Changes in body mass index following newly diagnosed type 2 diabetes and risk of cardiovascular mortality: a cohort study of 8486 primary-care patients

Temporal Dietary Pattern Cluster Membership Varies on Weekdays and Weekends but Both Link to Health

BACKGROUND

Energy and dietary quality are known to differ between weekdays and weekends. Data-driven approaches that incorporate time, amount, and duration of dietary intake have previously been used to partition participants' daily weekday dietary intake time series into clusters representing weekday temporal dietary patterns (TDPs) linked to health indicators in United States adults. Yet, neither the relationship of weekend day TDPs to health indicators nor how the TDP membership may change from weekday to weekend is known.

OBJECTIVES

This study was conducted to determine the association between TDPs on weekdays and weekend days and health indicators [diet quality, waist circumference (WC), body mass index (BMI), and obesity] and their overlap among participants.

METHODS

A weekday and weekend day 24-hour dietary recall of 9494 nonpregnant United States adults aged 20-65 years from the cross-sectional National Health and Nutrition Examination Survey 2007-2018 was used to determine the timing and amount of energy intake. Modified dynamic time warping and kernel k-means algorithm clustered participants into 4 TDPs on weekdays and weekend days. Multivariate regression models determined the associations between TDPs and health indicators, controlling for potential confounders and adjusting for the survey design and multiple comparisons. The percentages of overlap in cluster membership between TDPs on weekdays and weekend days were also determined.

RESULTS

United States adults with a TDP of evenly spaced, energy-balanced eating occasions, representing the TDP of more than one-third of all adults on weekdays and weekends, had significantly higher diet quality, lower BMI, WC, and odds of obesity when compared to those with other TDPs. Membership of most United States adults to TDPs varied from weekdays to weekends.

CONCLUSIONS

Both weekday and weekend TDPs were significantly associated with health indicators. TDP membership of most United States adults was not consistent on weekdays and weekends.

Association between body mass index change and mortality in critically ill patients: A retrospective observational study

OBJECTIVE

Previous studies have emphasized the association between baseline body mass index (BMI) and mortality in patients during a stay in the intensive care unit (ICU). However, to our knowledge, few studies have focused on BMI change during an ICU stay. The aim of this study was to explore the prognostic value of BMI change during ICU hospitalization.

METHODS

This was a multicenter, retrospective cohort study with data extracted from the eICU Collaborative Research Database. Logistic regression models were used to explore the relationship between BMI change and mortality in ICU patients. BMI change was calculated as follows: {[discharge ICU weight (kg) - admission ICU weight (kg)] / height (m)²]}. Interaction and subgroup analyses were conducted for patients grouped with baseline BMI on ICU admission (≥30 versus 25-29.9 versus <25 kg/m²), Acute Physiology and Chronic Health Evaluation (APACHE) IV score (<53 versus ≥53), and ICU length of stay (≥3 versus <3 d).

RESULTS

Compared with those with weight loss (n = 17 134), patients with weight gain during ICU hospitalization (n = 17 436) were associated with higher hospital mortality (odds ratio [OR], 1.251; 95% confidence interval [CI], 1.155-1.356; P < 0.001) and ICU mortality (OR, 1.360; 95% CI, 1.227-1.506; P < 0.001) after multivariable adjustment. The associations remained robust in patients with different baseline BMI levels and were especially remarkable among those with higher APACHE IV score and the longer ICU stay.

CONCLUSIONS

The present study exposed the potential hazard of increasing BMI for hospital and ICU mortalities during ICU hospitalization and indicating that patients in the ICU may benefit from a more balanced nutritional strategy.

The Discovery of Data-Driven Temporal Dietary Patterns and a Validation of Their Description Using Energy and Time Cut-Offs

Data-driven temporal dietary patterning (TDP) methods were previously developed. The objectives were to create data-driven temporal dietary patterns and assess concurrent validity of energy and time cut-offs describing the data-driven TDPs by determining their relationships to BMI and waist circumference (WC). The first day 24-h dietary recall timing and amounts of energy for 17,915 U.S. adults of the National Health and Nutrition Examination Survey 2007−2016 were used to create clusters representing four TDPs using dynamic time warping and the kernel k-means clustering algorithm. Energy and time cut-offs were extracted from visualization of the data-derived TDPs and then applied to the data to find cut-off-derived TDPs. The strength of TDP relationships with BMI and WC were assessed using adjusted multivariate regression and compared. Both methods showed a cluster, representing a TDP with proportionally equivalent average energy consumed during three eating events/day, associated with significantly lower BMI and WC compared to the other three clusters that had one energy intake peak/day at 13:00, 18:00, and 19:00 (all p < 0.0001). Participant clusters of the methods were highly overlapped (>83%) and showed similar relationships with obesity. Data-driven TDP was validated using descriptive cut-offs and hold promise for obesity interventions and translation to dietary guidance.

The Risks of Cardiovascular Disease Following Weight Change in Adults with Diabetes: A Cohort Study and Meta-analysis (jc.2022-01089)

CONTEXT

Weight management is recognized as critical in reducing cardio-metabolic risk factors for adults with diabetes, but the effects of weight change on cardiovascular disease in patients with diabetes are unknown.

OBJECTIVE

To evaluate 18-month weight change and subsequent risk of macrovascular and microvascular complications in established individuals with type 2 diabetes.

DESIGN AND SETTING

This study consisted of a cohort study and a meta-analysis. In the cohort study, weight change over 18 months was divided into: gain ≥5%, gain 1%-5%, stable (-1%-1%), loss 1%-5%, and loss ≥5%. Cox regression analyses were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). We then used random-effect models to pool the results combing our study with other relevant studies.

RESULTS

In the cohort study, 8920 participants with valid weight measurements were included. Compared with patients with stable weight, higher risks were seen in those with weight change for total vascular complications (gain ≥5%: HR=1.43, 95% CI: 1.10-1.85; gain 1-5%: HR=1.44, 95% CI: 1.02-2.03; loss ≥5%: HR=1.58, 95% CI: 1.20-2.08), macrovascular complications (gain ≥5%: HR=1.84, 95% CI: 1.16-2.91; loss 1-5%: HR=1.91, 95% CI: 1.06-3.43; loss ≥5%: HR=2.18, 95% CI: 1.36-3.49) and microvascular complications (loss ≥5%: HR=1.48, 95% CI: 1.06-2.06). Meta-analysis also showed similar results.

CONCLUSIONS

Weight gain and loss over 18 months among patients with type 2 diabetes, especially weight change ≥5%, may be a warning sign of adverse cardiovascular outcomes.

Association of magnitude of weight loss and weight variability with mortality and major cardiovascular events among individuals with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Weight management is strongly promoted for overweight or obese patients with type 2 diabetes (T2DM) by current guidelines. However, the prognostic impact of weight loss achieved without behavioural intervention on the mortality and cardiovascular (CV) outcomes in diabetic patients is still contested.

Methods

We searched the PubMed, Embase, and Cochrane Library databases for studies that investigated the association of weight loss or weight variability with mortality and CV outcomes. Results of studies that measured weight loss by percentage weight loss from baseline and stratified it as > 10% and 5–10% or studies that computed weight variability were pooled using random effects model. Study quality was evaluated using the Newcastle–Ottawa Scale.

Results

Thirty eligible studies were included in the systematic review and 13 of these were included in the meta-analysis. Large weight loss (> 10%) was associated with increased risk of all-cause mortality (pooled hazard ratio (HR) 2.27, 95% CI 1.51–3.42), composite of major CV events (pooled HR 1.71, 95% CI 1.38–2.12) and CV mortality (pooled HR 1.50, 95% CI 1.27–1.76) among T2DM patients. Moderate weight loss showed no significant association with all-cause mortality (pooled HR 1.17, 95% CI 0.97–1.41) or CV outcomes (pooled HR 1.12, 95% CI 0.94–1.33). Weight variability was associated with high hazard of all-cause mortality (pooled HR 1.54, 95% CI 1.52–1.56).

Conclusions

Large weight loss and large fluctuations in weight are potential markers of increased risk of mortality and CV events in T2DM patients. Maintaining a stable weight may have positive impact in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01503-x.

Association between weight change and incidence of cardiovascular disease events and mortality among adults with type 2 diabetes: a systematic review of observational studies and behavioural intervention trials

AIMS/HYPOTHESIS

Weight loss is often recommended in the treatment of type 2 diabetes. While evidence has shown that large weight loss may lead to diabetes remission and improvement in cardiovascular risk factors, long-term impacts are unclear. We performed a systematic review of studies of weight loss and other weight changes and incidence of CVD among people with type 2 diabetes.

METHODS

Observational studies of behavioural (non-surgical and non-pharmaceutical) weight changes and CVD events among adults with type 2 diabetes, and trials of behavioural interventions targeting weight loss, were identified through searches of MEDLINE, EMBASE, Web of Science, CINAHL, and The Cochrane Library (CENTRAL) until 9 July 2019. Included studies reported change in weight and CVD and/or mortality outcomes among adults with type 2 diabetes. We performed a narrative synthesis of observational studies and meta-analysis of trial data.

