different age groups presented different risk factors for VI. Timely screening should be in place for middle‐aged high myopes.

Lifestyles Under Lockdown: A Scoping Review of International Studies on Type 2 Diabetes Self-Management Behaviors During COVID-19

Background

The effect of the COVID-19 pandemic on diabetes self-management behaviors is unclear.

Objectives

This paper is a scoping review of studies examining health behaviors among people with type 2 diabetes during the COVID-19 pandemic.

Eligibility Criteria

We searched articles available in English using the Search terms “COVID” and “diabetes”, and, separately, each of the following terms: “lifestyle”, “health behavior”, “self-care”, “self-management”, “adherence”, “compliance”, “eating”, “diet”, “physical activity”, “exercise”, “sleep”, “self-monitoring of blood glucose”, or “continuous glucose monitoring”.

Sources of Evidence

We searched PubMed, PsychInfo, and Google Scholar databases from December 2019 through August 2021.

Charting Methods

Data were extracted by 4 calibrated reviewers and study elements were charted.

Results

The search identified 1,710 articles. After screening for relevance and eligibility, 24 articles were included in this review. Findings show the strongest evidence for reduced physical activity and stable glucose monitoring and substance use. There was equivocal evidence for deleterious changes in sleep, diet, and medication intake. With one minor exception, there was no evidence for favorable changes in health behaviors. Limitations of the literature include small samples, predominantly cross-sectional study designs, reliance on retrospective self-reports, sampling through social media, and few standardized measures.

Conclusions

Early studies of health behaviors among people with type 2 diabetes during the COVID-19 pandemic suggest a need for novel interventions to support diabetes self-management, especially targeting physical activity. Future studies should go beyond documenting changes in health behaviors and examine predictors of change over time.

Renalase gene Glu37Asp polymorphism affects susceptibility to diabetic retinopathy in type 2 diabetes mellitus

AIMS

Renalase (RNLS) is an enzyme with monoamine oxidase activity that metabolizes circulating catecholamines. The RNLS gene Asp37Glu missense polymorphism (rs2296545) has been associated with hypertension, cardiac hypertrophy and dysfunction, and stroke. The purpose of our study was to investigate the potential involvement of this polymorphism in the microvascular complications of type 2 diabetes (T2DM).

METHODS

In this case-control study, the polymorphism was genotyped in 860 patients with T2DM and 400 healthy controls. The genotype and allele distribution was compared in subgroups of patients: with diabetic nephropathy (DN+) (n = 405) versus DN- (independently of the presence of DR) and, similarly, patients with diabetic retinopathy (DR+) (n = 328) versus DR- (independently of the presence of DN).

RESULTS

No significant association was detected between analyzed polymorphism and DN. In contrast, the retinopathy subgroup showed a significantly higher frequency of G allele (OR 1.4, 95% CI 1.16-1.72, p = 0.0005) and GG genotype (OR 1.86, 95% CI 1.26-2.75, p = 0.001) than DR- patients. The effect of RNLS Glu37Asp polymorphism on DR remained significant after adjustments for age, gender, BMI, and duration of T2DM (p = 0.005).

CONCLUSIONS

This is the first study to investigate RNLS gene polymorphism in microvascular complications of T2DM. The results suggest that RNLS rs2296545 SNP might be considered a risk factor for diabetic retinopathy in T2DM patients. This can provide new insight into the role of renalase gene in the pathophysiology of microvascular complications of diabetes.

