Incidence of complications in young-onset diabetes: Comparing type 2 with type 1 (the young diab study)

Cohort prevalence of young-onset type 2 diabetes in South Asia: A systematic review

BACKGROUND & AIM

The prevalence of young onset (≤30 years) type 2 diabetes (T2D) is increasing in South Asians, reflecting rise in childhood obesity. This systematic review analyses current data on thecohort prevalence of young onset T2D in South Asians.

METHODS

PubMed, Scopus,Science Direct,and Ebscohost were searched for articles published between 1990 and 2024, anda manual search identified additional articles. This study included case series, cross-sectional, retrospective cohort, or case reports.

RESULTS

Out of 5073 studies, 26 eligible studies were found including three case reports. Seventeen studies were from India, five werefrom other South Asian countries (Pakistan, Bangladesh, Nepal, Maldives), and nine were on migrant South Asians residing in different countries (UK,USA,Qatar, Canada). The cohort prevalence of young onset T2D in South Asians ranged from 0.1 % to 28.3 % (India 0.4 to 26.8 %, other SA countries 0.1 to 28.3 %, and migrant South Asians 4.1 to 18.1 %).

CONCLUSION

The burden of T2D among native South Asian children and young adults is higher than among migrant South Asians. This contrasts with traditional perceptions that T2D primarily affects older individuals and the South Asian diaspora i.e., those who have migrated from South Asia.

Ahmedabad declaration: A framework to combat growing epidemic of young-onset type 2 diabetes in Asia

AIM

Rising prevalence of Type 2 Diabetes (T2D) among young Asians has emerged as a public health crisis that threatens the long-term health, economic stability, and productivity of nations across Asia (1). Early-onset T2D poses unique challenges, including higher rates of undiagnosed cases, more aggressive disease progression, an increased risk of chronic complications and higher mortality (2). Hyperglycemia during the reproductive age especially among the female population can potentially have transgenerational impact through epigenetic changes.

METHODS

A comprehensive search was conducted on PubMed with a combination of relevant keywords. A preliminary draft prepared after review of literature was electronically circulated among a panel of 64 experts from various parts of the region and representatives of the participating organizations - Diabetes India (www.diabetesindia.org.in) and the Diabetes Asia Study Group (DASG, www.da-sg.org).

RESULTS

This Ahmedabad Declaration outlines the scale of the problem, its root causes, and a comprehensive action plan for Asian populations. The objectives of this declaration include raising awareness, addressing systemic barriers, and advocating for evidence-based policies and interventions, limited to people with T2D. Through collaborative efforts, we aim to mitigate the growing burden of diabetes in young Asians and secure a healthier future.

Young-Onset Diabetes in Sri Lanka: Experience From the Developing World

Background: Young-onset diabetes (YOD) is characterised by unique diagnostic and management challenges more pronounced in resource-limited settings like Sri Lanka. Aims: We aimed to ascertain the prevalence, patterns and characteristics of YOD in Sri Lanka and describe the state of care. Methods: Retrospective review of baseline data of all patients enrolled in the prospective multicentre Database for Young-Onset Diabetes, Sri Lanka (DYOD-SL), was performed, from April 2021 to April 2023. Results: A total of 2531 patient data were included from 28 centres island-wide. Females were 57.6%. The median age was 20 years (interquartile range (IQR) 17, 23), and the age at diagnosis was 15 years (IQR 12, 18). Type 1 diabetes (T1D) was the commonest (57.6%), followed by Type 2 diabetes (T2D) at 34.3%. Younger age at disease onset (p < 0.001), lower BMI (p < 0.001), and diabetic ketoacidosis (DKA) at presentation (p < 0.001) favoured T1D. In the total cohort, the median HbA1c was 9.8% (IQR 7.8, 12.1) with younger patients having poorer control (p = 0.001). Prevalence of nephropathy was 8.1%, retinopathy was 6.6%, neuropathy was 4.1%, moderate-high-risk diabetic foot disease was 1.9%, and macrovascular complications were 0.5%. Hypertension and dyslipidaemia occurred in 2.7% and 14%, respectively. Among patients > 18 years, overweight and obese were 22.2% and 10.4%. Corresponding prevalence in the 5-18-year age group was 20% and 14.7%. Among the insulin users (76%) in the total cohort, the majority (64.7%) were on premixed-based insulin regimens delivered by syringes. Self-monitoring of blood glucose (BG) was reported in 71.3% of the total population. None were on continuous/flash glucose monitoring or insulin pumps. Conclusion: T1D was the commonest subtype of YOD in this hospital-based population. However, T2D was notably higher and is of significant concern. Overall, suboptimal glycaemic control and high rate of complications were noted along with substandard insulin regimens and BG monitoring.