RESULTS

Of 13,227 identified articles, 17 (14 observational studies, three trials) met inclusion criteria. Weight gain (vs no change) was associated with higher hazard of CVD events (HRs [95% CIs] ranged from 1.13 [1.00, 1.29] to 1.63 [1.11, 2.39]) and all-cause mortality (HRs [95% CIs] ranged from 1.26 [1.12, 1.41] to 1.57 [1.33, 1.85]). Unintentional weight loss (vs no change) was associated with higher risks of all-cause mortality, but associations with intentional weight loss were unclear. Behavioural interventions targeting weight loss showed no effect on CVD events (pooled HR [95% CI] 0.95 [0.71, 1.27]; I² = 50.1%). Risk of bias was moderate in most studies and was high in three studies, due to potential uncontrolled confounding and method of weight assessment.

CONCLUSIONS/INTERPRETATION

Weight gain is associated with increased risks of CVD and mortality, although there is a lack of data supporting behavioural weight-loss interventions for CVD prevention among adults with type 2 diabetes. Long-term follow-up of behavioural intervention studies is needed to understand effects on CVD and mortality and to inform policy concerning weight management advice and support for people with diabetes. PROSPERO registration CRD42019127304.

Weight Change, Lifestyle, and Mortality in Patients With Type 2 Diabetes

CONTEXT

The association between weight change and mortality among participants with incident type 2 diabetes (T2D) was unclear.

OBJECTIVE

To examine above association and evaluate the impact of lifestyle on it.

METHODS

This prospective analysis included 11 262 incident T2D patients from Nurses' Health Study and Health Professionals Follow-up Study. We assessed weight change bracketing T2D diagnosis in relation to mortality. We also examined potential effect modification by a healthy lifestyle consisting of high-quality diet, regular physical activity, nonsmoking status, and moderate alcohol consumption.

RESULTS

On average, T2D patients lost 2.3 kg during a 2-year time window spanning the T2D diagnosis, and body weight increased afterwards following a trajectory similar to that of nondiabetics. Compared with patients with a stable weight, T2D patients who lost ≥10% body weight had a 21% (95% CI, 9%-35%) increased all-cause mortality. Lifestyle significantly modified these associations: the hazard ratios (95% CIs) of all-cause mortality comparing ≥10% weight loss with stable weight were 1.63 (1.26-2.09) among participants with a deteriorated lifestyle, 1.27 (1.11-1.46) for a stable lifestyle, and 1.02 (0.81-1.27) for an improved lifestyle (Pinteraction < 0.001). Major weight loss was associated with increased cause-specific mortality and similar effect modifications by lifestyle were also observed.

CONCLUSION

Significant weight loss upon T2D incidence was associated with increased mortality, although improved lifestyle quality abolished these associations. These results highlight the role of adopting a healthy lifestyle for newly diagnosed T2D patients, especially among those who might lose weight unintentionally, and improving long-term survival.

Joint temporal dietary and physical activity patterns: associations with health status indicators and chronic diseases

BACKGROUND

Diet and physical activity (PA) are independent risk factors for obesity and chronic diseases including type 2 diabetes mellitus (T2DM) and metabolic syndrome (MetS). The temporal sequence of these exposures may be used to create patterns with relations to health status indicators.

OBJECTIVES

The objectives were to create clusters of joint temporal dietary and PA patterns (JTDPAPs) and to determine their association with health status indicators including BMI, waist circumference (WC), fasting plasma glucose, glycated hemoglobin, triglycerides, HDL cholesterol, total cholesterol, blood pressure, and disease status including obesity, T2DM, and MetS in US adults.

METHODS

A 24-h dietary recall and random day of accelerometer data of 1836 participants from the cross-sectional NHANES 2003-2006 data were used to create JTDPAP clusters by constrained dynamic time warping, coupled with a kernel k-means clustering algorithm. Multivariate regression models determined associations between the 4 JTDPAP clusters and health and disease status indicators, controlling for potential confounders and adjusting for multiple comparisons.

RESULTS

A JTDPAP cluster with proportionally equivalent energy consumed at 2 main eating occasions reaching ≤1600 and ≤2200 kcal from 11:00 to 13:00 and from 17:00 to 20:00, respectively, and the highest PA counts among 4 clusters from 08:00 to 20:00, was associated with significantly lower BMI (P < 0.0001), WC (P = 0.0001), total cholesterol (P = 0.02), and odds of obesity (OR: 0.2; 95% CI: 0.1, 0.5) than a JTDPAP cluster with proportionally equivalent energy consumed reaching ≤1600 and ≤1800 kcal from 11:00 to 14:00 and from 17:00 to 21:00, respectively, and high PA counts from 09:00 to 12:00.

CONCLUSIONS

The joint temporally patterned sequence of diet and PA can be used to cluster individuals with meaningful associations to BMI, WC, total cholesterol, and obesity. Temporal patterns hold promise for future development of lifestyle patterns that integrate additional temporal and contextual activities.

Weight Changes in Type 2 Diabetes and Cancer Risk: A Latent Class Trajectory Model Study

INTRODUCTION

Body mass index (BMI) is often elevated at type 2 diabetes (T2D) diagnosis. Using latent class trajectory modelling (LCTM) of BMI, we examined whether weight loss after diagnosis influenced cancer incidence and all-cause mortality.

METHODS

From 1995 to 2010, we identified 7,708 patients with T2D from the Salford Integrated Record database (UK) and linked to the cancer registry for information on obesity-related cancer (ORC), non-ORC; and all-cause mortality. Repeated BMIs were used to construct sex-specific latent class trajectories. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models.

RESULTS

Four sex-specific BMI classes were identified; stable-overweight, stable-obese, obese-slightly-decreasing, and obese-steeply-decreasing; comprising 41%, 45%, 13%, and 1% of women, and 45%, 37%, 17%, and 1% of men, respectively. In women, the stable-obese class had similar ORC risks as the obese-slightly-decreasing class, whereas the stable-overweight class had lower risks. In men, the obese-slightly-decreasing class had higher risks of ORC (HR = 1.86, 95% CI: 1.05-3.32) than the stable-obese class, while the stable-overweight class had similar risks No associations were observed for non-ORC. Compared to the stable-obese class, women (HR = 1.60, 95% CI: 0.99-2.58) and men (HR = 2.37, 95% CI: 1.66-3.39) in the obese-slightly-decreasing class had elevated mortality. No associations were observed for the stable-overweight classes.

CONCLUSION

Patients who lost weight after T2D diagnosis had higher risks for ORC (in men) and higher all-cause mortality (both genders) than patients with stable obesity.

Chinese famine exposure in early life and metabolic obesity phenotype in middle age: Results from the China health and retirement longitudinal study

OBJECTIVE

To assess the association between early life exposure to famine and the risk of metabolic obesity phenotypes among adults in middle age.

METHODS

The study selected two comparison groups. Comparison A consisted of a non-exposed group born between 1963-1965 from the China Health and Retirement Longitudinal Study (CHARLS) 2015 wave (N=862) and a fetal-exposed group born between 1959-1961 from the 2011 wave (N=507). Comparison B consisted of an early childhood-exposed group born between 1955-1957 from the 2011 wave (N=830) and a fetal-exposed group born between 1959-1961 from the 2015 wave (N=552). Multivariable logistic regressions were conducted to explore the associations between different periods of famine exposure and obesity, metabolic health status, and metabolic obesity phenotypes, with stratification by sex.

RESULTS

Compared with the non-exposed group, participants exposed to famine in the fetal period had a significantly lower risk of overweight/obesity (OR: 0.78, 95%CI: 0.63-0.97) and a higher risk of metabolically unhealthy status (OR: 1.73, 95%CI: 1.34-2.23) and metabolically unhealthy non-obesity (MUNO) (OR: 2.12, 95%CI: 1.46-3.08) at the age of 50-52 years. In the sex-stratified analysis, males exposed to famine in the fetal period had a significantly lower risk of overweight/obesity (OR: 0.59, 95%CI: 0.43-0.80) and metabolically healthy obesity (MHO) (OR: 0.56, 95%CI: 0.37-0.85), while such associations were not found in females. Compared with the early childhood exposure group, participants in the fetal exposure group had a significantly lower risk of metabolic unhealthy status (OR: 0.65, 95%CI: 0.51-0.85) and MUNO (OR: 0.50, 95%CI: 0.35-0.72). Those associations were observed in both males and females.

CONCLUSION

Exposure to famine in early life increased the risk of metabolically unhealthy status in adulthood. Different metabolic subtypes should be identified at an early stage and followed by classification, intervention, and treatment.

Safety of add-on sulfonylurea therapy in patients with type 2 diabetes using metformin: a population-based real-world study

INTRODUCTION

Metformin is the initial oral antihyperglycemic agent (OHA) of choice for most patients with type 2 diabetes (T2D). However, more than one agent is often required for optimal glucose control. As the choice of preferred second OHAs is less well defined, we sought to compare the real-world safety of sulfonylureas to other OHAs as add-on therapy to metformin in patients with T2D.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included adults in Manitoba, Canada with T2D from 2006 to 2017. Using a new-user design, we divided patients who started on metformin into two groups: add-on therapy with a sulfonylurea and add-on therapy with a different OHA. Outcomes included all-cause mortality, cardiovascular events, and major hypoglycemic episodes. We calculated propensity scores and applied inverse probability of treatment weights to each individual. We compared groups using Cox proportional hazards regression and explored differences in HRs between pre-2008 (acarbose, meglitinides, and thiazolidinediones) and post-2008 (dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, and sodium-glucose linked transporter-2 inhibitors) OHAs.