Arginase Gene Polymorphism Increases Risk of Diabetic Retinopathy in Type 2 Diabetes Mellitus Patients

Studies have demonstrated that polymorphic variants of arginase 1 gene (ARG1) are involved in human diseases, such as coronary heart disease, hypertension, and diabetes. Our study aimed to investigate the association between ARG1 rs2781666 single nucleotide polymorphism (SNP) and diabetic retinopathy (DR) in type 2 diabetes (T2DM) patients. Polymorphism was genotyped in 740 T2DM patients and 400 healthy individuals. A significant difference in the genotype distribution was observed between the patients and the controls. The T allele and TT genotype were associated with an increased risk of T2DM (OR 1.4, 95% CI 1.14–1.72, p = 0.001 and OR 2.16, 95% CI 1.23–3.80, p = 0.007, respectively). When the T2DM subjects were stratified into DR+ and DR− subgroups, the T allele and TT genotype frequencies were significantly higher in the DR+ group compared to the DR− group, demonstrating OR 1.68 (1.33–2.12), p < 0.0001 and OR 2.39 (1.36–4.18), p = 0.002, respectively. Logistic regression analysis was applied to determine the interaction between the ARG1 genotypes and other risk factors. Only ARG1 rs2781666 SNP was a significant risk predictor of DR (p = 0.003). In conclusion, this is the first report discussing the effect of ARG1 polymorphism on the microvascular complications that are associated with diabetes. Our findings demonstrate that ARG1 rs2781666 SNP is significantly associated with an increased susceptibility to DR in T2DM patients.

Recent Advances in Epigenetics of Macrovascular Complications in Diabetes Mellitus

Diabetes mellitus is a metabolic and endocrine disorder characterised by hyperglycaemia. Type 2 diabetes mellitus accounts for >90% of people with diabetes. Disorders of blood glucose metabolism and a series of adverse reactions triggered by hyperglycaemia-such as oxidative stress and inflammation-are conducive to the occurrence of diabetic macrovascular complications, which pose severe challenges to the quality of life and life expectancy of people with diabetes. In recent years, epigenetics has attracted more and more researchers' attention as they explore the causes and treatment of diabetes. Epigenetics refers to the regulation of gene expression without changes in gene content. Research focusses on DNA methylation, histone post-translational modification and non-coding RNA. A series of studies have shown that epigenetic regulation accelerates the development of atherosclerosis by interfering with the physiological activities of macrophages, endothelial cells and smooth muscle cells, such as inflammation, lipid deposition and apoptosis. Therefore, it is particularly important to explore new epigenetic discoveries to reduce the severity and harmfulness of diabetes. This study reviewed recent advances in epigenetics in the pathogenesis of diabetes mellitus and its macrovascular complications.

Diabetes prevalence and risk factors of early-onset adult diabetes: results from the Indonesian family life survey

BACKGROUND

Diabetes is increasing rapidly in South-East Asia. Studies have reported typical risk factors associated with all-age adult diabetes and highlighted the roles of economic transition and childhood development factors in diabetes in later life. However, little is known about whether these factors were associated with young adult diabetes risk.

OBJECTIVES

The study has two main aims: (1) estimate diabetes prevalence among adult participants of the Indonesian Family Life Survey (IFLS), and (2) identify childhood development factors associated with early-onset adult diabetes (diagnosed between age 20 and 40) in Indonesia.

METHODS

Data were taken from adults participating in 4th and 5th IFLS (in 2007 and 2014) and linked to childhood history from previous surveys. Diabetes was ascertained from self-report and HbA1c testing in a subsample. Diabetes prevalence rates were estimated by age and source of diagnosis. Cox regression analysis was applied to assess potential risk factors for early-onset adult diabetes.

RESULTS

A total of 34,767 participants were included in the study. Crude total prevalence estimate from self-report was 2,3% and increased with age. Including HbA1c measurements yielded nearly eight times higher prevalence estimates, depending on age. The proportion of yet undiagnosed cases is considerably higher in young age groups. Regression analyses showed that urban childhood residence and high education increased early-onset diabetes risk by 50-70%. Sex, childhood general health, socio-economic level and starvation exposure were not associated with early-onset diabetes risk.