Corneal nerve loss in adolescents with obesity and acanthosis nigricans

BACKGROUND/AIM

Obesity and related metabolic abnormalities in adults are associated with peripheral neuropathy. Acanthosis nigricans (AN) is associated with insulin resistance, fatty liver, hyperlipidemia and glucose intolerance, all of which are risk factors for neuropathy. The aim of this study was to investigate if obese adolescents with AN have evidence of small nerve fiber damage.

MATERIAL AND METHODS

Adolescents with obesity with and without AN underwent body composition analysis, assessment of vibration perception threshold (VPT), monofilament sensitivity and corneal confocal microscopy (CCM) to quantify corneal nerve fiber density (CNFD), branch density (CNBD), length (CNFL) and inferior whorl length (IWL).

RESULTS

Forty-six participants with obesity with (n = 31) and without (n = 15) AN aged 15(14-17) years were compared to 20 healthy controls aged 13(12-14) years. There was no difference in VPT, monofilament sensitivity and CCM measures between adolescents with obesity and controls. However, adolescents with AN had a significantly higher weight (P = 0.022), fat% (P = 0.029) and fat-muscle ratio (P = 0.012) with a lower CNFD (P = 0.045) compared to those with obesity without AN.

CONCLUSION

Adolescents with obesity and acanthosis nigricans have a higher fat mass and small nerve fibre loss, indicative of a sub-clinical neuropathy.

Rising tide: The global surge of type 2 diabetes in children and adolescents demands action now

Childhood-onset obesity has emerged as a major public healthcare challenge across the globe, fueled by an obesogenic environment and influenced by both genetic and epigenetic predispositions. This has led to an exponential rise in the incidence of type 2 diabetes mellitus in children and adolescents. The looming wave of diabetes-related complications in early adulthood is anticipated to strain the healthcare budgets in most countries. Unless there is a collective global effort to curb the devastation caused by the situation, the impact is poised to be pro-found. A multifaceted research effort, governmental legislation, and effective social action are crucial in attaining this goal. This article delves into the current epidemiological landscape, explores evidence concerning potential risks and consequences, delves into the pathobiology of childhood obesity, and discusses the latest evidence-based management strategies for diabesity.

Three-Year Follow-Up Study Investigating Changes in Retinal Vascular Morphology and the Relationship with Diabetic Retinopathy in Children with Type 1 Diabetes Mellitus

INTRODUCTION

This study aimed to investigate changes in retinal microvascular morphology and associated factors, and their relationship with diabetic retinopathy (DR) in children with type 1 diabetes mellitus (T1DM).

METHODS

Thirty-eight children enrolled in this 3-year follow-up study underwent complete ophthalmic examinations including fundus photography. Retinal vascular parameters were measured automatically and compared between baseline and follow-up. Multiple linear regression was used to investigate factors affecting changes in vascular parameters. Binary logistic regression was used to analyze the relationship between retinal microvascular morphology and DR.

RESULTS

The caliber of all retinal vessels (within 1-1.5 papillary diameter [PD] from the center of the optic disc, p = 0.030; 1.5-2 PD, p = 0.003), arterioles, and venules (1.5-2 PD, p = 0.001) was narrower in nearly all regions in the follow-up group compared with the baseline group. Vascular tortuosity increased in the central part of the retina and decreased in the periphery. The density (1-1.5 PD, p = 0.030) and fractal dimension (p = 0.037) of retinal vessels were increased at the end of the follow-up compared with baseline. Retinal vascular caliber was independently correlated with DR (odds ratio 0.793 [95% confidence interval 0.633-0.993]; p = 0.044).

CONCLUSION

Retinal microvascular morphology in children with T1DM varied with the disease course. Narrower retinal vessels may be an independent risk factor for DR. Results of this study emphasized the importance of regular follow-up of fundus vascular morphology for the detection of early DR in children with T1DM.

Deteriorated sleep quality and associate factors in patients with type 2 diabetes mellitus complicated with diabetic peripheral neuropathy

Objectives

To understand the sleep quality and its influencing factors in patients with type 2 diabetes mellitus (T2DM) who suffered diabetic peripheral neuropathy (DPN), and provide evidence for clinicians to carry out comprehensive intervention measures to improve the sleep quality of patients.