RESULTS

Our cohort included 32 576 individuals (28 077 metformin plus sulfonylurea and 4499 metformin plus 'other'). Patients newly prescribed a sulfonylurea in the setting of metformin had a higher risk of all-cause mortality (HR 1.44, 95% CI 1.12 to 1.84, p=0.005) and major hypoglycemic episodes (HR 2.78, 95% CI 1.66 to 4.66, p<0.001) than those prescribed an 'other' OHA. No differences in cardiovascular events were observed (HR 0.99, 95% CI 0.81 to 1.22, p=0.92). In subgroup analyses, mortality and cardiovascular event risk was higher in patients prescribed sulfonylureas versus post-2008 OHAs.

CONCLUSIONS

Sulfonylureas as add-on therapy to metformin are associated with increased risk of all-cause mortality and major hypoglycemic episodes compared with 'other' OHAs. Post hoc analysis suggests newer OHAs may be preferred to sulfonylureas as second-line therapy for glycemic control.

Do Weight trajectories influence diabetes control? A prospective study in Switzerland (CoLaus study)

OBJECTIVE

Identify anthropometric trajectories among subjects with type 2 diabetes mellitus (T2DM), and associate them with glycaemic control.

METHODS

Prospective study including 268 community-dwelling participants with T2DM (34% women, mean age 68.7 ± 8.9 years) followed for 10.7 years (range: 8.8-13.6 years). T2DM control was considered for 1) fasting plasma glucose (FPG) < 7.0 mmol/L, or 2) HbA1c < 7.0% (53 nmol/mol). Changes in weight or waist and weight variability were considered.

RESULTS

One half (FPG) and one third (HbA1c) of participants presented with uncontrolled T2DM. Half of the participants presented with obesity and 75% with abdominal obesity. During follow-up, half of the participants maintained their weight, 25% gained > 5 kg, and 25% lost < 5 kg; almost half increased their waist by > 5 cm. Using FPG as criterion, participants who lost > 5 cm waist were more likely to be controlled: multivariable-adjusted odds ratio (OR) and 95% confidence interval (CI): 3.10 (1.23-7.78). Participants with controlled T2DM also presented with a higher weight variability: multivariable adjusted mean ± standard error 4.8 ± 0.3 vs. 3.9 ± 0.3 kg, p = 0.028. Using HbA1c as criterion, participants who lost > 5 kg were less likely to be controlled: OR and (95% CI): 0.35 (0.18-0.66). Similar findings were obtained when restricting the analysis to participants who were diabetic throughout the whole study period.

CONCLUSION

In a Swiss community-based sample of participants with T2DM, T2DM control rates could be implemented. Neither weight nor waist variability was significantly and consistently associated with T2DM control.

Weight change and risk of cardiovascular disease among adults with type 2 diabetes: more than 14 years of follow-up in the Tehran Lipid and Glucose Study

BACKGROUND

To examine the impact of weight change on incident cardiovascular disease and coronary heart disease (CVD/CHD) among an Iranian population with type 2 diabetes mellitus (T2DM).

METHODS

The study population included 763 participants with T2DM aged ≥ 30 years without a history of CVD and cancer at baseline. Two weight measurements done at baseline and about 3 years later. Based on their weight change, they categorized into: > 5% loss, 3-5% loss, stable (± < 3%), 3-5% gain, > 5% gain. Participants were then followed for incident CVD/CHD annually up to 20 March 2018. Multivariable Cox proportional hazard models, adjusted for age, sex, body mass index, educational level, current smoking, glucose-lowering drug use, family history of CVD, hypertension, hypercholesterolemia, chronic kidney disease, and fasting plasma glucose (FPG) were applied to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of weight change categories for incident CVD/CHD, considering stable weight as reference.

RESULTS

After the weight change measurement, during a median follow-up of 14.4 years, 258 CVD and 214 CHD occurred. Over 5% weight gain was associated with reduced risks of CVD and CHD development by the HRs of 0.70 [95% CI 0.48-1.01; P-value: 0.058] and 0.61 [0.40-0.93], respectively, in multivariable analysis. After further adjustment for FPG change, the HRs of weight gain > 5% were attenuated to 0.75 [0.51-1.10; P-value: 0.138] and 0.66 [043-1.01; P-value: 0.053] for incident CVD and CHD, respectively. The effect of weight loss > 5% was in opposite direction among those older versus younger than 60 years; with suggestive increased risk (not statistically significant) of incident CHD/CVD for the older group. Moreover, weight gain > 5% significantly reduced the risk of CHD only among those older than 60 years (P-value for interaction < 0.2). Furthermore, weight gain > 5% had an association with lower risk of CVD and CHD among sulfonylurea users (0.56 [0.32-0.98] for CVD and 0.54 [0.29-0.99] for CHD).

CONCLUSIONS

Our results with a long-term follow-up showed that weight gain > 5% was associated with better CVD/CHD outcomes among Iranian participants with T2DM, especially older ones. Moreover, we did not find an unfavorable impact on incident CVD/CHD for sulfonylurea-induced weight gain.

Temporal physical activity patterns are associated with obesity in U.S. adults

Few attempts have been made to incorporate multiple aspects of physical activity (PA) to classify patterns linked with health. Temporal PA patterns integrating time and activity counts were created to determine their association with health status. Accelerometry data from the National Health and Nutrition Examination Survey 2003-2006 was used to pattern PA counts and time of activity from 1999 adults with one weekday of activity. Dynamic time warping and kernel k-means clustering partitioned 4 participant clusters representing temporal PA patterns. Multivariate regression models determined associations between clusters and health status indicators and obesity, type 2 diabetes, and metabolic syndrome. Cluster 1 with a temporal PA pattern of the lowest activity counts reaching 4.8e4 cph from 6:00-23:00 was associated with higher body mass index (BMI) (β = 2.5 ± 0.6 kg/m2, 95% CI: 1.0, 4.1), higher waist circumference (WC) (β = 6.4 ± 1.3 cm, 95% CI: 2.8, 10.0), and higher odds of obesity (OR: 2.4; 95% CI: 1.3, 4.4) compared with Cluster 3 with activity counts reaching 9.6e4-1.2e5 cph between 16:00-21:00. Cluster 1 was also associated with higher BMI (β = 1.5 ± 0.5 kg/m2, 95% CI: 0.1, 2.8) and WC (β = 3.6 ± 1.3 cm, 95% CI: 0.1, 7.0) compared to Cluster 4 with activity counts reaching 9.6e4 cph between 8:00-11:00. A Temporal PA pattern with the lowest PA counts had significantly higher mean BMI and WC compared to temporal PA patterns of higher activity counts performed early (8:00-11:00) or late (16:00-21:00) throughout the day. Temporal PA patterns appear to meaningfully link to health status.

Association of weight loss and weight loss maintenance following diabetes diagnosis by screening and incidence of cardiovascular disease and all-cause mortality: An observational analysis of the ADDITION-Europe trial

AIMS

Short-term weight loss may lead to remission of type 2 diabetes but the effect of maintained weight loss on cardiovascular disease (CVD) is unknown. We quantified the associations between changes in weight 5 years following a diagnosis of diabetes, and incident CVD events and mortality up to 10 years after diagnosis.

MATERIALS AND METHODS

Observational analysis of the ADDITION-Europe trial of 2730 adults with screen-detected type 2 diabetes from the UK, Denmark and the Netherlands. We defined weight change based on the maintenance at 5 years of weight loss achieved during the year after diabetes diagnosis, and as 5-year overall change in weight. Incident CVD events (n = 229) and all-cause mortality (n = 225) from 5 to 10 years follow-up were ascertained from medical records.

RESULTS

Gaining >2% weight during the year after diabetes diagnosis was associated with higher hazard of all-cause mortality versus maintaining weight [hazard ratio (95% confidence interval): 3.18 (1.30-7.82)]. Losing ≥5% weight 1 year after diagnosis was also associated with mortality, whether or not weight loss was maintained at 5 years: 2.47 (0.99-6.21) and 2.72 (1.17-6.30), respectively. Losing ≥10% weight over 5 years was associated with mortality among those with body mass index <30 kg/m² [4.62 (1.87-11.42)]. Associations with CVD incidence were inconclusive.

CONCLUSIONS

Both weight loss and weight gain after screen-detected diabetes diagnosis were associated with higher mortality, but not CVD events, particularly among participants without obesity. The clinical implications of weight loss following a diagnosis of diabetes probably depend on its magnitude and timing, and may differ by body mass index status. Personalization of weight loss advice and support may be warranted.

Temporal Dietary Patterns Are Associated with Obesity in US Adults

BACKGROUND

The integration of time with dietary patterns throughout a day, or temporal dietary patterns (TDPs), have been linked with dietary quality but relations to health are unknown.

OBJECTIVE

The association between TDPs and selected health status indicators and obesity, type 2 diabetes (T2D), and metabolic syndrome (MetS) was determined.

METHODS

The first-day 24-h dietary recall from 1627 nonpregnant US adult participants aged 20-65 y from the NHANES 2003-2006 was used to determine timing, amount of energy intake, and sequence of eating occasions (EOs). Modified dynamic time warping (MDTW) and kernel k-means algorithm clustered participants into 4 groups representing distinct TDPs. Multivariate regression models determined associations between TDPs and health status, controlling for potential confounders, and adjusting for the survey design and multiple comparisons (P <0.05/6).