CONCLUSION

Remarkable differences between diabetes prevalence rates based on self-report and HbA1c measurement indicated the need for better diagnosis, especially in young adults. Urban childhood residence and high education increased early-onset adult diabetes risk. Incorporating these factors and diabetes awareness in existing child health programs, together with screening of individuals at risk, could improve early diabetes detection and prevention strategies among young urban Indonesian adults.

Global trend of diabetes mortality attributed to vascular complications, 2000-2016

Background

The global epidemic of diabetes mellitus continues to grow and affects developed and developing countries alike. Intensive glycemic control is thought to modify the risks for vascular complications, hence the risks for diabetes-related death. We investigated the trend of diabetic vascular complication-related deaths between 2000 and 2016 in the global diabetes landscape.

Methods

We collected 17 years of death certificates data from 108 countries in the World Health Organization mortality database between 2000 and 2016, with coding for diabetic complications. Crude and age-standardized proportions and rates were calculated. Trend analysis was done with annual average percentage change (AAPC) of rates computed by joinpoint regression.

Results

From 2000 through 2016, 7,108,145 deaths of diabetes were reported in the 108 countries. Among them, 26.8% (1,904,787 cases) were attributed to vascular complications in damaged organs, including the kidneys (1,355,085 cases, 71.1%), peripheral circulatory (515,293 cases, 27.1%), nerves (28,697 cases, 1.5%) and eyes (5751 cases, 0.3%). Overall, the age-standardized proportion of vascular complication-related mortality was 267.8 [95% confidence interval (95% CI), 267.5–268.1] cases per 1000 deaths and the rate was 53.6 (95% CI 53.5–53.7) cases per 100,000 person-years. Throughout the 17-year period, the overall age-standardized proportions of deaths attributable to vascular complications had increased 37.9%, while the overall age-standardized mortality rates related to vascular complications had increased 30.8% (AAPC = 1.9% [1.4–2.4%, p < 0.05]). These increases were predominantly driven by a 159.8% increase in the rate (AAPC = 2.7% [1.2–4.3%, p < 0.05]) from renal complications. Trends in the rates and AAPC of deaths varied by type of diabetes and of complications, as well as by countries, regions and domestic income.

Conclusion

Diabetic vascular complication-related deaths had increased substantially during 2000–2016, mainly driven by the increased mortality of renal complications.

How do self-care maintenance, self-care monitoring, and self-care management affect glycated haemoglobin in adults with type 2 diabetes? A multicentre observational study

PURPOSE

To evaluate how self-care maintenance, self-care monitoring, and self-care management affect glycated haemoglobin in type 2 diabetes mellitus patients and to set cut-off points of the Self-Care of Diabetes Inventory scales using glycated haemoglobin as outcome of interest.

METHODS

A secondary analysis of a previous multicentre observational cross-sectional study was conducted. Overall, 540 adults with type 2 diabetes mellitus confirmed diagnosis were involved. Socio-demographic and clinical data were collected. Self-care maintenance, self-care monitoring, and self-care management were measured by the Self-Care of Diabetes Inventory. Linear regression models were performed to assess the relationship between self-care maintenance, self-care monitoring, and self-care management and glycated haemoglobin. Receiver operating characteristics curves were carried out to identify the best cut-off score for each self-care scale considering glycated haemoglobin >7% as outcome of interest.

RESULTS

Self-care monitoring and self-care management were associated to glycated haemoglobin in both patients without (self-care monitoring p = 0.0008; self-care management p = 0.0178) and with insulin therapy (self-care monitoring p = 0.0007; self-care management p = 0.0224). Self-care maintenance was associated to glycated haemoglobin in patients without insulin therapy (p = 0.0118). Cut-off scores providing the best performance were 70 points for self-care maintenance and self-care monitoring, and 60 points for self-care management.

CONCLUSIONS

Self-care maintenance, self-care monitoring, and self-care management differently affect glycated haemoglobin in patients with type 2 diabetes mellitus. Clinicians could implement tailored interventions to improve glycaemic control considering the lacking area of self-care.