Methods

Patients who were admitted to the Endocrinology Department of Affiliated Hospital of Zunyi Medical University were recruited from May to December 2022, and the investigation were conducted by face-to-face interview. The questionnaires included PSQI questionnaire and influencing factors, such as lifestyle and health status.

Results

Among the 193 patients, 40.4% of the patients never took physical examination, 56.5% of the patients had duration of illness greater than 5 years, 61.7% of the patients had had an operation, 10.4% of the patients had bad dietary status, and 55.4% of the patients had physical pain. In addition, the PSQI general score was 8.34 ± 3.98, the occurrence rate of poor sleep quality (PSQI ≥ 8) was 54.4%, and the results showed that sleep quality of the physical pain group was worse than the no pain group. Moreover, the results of multivariate analysis revealed that the factors affecting sleep quality were lower frequency of exercise, bad dietary status, lower frequency of physical examination, longer duration of illness, and smoking, and the OR and 95% CI were [1.40, 1.04∼1.89], [3.42, 1.86∼6.29], [1.49, 1.01∼2.20], [1.78, 1.09∼2.92], [2.38, 1.17∼4.88], respectively.

Conclusion

Patients with DPN have higher risk of poor sleep quality. Moreover, there were many risk factors associated with poor sleep quality, clinicians and health policymakers should timely detect and effectively intervene in these factors to improve the sleep quality, which is important to enhance the quality of life of T2DM patients complicated with DPN.

The p66Shc Redox Protein and the Emerging Complications of Diabetes

Diabetes mellitus is a chronic metabolic disease, the prevalence of which is constantly increasing worldwide. It is often burdened by disabling comorbidities that reduce the quality and expectancy of life of the affected individuals. The traditional complications of diabetes are generally described as macrovascular complications (e.g., coronary heart disease, peripheral arterial disease, and stroke), and microvascular complications (e.g., diabetic kidney disease, retinopathy, and neuropathy). Recently, due to advances in diabetes management and the increased life expectancy of diabetic patients, a strong correlation between diabetes and other pathological conditions (such as liver diseases, cancer, neurodegenerative diseases, cognitive impairments, and sleep disorders) has emerged. Therefore, these comorbidities have been proposed as emerging complications of diabetes. P66Shc is a redox protein that plays a role in oxidative stress, apoptosis, glucose metabolism, and cellular aging. It can be regulated by various stressful stimuli typical of the diabetic milieu and is involved in various types of organ and tissue damage under diabetic conditions. Although its role in the pathogenesis of diabetes remains controversial, there is strong evidence regarding the involvement of p66Shc in the traditional complications of diabetes. In this review, we will summarize the evidence supporting the role of p66Shc in the pathogenesis of diabetes and its complications, focusing for the first time on the emerging complications of diabetes.

A Cross-Sectional Multicentre Study to Validate Insulin Sensitivity Index Cut-Offs for Detection of Metabolic Syndrome in Indian Adolescents with Type-1 Diabetes

Background

A previous study compared insulin sensitivity indices for the detection of double diabetes (DD) in Indian adolescents with type-1 diabetes (T1D) and derived a cut-off to predict future risk for the development of metabolic syndrome (MS) in adolescents with T1D. We conducted the current study with the aim to validate these cut-offs for detecting DD among Indian subjects with T1D from various geographical locations.

Methods

This multicentric cross-sectional study included 161 Indian adolescents with T1D. Demographic, anthropometric, clinical, and biochemical data were collected using standard protocols. Insulin sensitivity (IS) was calculated using various equations developed to determine insulin sensitivity in subjects with T1D. Metabolic syndrome was diagnosed using International Diabetes Federation (IDF) Consensus Definition 2017.

Results

We report 4.3% prevalence of MS in Indian adolescents with T1D with an additional 29.8% of study participants at risk of development of MS. Low High density lipoprotein (HDL) (23.6%) was the commonest abnormal component of the MS definition. Insulin sensitivity calculated by an equation derived by the SEARCH group was the most appropriate index to identify MS and metabolic risk in Indian adolescents with T1D. The proposed cut-off of 5.48 had high specificity, positive predictive value, and negative predictive value in identifying the risk of the development of DD.

Conclusions

Insulin sensitivity calculated by the equation proposed by the SEARCH group together with cut-offs derived in earlier study may be used effectively to identify risk of development of MS/DD in Indian adolescents with T1D from various geographical locations.