RESULTS

A cluster representing a TDP with evenly spaced, energy balanced EOs reaching ≤1200 kcal between 06:00 to 10:00, 12:00 to 15:00, and 18:00 to 22:00, had statistically significant and clinically meaningful lower mean BMI (P <0.0001), waist circumference (WC) (P <0.0001), and 75% lower odds of obesity compared with 3 other clusters representing patterns with much higher peaks of energy: 1000-2400 kcal between 15:00 and 18:00 (OR: 5.3; 95% CI: 2.8, 10.1), 800-2400 kcal between 11:00 and 15:00 (OR: 4.4; 95% CI: 2.5, 7.9), and 1000-2600 kcal between 18:00 and 23:00 (OR: 6.7; 95% CI: 3.9, 11.6).

CONCLUSIONS

Individuals with a TDP characterized by evenly spaced, energy balanced EOs had significantly lower mean BMI, WC, and odds of obesity compared with the other patterns with higher energy intake peaks at different times throughout the day, providing evidence that incorporating time with other aspects of a dietary pattern may be important to health status.

The Impact of BMI Categories on Metabolic Abnormality Development in Chinese Adults Who are Metabolically Healthy: A 7-Year Prospective Study

PURPOSE

To determine what metabolic abnormalities develop frequently among metabolically healthy adults over time according to different baseline body mass index (BMI) categories.

PATIENTS AND METHODS

A prospective cohort study was performed on 10,805 adults, who were metabolically healthy at the time of the 2008 survey. Participants were divided into four groups: metabolically healthy obese (MHO), metabolically healthy overweight (MHOW), metabolically healthy normal-weight (MHN), and metabolically healthy underweight (MHU). Modified Poisson regression models were used to evaluate the relationship of BMI with the development of metabolic abnormalities. Association rule mining was used to identify the most frequent abnormalities that developed over time.

RESULTS

Compared with the MHN group, the adjusted relative risks of the MHO group were 1.57 (95% CI: 1.09-2.27) and 2.08 (95% CI: 1.59-2.73) for developing elevated fasting glucose and elevated blood pressure, respectively, after adjusting for lifestyle behaviours and dietary factors. At the end of follow-up, 33 (19.1%) MHO subjects and 342 (16.6%) MHOW subjects had elevated blood pressure as the predominant metabolic syndrome component, whereas 236 (9.0%) MHU subjects had elevated plasma glucose. The results were similar after stratification by sex.

CONCLUSION

MHO and MHOW subjects developed elevated blood pressure most frequently, and MHU subjects developed elevated blood glucose most commonly, regardless of sex.

Orally Administered Semaglutide Versus GLP-1 RAs in Patients with Type 2 Diabetes Previously Receiving 1-2 Oral Antidiabetics: Systematic Review and Network Meta-Analysis

INTRODUCTION

Orally administered semaglutide is the first glucagon-like peptide 1 receptor agonist (GLP-1 RA) for oral administration. As head-to-head trials assessing orally administered semaglutide as an add-on to 1-2 oral antidiabetic drugs (OADs) vs other GLP-1 RAs are limited, a network meta-analysis (NMA) was performed to assess the relative efficacy and safety of orally administered semaglutide 14 mg once-daily (QD) vs injectable GLP-1 RAs in patients with type 2 diabetes inadequately controlled on 1-2 OADs.

METHODS

A systematic literature review was conducted to identify randomised controlled trials of GLP-1 RAs in patients inadequately controlled on 1-2 OADs. Data at 26 ± 4 weeks were extracted for efficacy and safety outcomes feasible for the NMA: change from baseline in glycated haemoglobin (HbA1c), weight, HbA1c target levels (< 7.0% and ≤ 6.5%), blood pressure, and any gastrointestinal adverse events specified in system organ class. Data were synthesised using NMA and a Bayesian framework.

RESULTS

In total, 27 studies were included in the analyses. Orally administered semaglutide 14 mg QD was associated with significantly greater reductions in HbA1c vs most comparators, and numerically greater reductions vs semaglutide 0.5 mg once-weekly (QW), dulaglutide 1.5 mg QW and liraglutide 1.8 mg QD. HbA1c reductions with semaglutide 1 mg QW were numerically greater than those with orally administered semaglutide 14 mg QD. Reductions in body weight for orally administered semaglutide 14 mg QD were significantly greater than all comparators except semaglutide QW (both doses). Orally administered semaglutide QD 14 mg was associated with statistically similar odds of experiencing gastrointestinal adverse events vs injectable GLP-1 RAs.

CONCLUSION

Orally administered semaglutide 14 mg QD as an add-on to 1-2 OADs is one of the most efficacious GLP-1 RAs for reducing HbA1c and body weight at 26 ± 4 weeks. Orally administered semaglutide 14 mg QD is well tolerated, with a safety profile in line with the GLP-1 RA class.

FUNDING

Novo Nordisk.

Moderate weight change following diabetes diagnosis and 10 year incidence of cardiovascular disease and mortality

AIMS/HYPOTHESIS

Adults with type 2 diabetes are at high risk of developing cardiovascular disease (CVD). Evidence of the impact of weight loss on incidence of CVD events among adults with diabetes is sparse and conflicting. We assessed weight change in the year following diabetes diagnosis and estimated associations with 10 year incidence of CVD events and all-cause mortality.

METHODS

In a cohort analysis among 725 adults with screen-detected diabetes enrolled in the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION)-Cambridge trial, we estimated HRs for weight change in the year following diabetes diagnosis and 10 year incidence of CVD (n = 99) and all-cause mortality (n = 95) using Cox proportional hazards regression. We used linear regression to estimate associations between weight loss and CVD risk factors. Models were adjusted for age, sex, baseline BMI, smoking, occupational socioeconomic status, cardio-protective medication use and treatment group.

RESULTS

Loss of ≥5% body weight in the year following diabetes diagnosis was associated with improvements in HbA_1c and blood lipids and a lower hazard of CVD at 10 years compared with maintaining weight (HR 0.52 [95% CI 0.32, 0.86]). The associations between weight gain vs weight maintenance and CVD (HR 0.41 [95% CI 0.15, 1.11]) and mortality (HR 1.63 [95% CI 0.83, 3.19]) were less clear.

CONCLUSIONS/INTERPRETATION

Among adults with screen-detected diabetes, loss of ≥5% body weight during the year after diagnosis was associated with a lower hazard of CVD events compared with maintaining weight. These results support the hypothesis that moderate weight loss may yield substantial long-term CVD reduction, and may be an achievable target outside of specialist-led behavioural treatment programmes.

The Effect of Canola Oil on Body Weight and Composition: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials

A number of clinical trials have examined the effect of canola oil (CO) on body composition in recent years; however, the results have been inconsistent. The present investigation aims to examine the effect of CO on body weight (BW) and body composition using a systematic review and meta-analysis of controlled clinical trials. Online databases including PubMed, Scopus, and Google Scholar were searched up to February, 2018 for randomized controlled clinical trials that examined the effect of CO on anthropometric measures and body composition indexes in adults. The Cochrane Collaboration's tool was used to assess the risk of bias in individual studies. A random-effects model was used to evaluate the effect of CO consumption on several outcomes: BW, body mass index, waist circumference, hip circumference, waist-to-hip ratio, android-to-gynoid ratio, and body lean and fat mass. In total, 25 studies were included in the systematic review. The meta-analysis revealed that CO consumption reduces BW [weighted mean difference (WMD) = -0.30 kg; 95% CI: -0.52, -0.08 kg, P = 0.007; n = 23 effect sizes], particularly in participants with type 2 diabetes (WMD = -0.63 kg; 95% CI: -1.09, -0.17 kg, P = 0.007), in studies with a parallel design (WMD = -0.49 kg; 95% CI: -0.85, -0.14 kg, P = 0.006), in nonfeeding trials (WMD = -0.32 kg; 95% CI: -0.55, -0.09 kg, P = 0.006), and when compared with saturated fat (WMD = -0.40 kg; 95% CI: -0.74, -0.06 kg, P = 0.019). CO consumption did not significantly affect any other anthropometric measures or body fat markers (P > 0.05). Although CO consumption results in a modest decrease in BW, no significant effect was observed on other adiposity indexes. Further well-constructed clinical trials that target BW and body composition as their primary outcomes are needed.

Phytonutrient and anti-diabetic functional properties of flavonoid-rich ethanol extract from Angelica Keiskei leaves

An extraction method was optimized to get a flavonoid-rich ethanol extract from Angelica keiskei leaves (FREE-AK). Trace elements and total flavonoid content of FREE-AK were identified, and the hypoglycemic and hypolipidemic effects of FREE-AK were studied in streptozotocin-induced diabetic mice. For FREE-AK extraction the optimal conditions were 65% ethanol, 45 °C and 15 min, resulting in a total flavonoid content up to 10.18% and K, Mg, Na, and Ca, content of about 36.59, 1.52, 14.51 and 7.486 mg/g, respectively. FREE-AK uptake could cause a marked decrease of fasting blood glucose and a significant improvement on glucose tolerance in diabetic mice. In addition, FREE-AK treatment with a dose of 800 mg/kg b.w. resulted in a reduction in the total triglyceride level (TC) in serum. Results demonstrated the effectiveness of FREE-AK for hypoglycemia and hypolipidemia in streptozotocin-induced mice and FREE-AK may be a potential dietary treatment for type 2 diabetes.

Cost Effectiveness of Exenatide Once Weekly Versus Insulin Glargine and Liraglutide for the Treatment of Type 2 Diabetes Mellitus in Greece

OBJECTIVE

The objective of this study was to evaluate the long-term cost effectiveness of exenatide once weekly (ExQW) versus insulin glargine (IG) or liraglutide 1.2 mg (Lira1.2mg) for the treatment of adult patients with type 2 diabetes mellitus (T2DM) not adequately controlled on oral antidiabetic drug (OAD) therapy in Greece.

METHODS

The published and validated Cardiff Diabetes Model was used to project clinical and economic outcomes over a patient's lifetime. Clinical data were retrieved from a head-to-head clinical trial (DURATION 3) and a published network meta-analysis comparing ExQW with IG or Lira1.2mg, respectively. Following a Greek third-party payer perspective, direct medical costs related to drug acquisition, consumables, developed micro- and macrovascular complications, maintenance treatment, as well as treatment-related adverse events were considered. Cost and utility data were extracted from literature and publicly available official sources and assigned to model parameters to calculate total quality-adjusted life-years (QALYs) and total costs as well as incremental cost-effectiveness ratios (ICERs). Sensitivity analyses explored the impact of changes in input data.

RESULTS

Over a patient's lifetime, ExQW was associated with 0.458 or 0.039 incremental QALYs compared with IG or Lira1.2mg, respectively, at additional costs of €2061 or €110, respectively. The ICER for ExQW was €4499/QALY compared with IG and €2827/QALY compared with Lira1.2mg. Results were robust across various one-way and scenario analyses. At the defined willingness-to-pay threshold of €36,000/QALY, probabilistic sensitivity analysis showed that ExQW had a 100 or 88.2% probability of being cost effective relative to IG or Lira1.2mg, respectively.

CONCLUSIONS

ExQW was estimated to be cost effective relative to IG or Lira1.2mg for the treatment of T2DM in adults not adequately controlled on OAD therapy in Greece.

When metformin is not enough: Pros and cons of SGLT2 and DPP-4 inhibitors as a second line therapy

The newer oral therapies for type 2 diabetes mellitus, dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors, have advantages over older agents. Dipeptidyl peptidase-4 inhibitors are weight neutral and have few adverse effects. Sodium glucose cotransporter 2 inhibitors have additional benefits: weight loss, blood pressure reduction, cardiovascular risk reduction, and renoprotective effects. Sodium glucose cotransporter 2 inhibitors have increased risk of urogenital infections and possible risk of "euglycaemic" diabetic ketoacidosis. It is important to balance the benefits over the older-oral therapies as these agents are more expensive; yet some analyses suggest that they are within the limits of what is considered cost-effective in health care. We discuss the relative merits and drawbacks of these 2 classes and consider their roles in the treatment of type 2 diabetes mellitus. We suggest a number of patient profiles where early use of these agents could be used. We favour the use of SGLT2 inhibitors over DPP-4 inhibitors as add on therapy to metformin when glycaemic targets have not been achieved given their similar glycaemic efficacy and the additional benefits of SGLT2 inhibitors. We particularly favour SGLT2 inhibitors in those where additional weight loss and blood pressure reductions are desired, and in patients with heart failure or cardiovascular disease. Care should be taken to warn patients about genital fungal infections and to avoid use in people with risk factors for SGLT2 associated ketoacidosis. We favour DPP-4 inhibitors in those where side effects of other agents are of concern, the frail elderly population, and those with renal disease precluding SGTL2 inhibitor use.

Changes in Body Mass Related to the Initiation of Disease-Modifying Therapies in Rheumatoid Arthritis

OBJECTIVE

Unintentional weight loss is important and can be predictive of long-term outcomes in patients with rheumatoid arthritis (RA). This study was undertaken to assess how primary therapies for RA may influence changes in body mass index (BMI) in RA patients from a large administrative database.

METHODS

Unique dispensing episodes of methotrexate, prednisone, leflunomide, and tumor necrosis factor inhibitors (TNFi) administered to RA patients were identified from the US Department of Veterans Affairs pharmacy databases. Values for C-reactive protein (CRP) level and BMI closest to the time point within 30 days of the treatment course start date and at follow-up time points were linked. Missing laboratory values were imputed. Weight loss was defined as a decrease in BMI of >1 kg/m(2) . Regression models were used to evaluate changes in BMI during each drug treatment as compared to treatment with methotrexate. To assess the impact of confounding by indication, propensity scores for use of each drug were incorporated in analyses using matched-weighting techniques.

RESULTS

In total, 52,662 treatment courses in 32,859 RA patients were identified. At 6 months from the date of prescription fill, weight gain was seen among patients taking methotrexate, those taking prednisone, and those taking TNFi. On average, compared to methotrexate-treated patients, prednisone-treated patients had significantly more weight gain, while leflunomide-treated patients demonstrated weight loss. In multivariable models, more weight loss (β = -0.41 kg/m(2) , 95% confidence interval [95% CI] -0.46, -0.36; P < 0.001) and a greater risk of weight loss (odds ratio 1.73, 95% CI 1.55, 1.79; P < 0.001) were evident among those receiving leflunomide compared to those receiving methotrexate. Treatment with prednisone was associated with greater weight gain (β = 0.072 kg/m(2) , 95% CI 0.042, 0.10; P < 0.001). These associations persisted in analyses adjusted for propensity scores and in sensitivity analyses.

CONCLUSION

Leflunomide is associated with significantly more, but modest, weight loss, while prednisone is associated with greater weight gain compared to other therapies for RA.

Weight change patterns and healthcare costs in patients with newly-diagnosed type-2 diabetes in Sweden

AIMS

To describe weight-change pathways in patients with type 2 diabetes (T2D) and associated healthcare costs using repeated BMI measurements and healthcare utilization data.

METHODS

Patients with newly-diagnosed T2D with body mass index (BMI, kg/m²) at diagnosis and subsequent measures at year 1-3 were identified. Based on three-year BMI change, patients were assigned to one of 27 BMI change pathways defined by annual BMI change: BMI↗ (≥1 BMI unit increase), BMI→ (<1 BMI unit change), and BMI↘ (≥1 BMI unit decrease). Mean annual and three-year cumulative healthcare costs were estimated for each pathway by combining Swedish unit costs with resource use from primary care and national patient registers.

RESULTS

Cohort consisted of 15,819 patients; 44% women, mean age of 61 years, HbA1c of 6.7% (50mmol/mol), BMI of 30.6kg/m². Most common BMI pathways (mean costs): BMI→→→ (€5,311), BMI↘→→ (€5,461), and BMI→→↘ (€6,281). General trends: BMI→→→ linked to lowest, BMI↗→↗ linked to highest costs.

CONCLUSION

In patients with newly-diagnosed T2D, weight stability was the most common BMI change pattern over 3 years and associated with lowest healthcare costs. Relationship between weight change and healthcare costs appears complex warranting further investigation.

Novel oral glucose-lowering drugs are associated with lower risk of all-cause mortality, cardiovascular events and severe hypoglycaemia compared with insulin in patients with type 2 diabetes

AIMS

To investigate the association of novel oral glucose-lowering drugs (GLDs), compared with that of insulin, with risk of all-cause mortality, cardiovascular disease (CVD) and severe hypoglycaemia.

METHODS

During 2013 to 2014 all patients with type 2 diabetes in Sweden identified as new users of novel oral GLDs, either dipeptidyl peptidase-4 (DPP-4) inhibitors or sodium-glucose cotransporter-2 (SGLT2) inhibitors (only dapagliflozin available in Sweden during the study period), with those initiating insulin as a comparison group, in the Prescribed Drug Register were included and followed in the Patient and Cause of Death Registers. The novel GLD group and insulin group were matched 1:1 using propensity score. Cox regression models were used to estimate risks.

RESULTS

Of 37 603 patients, 21 758 were matched 1:1 to novel GLD vs insulin groups, with median follow-up times of 1.51 years (16 304 patient-years) and 1.53 years (16 306 patient-years), respectively. Treatment with novel GLDs was associated with a 44% (hazard ratio [HR] 0.56 [95% confidence interval {CI} 0.49-0.64]), 15% (HR 0.85 [95% CI 0.73-0.99]) and 74% (0.26 [95% CI 0.12-0.57]) lower risk of all-cause mortality, CVD and hypoglycaemia, respectively, compared with insulin treatment. In separate analyses for the two novel GLDs, dapagliflozin was associated with lower risks of all-cause mortality and CVD (56% [HR 0.44, 95% CI 0.28-0.70] and 49% [HR 0.51, 95% CI 0.30-0.86], respectively), while DPP-4 inhibitor treatment was associated with lower risk of all-cause mortality (41% [HR 0.59, 95% CI 0.51-0.67]), but not with CVD (HR 0.87, 95% CI 0.75-1.01).

CONCLUSIONS

Novel oral GLD treatment was associated with lower risk of all-cause mortality, CVD and severe hypoglycaemia compared with insulin treatment. Dapagliflozin was associated with a lower risk of both all-cause mortality and CVD, whereas DPP-4 inhibitor treatment was only associated with lower risk of all-cause mortality.

Increased healthcare utilization costs following initiation of insulin treatment in type 2 diabetes: A long-term follow-up in clinical practice

AIMS

To compare long-term changes in healthcare utilization and costs for type 2 diabetes patients before and after insulin initiation, as well as healthcare costs after insulin versus non-insulin anti-diabetic (NIAD) initiation.