Cardiovascular outcomes in type 1 and type 2 diabetes

Diabetes is one of the most prevalent cardiometabolic disorders on the planet. Type 1 diabetes accounts for only a minority of all cases (recently estimated to be ~2% globally); however, since this is a disorder with an early onset, many people live with type 1 diabetes for a long time. CVD and premature death are the main long-term outcomes for both types of diabetes; however, the type of diabetes that carries the highest risk of these outcomes is a controversial topic and has not been widely studied. Because of the association between diabetes and CVD, the rise in type 2 diabetes prevalence over the past decades has huge effects on global health. The excess risk in people with diabetes compared with those without depends, to a large extent, on the presence of other factors, such as general cardiovascular risk factors (e.g. elevated LDL-cholesterol, hypertension and smoking) and also factors that are more specific to diabetes (e.g. HbA1c, and micro- and macroalbuminuria). Some contributory factors are modifiable, while others are not, such as age, sex and type of diabetes. Older people with type 2 diabetes who have risk factors that are under control can achieve levels of CVD risk that are similar to that of the general population, while younger individuals with type 1 diabetes are mostly unable to achieve similar levels of risk, probably because of long and cumulative exposure to raised blood glucose levels. Despite reports of declining rates of CVD among people with type 1 and type 2 diabetes, rising rates of both types of diabetes lead to a continuing rise in the number of people with cardiometabolic disorders worldwide, offsetting the progress made in many countries. Comparison between individuals with type 1 and type 2 diabetes with respect to risk of CVD is fraught with difficulties and highly dependent on other, concomitant factors, some of which are modifiable and others not. Nonetheless, as a whole, what matters most in determining the management of diabetes is absolute risk and lifetime risk. Life-long efforts to achieve glycaemic control, control of lipids and hypertension, and not smoking are key to prevention, with a healthy lifestyle and pharmacological therapy to be implemented as needed.

Youth versus adult-onset type 2 diabetic kidney disease: Insights into currently known structural differences and the potential underlying mechanisms

Type 2 diabetes (T2D) is a global health pandemic with significant humanitarian, economic, and societal implications, particularly for youth and young adults who are experiencing an exponential rise in incident disease. Youth-onset T2D has a more aggressive phenotype than adult-onset T2D, and this translates to important differences in rates of progression of diabetic kidney disease (DKD). We hypothesize that youth-onset DKD due to T2D may exhibit morphometric, metabolic, and molecular characteristics that are distinct from adult-onset T2D and develop secondary to inherent differences in renal energy expenditure and substrate metabolism, resulting in a central metabolic imbalance. Kidney structural changes that are evident at the onset of puberty also serve to exacerbate the organ’s baseline high rates of energy expenditure. Additionally, the physiologic state of insulin resistance seen during puberty increases the risk for kidney disease and is exacerbated by both concurrent diabetes and obesity. A metabolic mismatch in renal energetics may represent a novel target for pharmacologic intervention, both for prevention and treatment of DKD. Further investigation into the underlying molecular mechanisms resulting in DKD in youth-onset T2D using metabolomics and RNA sequencing of kidney tissue obtained at biopsy is necessary to expand our understanding of early DKD and potential targets for therapeutic intervention. Furthermore, large-scale clinical trials evaluating the duration of kidney protective effects of pharmacologic interventions that target a metabolic mismatch in kidney energy expenditure are needed to help mitigate the risk of DKD in youth-onset T2D.

Childhood diabetes mellitus and early-onset kidney diseases later in life: a nationwide population-based matched cohort study

BACKGROUND

The empirical evidence remains inconclusive for an association between diabetes mellitus (DM) in children and early-onset kidney disease later in life, and little is known about the effects of DM types (i.e., type 1 diabetes [T1DM] and type 2 diabetes [T2DM]) in childhood on type-specific kidney diseases. We aimed to evaluate the association of childhood DM with overall and type-specific early-onset kidney diseases later in life.

METHODS

The population-based matched cohort study included 9356 individuals with DM (T1DM: 8470, T2DM: 886) diagnosed in childhood (&lt; 18 years) who were born between 1977 and 2016, and 93,560 individuals without DM matched on sex and year of birth in Denmark. The main outcomes were overall and type-specific early-onset kidney diseases. The follow-up period of all included participants was from the date of DM diagnosis in the exposure group until the first diagnosis of kidney disease, emigration, or 31 December 2018, whichever came first.