METHODS

Patients newly initiated on insulin (n=2823) were identified in primary health care records from 84 Swedish primary care centers, between 1999 to 2009. First, healthcare costs per patient were evaluated for primary care, hospitalizations and secondary outpatient care, before and up to seven years after insulin initiation. Second, patients prescribed insulin in second line were matched to patients prescribed NIAD in second line, and the healthcare costs of the matched groups were compared.

RESULTS

The total mean annual healthcare cost increased from €1656 per patient 2 years before insulin initiation to €3814 seven years after insulin initiation. The total cumulative mean healthcare cost per patient at year 5 after second-line treatment was €13,823 in the insulin group compared to €9989 in the NIAD group.

CONCLUSIONS

Initiation of insulin in type 2 diabetes patients was followed by increased healthcare costs. The increases in costs were larger than those seen in a matched patient population initiated on NIAD treatment in second-line.

Risk of mortality and recurrent cardiovascular events in patients with acute coronary syndromes on high intensity statin treatment

Several randomized controlled trials have shown a benefit of high-dose intensive statin treatment in reducing risk of death and second cardiovascular disease (CVD) events in patients previously diagnosed with an acute coronary syndrome (ACS). Non-randomized studies in clinical settings support these findings, but large, long-term, observational studies addressing CVD and non-CVD endpoints are lacking. In this retrospective longitudinal study, we followed ACS patients in Sweden during 2001–2012 using national health registry and medical record data. A total of 49,857 patients were identified, of whom 10,092 (20.2%) received high dose statins and 21,174 (42.7%) received no statins. Royston-Parmar parametric time-to-event models were implemented to model hazard for second CVD events and death, stratified by gender and diabetes diagnosis. We found that risk of a second CVD event developed similarly in both treatment groups, but was much higher in the no statin group. Risk of CVD-related death remained relatively constant for the high-statin group, while it increased over time for the no-statin group. Interestingly, males had higher mortality rates in the no-statin group, but not in the high-statin group. All-cause mortality and non-CVD-related death followed similar trends to those observed for CVD-related death. This work provides additional real-world evidence for effect of statins in CVD-related mortality. The hazard functions presented here can provide a basis for future survival modeling and health economic evaluation.

•

10,092 ACS patients on high dose and 21,174 on no statins were followed 2001–12.

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Royston-Parmar models were implemented to model hazard for new CVD events and death.

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Risk of a new event developed similarly, but was much higher for those not on statins.

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Risk of death increased over time for the no-statin, but not the high statin, group.

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High statin treatment reduced gender effects on risk of mortality and new events.

Second line initiation of insulin compared with DPP-4 inhibitors after metformin monotherapy is associated with increased risk of all-cause mortality, cardiovascular events, and severe hypoglycemia

AIMS

The objective of this nationwide study was to compare the risk of all-cause mortality, fatal and nonfatal cardiovascular disease (CVD), and severe hypoglycemia in patients with type 2 diabetes (T2D) on metformin monotherapy treatment starting second-line treatment with either insulin or dipeptidyl peptidase-4 inhibitor (DPP-4i).

METHODS

All patients with T2D in Sweden who initiated second-line treatment with insulin or DPP-4i after metformin monotherapy during 2007-2014 identified in the Swedish Prescribed Drug Register were followed for outcome in the Cause of Death and National Patient Registers. Insulin and DPP-4i patients were matched 1:1 using propensity-score matching. Comparisons between groups were performed using unadjusted Cox regression models. Additionally, multivariate adjusted survival models were used to test the results using the full population without matching.

RESULTS

Of 27,767 mono-metformin-treated patients, 55.7% started insulin and 44.3% a DPP-4i, and after matching both groups had 9278 patients each. Median follow-up (patients years) times were 3.84 (37,578) and 3.93 (37,983) for insulin and DPP-4i-groups, respectively. Insulin compared with DPP-4i was associated with higher risk of subsequent all-cause mortality, fatal and nonfatal CVD, and severe hypoglycemia; adjusted HR (95% CI): 1.69 (1.45-1.96); 1.39 (1.21-1.61); and 4.35 (2.26-8.35), respectively. When performing multivariate adjusted analyses on the full population similar results were found.

CONCLUSIONS

Initiation of insulin, compared with DPP-4i treatment, was associated with an increased risk of subsequent all-cause mortality, fatal and nonfatal CVD, and severe hypoglycemia. Results from randomized trials will be important to elucidate causal relationships.

Weight change after initiation of oral hypoglycemic monotherapy for diabetes predicts 5-year mortality: An observational study

PURPOSE

To investigate whether weight change in the first year after initiating an oral hypoglycemic agent (OHA) for type 2 diabetes treatment is associated with mortality in a national cohort.

PROCEDURES

We prospectively followed Veterans Health Administration patients with type 2 diabetes initiating treatment with an OHA and not receiving any other diabetes pharmacotherapy for at least one year. Information on OHAs, weight, co-morbidities, other medications, demographics, and laboratory measurements was obtained from electronic medical records. Logistic regression was used to estimate 5-year mortality odds by weight change during the first year after OHA treatment initiation.

FINDINGS

Patients (mean age 65years, 97% male, mean BMI 32.3kg/m2) initiating OHA monotherapy between 2003 and 2008 totaled 145,198 (metformin n=89,111, glipizide n=27,100, glyburide n=25,226, rosiglitazone n=3,761). Most patients (65%) maintained a stable weight (change ⩽5% from baseline) during the first year after OHA initiation. Those losing >5% of baseline weight had a significantly higher odds of death over the subsequent 5-years ranging from 1.64 to 2.13 depending on OHA type. In the metformin group, weight gain >5% of baseline was also associated with higher odds of 5-year mortality. The same results were obtained after conducting three sensitivity analyses that excluded patients for the following reasons: weight loss in the one year prior to OHA initiation, weight change >100lbs, or weight change >50lbs.

CONCLUSIONS

Weight loss was associated with higher odds of 5-year mortality among patients initiating an OHA, as was weight gain for metformin only.

Cost-Effectiveness of Dapagliflozin as Add-On to Metformin for the Treatment of Type 2 Diabetes Mellitus in Greece

BACKGROUND AND OBJECTIVE

Type 2 diabetes mellitus (T2DM) is a chronic progressive disease that has been spread worldwide over the past three decades and associated with increased morbidity and mortality resulting in considerable socioeconomic implications for national healthcare systems. Effective management of disease is highly needed ensuring patients receive the best possible care within the available budget. The objective of this study was to evaluate the long-term cost-effectiveness of dapagliflozin, a sodium-glucose co-transporter-2 (SGLT-2) inhibitor, compared with a sulfonylurea (SU) or a dipeptidyl-peptidase-4 inhibitor (DPP-4i), when added to metformin, in T2DM patients inadequately controlled on metformin alone in Greece.

METHODS

The published and validated Cardiff diabetes model, a lifetime micro-simulation model, was adapted to a Greek healthcare setting to determine the incidence of micro- and macro-vascular complications and diabetes-specific and all-cause mortality. Clinical, cost, and utility data were retrieved from literature and assigned to model parameters to calculate total quality-adjusted life-years (QALYs) and total costs as well as incremental cost-effectiveness ratios (ICERs). The analysis was conducted from the perspective of a third-party payer in Greece. Uncertainty surrounding important model parameters was explored with univariate and probabilistic sensitivity analyses (PSA).

RESULTS

Over a patient's lifetime, dapagliflozin was associated with 0.48 and 0.04 incremental QALYs compared with SU and DPP-4i, respectively, at additional costs of €5142 and €756, respectively. The corresponding ICERs were €10,623 and €17,695 per QALY gained versus the treatment with SU and DPP-4i, respectively. Results were robust across various univariate and scenario analyses. At the defined willingness-to-pay threshold of €34,000 per QALY gained, PSA estimated that treatment with dapagliflozin had a 100 % and 79.7 % probability of being cost-effective relative to the SU and DPP-4i treatments.

CONCLUSIONS

Dapagliflozin in combination with metformin was shown to be a cost-effective treatment alternative for patients with T2DM whose metformin regimen does not provide sufficient glycemic control in a Greek healthcare setting.

Cost-Effectiveness of Saxagliptin versus Acarbose as Second-Line Therapy in Type 2 Diabetes in China

Objective

This study assessed the long-term cost-effectiveness of saxagliptin+metformin (SAXA+MET) versus acarbose+metformin (ACAR+MET) in Chinese patients with type 2 diabetes mellitus (T2DM) inadequately controlled on MET alone.

Methods

Systematic literature reviews were performed to identify studies directly comparing SAXA+MET versus ACAR+MET, and to obtain diabetes-related events costs which were modified by hospital surveys. A Cardiff Diabetes Model was used to estimate the long-term economic and health treatment consequences in patients with T2DM. Costs (2014 Chinese yuan) were calculated from the payer’s perspective and estimated over a patient’s lifetime.

Results

SAXA+MET predicted lower incidences of most cardiovascular events, hypoglycemia events and fatal events, and decreased total costs compared with ACAR+MET. For an individual patient, the quality-adjusted life-years (QALYs) gained with SAXA+MET was 0.48 more than ACAR+MET at a cost saving of ¥18,736, which resulted in a cost saving of ¥38,640 per QALY gained for SAXA+MET versus ACAR+MET. Results were robust across various univariate and probabilistic sensitivity analyses.

Conclusion

SAXA+MET is a cost-effective treatment alternative compared with ACAR+MET for patients with T2DM in China, with a little QALYs gain and lower costs. SAXA is an effective, well-tolerated drug with a low incidence of adverse events and ease of administration; it is anticipated to be an effective second-line therapy for T2DM treatment.

Cost-Effectiveness of Dapagliflozin versus Acarbose as a Monotherapy in Type 2 Diabetes in China

OBJECTIVE

To estimate the long-term cost-effectiveness of dapagliflozin versus acarbose as monotherapy in treatment-naïve patients with type 2 diabetes mellitus (T2DM) in China.

METHODS

The Cardiff Diabetes Model, an economic model designed to evaluate the cost-effectiveness of comparator therapies in diabetes was used to simulate disease progression and estimate the long-term effect of treatments on patients. Systematic literature reviews, hospital surveys, meta-analysis and indirect treatment comparison were conducted to obtain model-required patient profiles, clinical data and costs. Health insurance costs (2015¥) were estimated over 40 years from a healthcare payer perspective. Univariate and probabilistic sensitivity analyses were performed.

RESULTS

The model predicted that dapagliflozin had lower incidences of cardiovascular events, hypoglycemia and mortality events, was associated with a mean incremental benefit of 0.25 quality-adjusted life-years (QALYs) and with a lower cost of ¥8,439 compared with acarbose. This resulted in a cost saving of ¥33,786 per QALY gained with dapagliflozin. Sensitivity analyses determined that the results are robust.

CONCLUSION

Dapagliflozin is dominant compared with acarbose as monotherapy for Chinese T2DM patients, with a little QALY gain and lower costs. Dapagliflozin offers a well-tolerated and cost-effective alternative medication for treatment-naive patients in China, and may have a direct impact in reducing the disease burden of T2DM.

Sulphonylurea compared to DPP-4 inhibitors in combination with metformin carries increased risk of severe hypoglycemia, cardiovascular events, and all-cause mortality

AIMS

There are safety concerns related to sulphonylurea treatment. The objective of this nationwide study was to compare the risk of cardiovascular disease (CVD), all-cause mortality and severe hypoglycemia in patients with type 2 diabetes (T2D) starting second-line treatment with either metformin+sulphonylurea or metformin+dipeptidyl peptidase-4 inhibitor (DPP-4i).

METHODS

All patients with T2D in Sweden who initiated second-line treatment with metformin+sulphonylurea or metformin+DPP-4i during 2006-2013 (n=40,736 and 12,024, respectively) were identified in this nationwide study. The Swedish Prescribed Drug Register and the Cause of Death and National Patient Registers were used, and Cox survival models adjusted for age, sex, fragility, prior CVD, and CVD-preventing drugs were applied to estimate risks of events. Propensity score adjustments and matching methods were used to test the results.

RESULTS

Of 52,760 patients; 77% started metformin+SU and 23% metformin+DPP-4i. Crude incidences for severe hypoglycemia, CVD, and all-cause mortality in the SU cohort were 2.0, 19.6, and 24.6 per 1000 patient-years and in the DPP-4i cohort were 0.8, 7.6, and 14.9 per 1000 patient-years, respectively. Sulphonylurea compared with DPP4i was associated with higher risk of subsequent severe hypoglycemia, fatal and nonfatal CVD, and all-cause mortality; adjusted HR (95% CI): 2.07 (1.11-3.86); 1.17 (1.01-1.37); and 1.25 (1.02-1.54), respectively. Results were confirmed by additional propensity-adjusted and matched analyses. Among the SU drugs, glibenclamide had the highest risks.

CONCLUSIONS

Metformin+SU treatment was associated with an increased risk of subsequent severe hypoglycemia, cardiovascular events, and all-cause mortality compared with metformin+DPP4i. Results from randomized trials will be important to elucidate causal relationships.

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria.

RESULTS

The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.

Healthcare utilization and costs following newly diagnosed type-2 diabetes in Sweden: A follow-up of 38,956 patients in a clinical practice setting

AIMS

To describe healthcare resource use patterns and estimate healthcare costs of newly diagnosed Type 2 diabetes mellitus (T2DM) patients in Sweden.

METHODS

Patients with a newly diagnosed T2DM between 1999 and 2009 were identified from 84 Swedish primary care centres. Healthcare resource use data, excluding pharmaceuticals, were extracted from electronic patient records and a national patient register, and reported as per patient mean number of primary care contacts, laboratory tests and hospitalizations. Per patient mean healthcare costs are reported as annual and cumulative costs.

RESULTS

During a median (maximum) of 4.6 (9.0) years follow-up; 38,956 patients (183,513 patient years) on average made 81 primary care contacts, was hospitalized 2.14 times, and took 31 laboratory tests. Mean per patient annual healthcare costs were €4128 (95% CI, 4054-4199) the first year after diagnosis, €2708 (95% CI, 2641-2776) the second year, and €3030 (95% CI, 2854-3204) in year 9 (2012 values). Mean per patient cumulative healthcare costs were €26,503 (95% CI, 26,025-26,970) at 9 years of follow-up. Hospitalizations accounted for the majority of healthcare costs.

CONCLUSIONS

Although newly diagnosed T2DM patients require a substantial amount of healthcare services in primary care, hospitalizations account for the majority of healthcare costs.

Validating prediction scales of type 2 diabetes mellitus in Spain: the SPREDIA-2 population-based prospective cohort study protocol

INTRODUCTION

The incidence of type 2 diabetes mellitus (T2DM) is increasing worldwide. When diagnosed, many patients already have organ damage or advance subclinical atherosclerosis. An early diagnosis could allow the implementation of lifestyle changes and treatment options aimed at delaying the progression of the disease and to avoid cardiovascular complications. Different scores for identifying undiagnosed diabetes have been reported, however, their performance in populations of southern Europe has not been sufficiently evaluated. The main objectives of our study are: to evaluate the screening performance and cut-off points of the main scores that identify the risk of undiagnosed T2DM and prediabetes in a Spanish population, and to develop and validate our own predictive models of undiagnosed T2DM (screening model), and future T2DM (prediction risk model) after 5-year follow-up. As a secondary objective, we will evaluate the atherosclerotic burden of the population with undiagnosed T2DM.

METHODS AND ANALYSIS

Population-based prospective cohort study with baseline screening, to evaluate the performance of the FINDRISC, DANISH, DESIR, ARIC and QDScore, against the gold standard tests: Fasting plasma glucose, oral glucose tolerance and/or HbA1c. The sample size will include 1352 participants between the ages of 45 and 74 years.

ANALYSIS

sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratio positive, likelihood ratio negative and receiver operating characteristic curves and area under curve. Binary logistic regression for the first 700 individuals (derivation) and last 652 (validation) will be performed. All analyses will be calculated with their 95% CI; statistical significance will be p<0.05.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of the Carlos III Hospital (Madrid). The score performance and predictive model will be presented in medical conferences, workshops, seminars and round table discussions. Furthermore, the predictive model will be published in a peer-reviewed medical journal to further increase the exposure of the scores.

Predictors of longterm changes in body mass index in rheumatoid arthritis

OBJECTIVE

Low body mass index (BMI) is a risk factor for poor longterm outcomes in rheumatoid arthritis (RA). The purpose of this study was to identify factors associated with longterm changes in BMI.

METHODS

Subjects with RA from the Veterans Affairs (VA) Rheumatoid Arthritis (VARA) Registry (n = 1474) were studied. Information on inflammatory markers, presence of erosions, and smoking status were extracted from the VARA database. BMI was extracted from VA electronic medical records within 14 days of each visit date. VA pharmacy records were queried to identify prescriptions for specific RA therapies within 1 month of the visit date. We used robust generalized estimating equations marginal regression models to calculate independent associations between clinical variables and BMI over time. Similar models determined predictors of change in weight and risk of weight loss over the subsequent study observation period.

RESULTS

Increasing age, active smoking, and the presence of erosions at baseline were associated with lower BMI. Weight decreased over time among older adults. Factors associated with greater reductions in BMI over time and a greater risk of weight loss were higher inflammatory markers, smoking, older age, higher BMI, and less subsequent improvement in inflammation. Methotrexate use was associated with a lower risk of weight loss. The use of prednisone or anti-tumor necrosis factor therapies was not associated with change in BMI or the risk of weight loss independent of other factors.

CONCLUSION

Greater age, greater inflammatory activity, and active smoking are associated with greater weight loss in RA over time.

Association of obesity and long-term mortality in patients with acute myocardial infarction with and without diabetes mellitus: results from the MONICA/KORA myocardial infarction registry

Background

Paradoxically, beneficial effects of overweight and obesity on survival have been found in patients after cardiovascular events such as acute myocardial infarction (AMI). This obesity paradox has not been analyzed in AMI patients with diabetes even though their cardiovascular morbidity and mortality is increased compared to their counterparts without diabetes. Therefore, the objective of this long-term study was to analyze the association between body mass index (BMI) and all-cause mortality in AMI patients with and without diabetes mellitus.

Methods

Included in the study were 1190 patients with and 2864 patients without diabetes, aged 28-74 years, recruited from a German population-based AMI registry. Patients were consecutively hospitalized between 1 January 2000 and 31 December 2008 with a first ever AMI and followed up until December 2011. Data collection comprised standardized interviews and chart reviews. To assess the association between BMI and long-term mortality from all causes, Cox proportional hazards models were calculated adjusted for risk factors, co-morbidities, clinical characteristics, in-hospital complications as well as medical and drug treatment.

Results

AMI patients of normal weight (BMI 18.5-24.9 kg/m²) had the highest long-term mortality rate both in patients with and without diabetes with 50 deaths per 1000 person years and 26 deaths per 1000 person years, respectively. After adjusting for a selection of covariates, a significant, protective effect of overweight and obesity on all-cause mortality was found in AMI patients without diabetes (overweight: hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.58-0.93; p=0.009; obesity: HR 0.64, 95% CI 0.47-0.87; p=0.004). In contrast, an obesity paradox was not found in AMI patients with diabetes. However, stratified analyses showed survival benefits in overweight AMI patients with diabetes who had been prescribed statins prior to AMI (HR 0.51, 95% CI 0.29-0.89, p=0.018) or four evidence-based medications at hospital-discharge (HR 0.52, 95% CI 0.34-0.80, p=0.003).

Conclusion

In contrast to AMI patients without diabetes, AMI patients with diabetes do not experience a survival benefit from an elevated BMI. To investigate the underlying reasons for these findings, further studies stratifying their samples by diabetes status are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-015-0189-0) contains supplementary material, which is available to authorized users.

Cost-effectiveness of dapagliflozin (Forxiga®) added to metformin compared with sulfonylurea added to metformin in type 2 diabetes in the Nordic countries

AIMS

The aim of this study was to assess the long-term cost-effectiveness of dapagliflozin (Forxiga(®)) added to metformin, compared with sulfonylurea (SU) added to metformin, in Nordic Type 2 diabetes mellitus (T2DM) patients inadequately controlled on metformin.

METHODS

Data from a 52-week clinical trial comparing dapagliflozin and SU in combination with metformin was used in a Cardiff simulation model to estimate long term diabetes-related complications in a cohort of T2DM patients. Costs and QALYs were calculated from a healthcare provider perspective and estimated over a patient's lifetime.

RESULTS

Compared with metformin+SU, the cost per QALY gained with dapagliflozin+metformin was €7944 in Denmark, €5424 in Finland, €4769 in Norway, and €6093 in Sweden. Metformin+dapagliflozin was associated with QALY gains ranging from 0.236 in Norway to 0.278 in Sweden and incremental cost ranging from €1125 in Norway to €1962 in Denmark. Results were robust across both one-way and probabilistic sensitivity analyses. Results were driven by weight changes associated with each treatment.

CONCLUSIONS

Results indicate that metformin+dapagliflozin is associated with gains in QALY compared with metformin+SU in Nordic T2DM patients inadequately controlled on metformin. Dapagliflozin treatment is a cost-effective treatment alternative for Type 2 diabetes in all four Nordic countries.

Body weight and risk of atrial fibrillation in 7,169 patients with newly diagnosed type 2 diabetes; an observational study

BACKGROUND

Obesity, type 2 diabetes and atrial fibrillation (AF) are closely associated, but the underlying mechanisms are not fully understood. We aimed to explore associations between body mass index (BMI) or weight change with risk of AF in patients with type 2 diabetes.

METHODS

A total of 7,169 participations with newly diagnosed type 2 diabetes were stratified according to baseline BMI, and after a second BMI measurement within 18 months, further grouped according to relative weight change as "weight gain" (>1 BMI unit), "stable weight" (+/- 1 BMI unit) and "weight loss" (<1 BMI unit). The mean follow-up period was 4.6 years, and the risk of AF was estimated using adjusted Cox regression models.

RESULTS

Average age at diabetes diagnosis was 60 years and the patients were slightly obese (mean BMI 30.2 kg/m(2)). During follow-up, 287 patients developed incident AF, and those with overweight or obesity at baseline had 1.9-fold and 2.9-fold higher risk of AF, respectively, than those with normal BMI. The 14% of the patients with subsequent weight gain had 1.5-fold risk of AF compared with those with stable weight or weight loss.

CONCLUSIONS

In patients with newly diagnosed type 2 diabetes, baseline overweight and obesity, as well as modest weight increase during the first 18 months after diagnosis, were associated with a substantially increased risk of incident AF. Patients with type 2 diabetes may benefit from efforts to prevent weight gain in order to reduce the risk of incident AF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01121315.

Cost-effectiveness of saxagliptin vs glimepiride as a second-line therapy added to metformin in Type 2 diabetes in China

OBJECTIVE

This study aims to estimate the long-term cost-effectiveness of saxagliptin + metformin (SAXA + MET) vs glimepiride + metformin (GLI + MET) in patients with Type 2 diabetes mellitus (T2DM) inadequately controlled with MET in China.

METHODS

The Cardiff Model was used to simulate disease progression and estimate the long-term effect of treatments on patients. Systematic literature reviews and hospital surveys were conducted to obtain patients profiles, clinical data, and costs. Health insurance costs (2014¥) were estimated over a 40-year period. One-way and probabilistic sensitivity analyses were performed.

RESULTS

SAXA + MET had lower predicted incidences of cardiovascular and hypoglycemia events and a decreased total cost compared with GLI + MET (¥241,072,807 vs ¥285,455,177). There were increased numbers of quality-adjusted life-years (QALYs; 1.01/patient) and life-years (Lys; 0.03/patient) gained with SAXA + MET compared with GLI + MET, and the incremental cost of SAXA + MET vs GLI + MET (-¥44,382) resulted in -¥43,883/QALY and -¥1,710,926/LY gained with SAXA + MET. Sensitivity analyses confirmed that the results were robust.

CONCLUSION

In patients with T2DM in China, SAXA + MET was more cost-effective and was well tolerated with fewer adverse effects (AEs) compared with GLI + MET. As a second-line therapy for T2DM, SAXA may address some of the unmet medical needs attributable to AEs in the treatment of T2DM.

Assessment of Unmet Clinical Need in Type 2 Diabetic Patients on Conventional Therapy in the UK

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is an increasing problem worldwide and a leading risk factor for cardiovascular disease. As beta cell function declines, the management of T2DM typically comprises of escalations in treatment from diet and exercise to oral therapies and eventually insulin. Treatment algorithms based on the attainment of blood glucose targets may not account for changes in other cardiovascular risk factors. The objective of this study is to describe unmet clinical need, defined as failure to reduce weight or meet targets for blood pressure, total cholesterol or glycated hemoglobin (HbA1c) levels.

METHODS

Anonymized UK patient data for those (1) initiating oral antidiabetic drug (OAD) monotherapy, (2) escalating to dual therapy, (3) escalating to triple therapy, and (4) escalating to insulin therapy over the study period (01/01/2005-31/12/2009) were obtained from The Health Improvement Network (THIN). Changes in risk factors were evaluated before and after therapy escalation, and the attainment of targets, assessed at the last recorded measurement, as follows: HbA1c <7.5%, systolic blood pressure (SBP) <140 mmHg, total cholesterol (TC) <5 mmol/L, and reduction in weight.

RESULTS

Prior to therapy escalation, mean HbA1c in each subgroup exceeded 7.5% and was higher respective to the number of OADs being used (monotherapy: 8.03%; double: 8.48%; triple: 8.71%). Insulin users displayed the highest HbA1c prior to treatment escalation (9.78%). Following escalation, a decline in HbA1c was observed in all subgroups. By contrast, mean SBP and TC levels decreased prior to the addition of a second and third oral therapy. Consistent improvements following treatment escalation were not observed across the other risk factors following therapy escalation. Overall, the proportion of subjects that attained all four targets ranged from 3% (monotherapy and insulin) to 6% (dual therapy).

CONCLUSION

The potential unmet clinical need among conventionally treated T2DM patients is significant, with respect to the control of blood glucose and other cardiovascular risk factors: SBP, TC, and weight. There clearly remains the need for new therapeutic approaches to alleviate the burden associated with T2DM.

High-protein-low-carbohydrate diet: deleterious metabolic and cardiovascular effects depend on age

High-protein-low-carbohydrate (HP-LC) diets have become widespread. Yet their deleterious consequences, especially on glucose metabolism and arteries, have already been underlined. Our previous study (2) has already shown glucose intolerance with major arterial dysfunction in very old mice subjected to an HP-LC diet. The hypothesis of this work was that this diet had an age-dependent deleterious metabolic and cardiovascular outcome. Two groups of mice, young and adult (3 and 6 mo old), were subjected for 12 wk to a standard or to an HP-LC diet. Glucose and lipid metabolism was studied. The cardiovascular system was explored from the functional stage with Doppler-echography to the molecular stage (arterial reactivity, mRNA, immunohistochemistry). Young mice did not exhibit any significant metabolic modification, whereas adult mice presented marked glucose intolerance associated with an increase in resistin and triglyceride levels. These metabolic disturbances were responsible for cardiovascular damages only in adult mice, with decreased aortic distensibility and left ventricle dysfunction. These seemed to be the consequence of arterial dysfunctions. Mesenteric arteries were the worst affected with a major oxidative stress, whereas aorta function seemed to be maintained with an appreciable role of cyclooxygenase-2 to preserve endothelial function. This study highlights for the first time the age-dependent deleterious effects of an HP-LC diet on metabolism, with glucose intolerance and lipid disorders and vascular (especially microvessels) and cardiac functions. This work shows that HP-LC lead to equivalent cardiovascular alterations, as observed in very old age, and underlines the danger of such diet.