RESULTS

During a median follow-up of 13 years, children with DM had a 154% increased risk of early-onset kidney diseases than children without DM (adjusted hazard ratios 2.54, 95% confidence intervals 2.38-2.72), and T1DM (2.48, 2.31-2.67) and T2DM (2.75, 2.28-3.31) showed similar results. Children with DM also had a higher risk of multiple specific kidney diseases including glomerular diseases, renal tubulo-interstitial diseases, renal failure, and urolithiasis. The risks of type-specific kidney diseases including glomerular diseases and renal failure tended to be higher for children with T2DM (glomerular diseases: 5.84, 3.69-9.24; renal failure: 14.77, 8.53-25.59) than those with T1DM (glomerular diseases: 3.14, 2.57-3.83; renal failure: 8.24, 6.66-10.20).

CONCLUSIONS

Children with DM had a higher increased risk of early-onset overall and specific kidney diseases later in life. Early prevention and treatment of both T1DM and T2DM in childhood may significantly reduce the risk of kidney diseases later in life.

Prevalence and risk of diabetic complications in young-onset versus late-onset type 2 diabetes mellitus

AIMS

To compare the prevalence and risk of diabetic complications between people with young-onset and late-onset type 2 diabetes mellitus (T2DM).

METHODS

In this observational study, 10,447 people with T2DM had at least one study of diabetic complications: retinopathy, neuropathy, chronic kidney disease (CKD), carotid artery plaque. We use odds ratios to compare complications between young-onset T2DM (YOD) and late-onset T2DM (LOD).

RESULTS

We compare 1,791 people with YOD (diagnosed < 40 years) and 8,656 with LOD (diagnosed ≥ 40 years). The YOD had a higher prevalence of these complications than the LOD (p < 0.011) after adjustment for confounding factors. Further adjustment for diabetes duration greatly attenuated the odds ratios however, neuropathy remained significantly more frequent in people with YOD (adjusted odds ratio: 1.39, 95% confidence interval: 1.13-1.71, p = 002). In cluster analysis on the 2,126 study participants who were diagnosed with T2DM within the previous two years, 47% of the YOD group were in the severe insulin-deficient diabetes cluster in comparison to 23% LOD; 28% and 44% respectively were in the mild age-related diabetes.

CONCLUSION

People with YOD had a higher prevalence of complications than those with LOD, but this was mostly attributed to a longer duration of diabetes. However, the prevalence of neuropathy remained significantly higher even after adjusting for factors including the duration of diabetes.

Levels and Correlates of Numeracy Skills in Lebanese Adults with Diabetes: A Cross-Sectional Study

Diabetes numeracy skills are required in the interpretation of food labels, insulin pump dosage, the interpretation of blood glucose meter data, and the determination of carbohydrate intake. This study assessed the levels and correlates of numeracy skills in Lebanese adults with diabetes to identify those most at risk of uncontrolled diabetes. In total, 299 adults with diabetes, mean age 47.4 ± 19.8 years, took the questionnaire. It consisted of self-developed items on sociodemographic and health-related factors, in addition to the Diabetes Numeracy Test-15 (DNT-15) and the Single Item Literacy Screener. Many participants (62%) scored < 10 on the DNT-15 indicating insufficient numeracy skills. DNT-15 scores were positively associated with literacy, exercise, healthy diet, perceived diabetes control, frequency of glycaemia measurement, ability to afford treatment, and ease of understanding information related to diabetes. Age, BMI, and complications were negatively correlated with DNT-15 score. Numeracy skills were higher in males, single individuals, and in people with type 1 diabetes, fewer complications, controlled HbA1c, higher income, higher education, a prior visit to a dietician, and ability to maintain personal care despite COVID-19. Interventions to strengthen numeracy skills would empower individuals with diabetes, lead to appropriate self-management behaviors, and prevent health complications in at-risk individuals.

Pathophysiology, phenotypes and management of type 2 diabetes mellitus in Indian and Chinese populations

Nearly half of all adults with type 2 diabetes mellitus (T2DM) live in India and China. These populations have an underlying predisposition to deficient insulin secretion, which has a key role in the pathogenesis of T2DM. Indian and Chinese people might be more susceptible to hepatic or skeletal muscle insulin resistance, respectively, than other populations, resulting in specific forms of insulin deficiency. Cluster-based phenotypic analyses demonstrate a higher frequency of severe insulin-deficient diabetes mellitus and younger ages at diagnosis, lower β-cell function, lower insulin resistance and lower BMI among Indian and Chinese people compared with European people. Individuals diagnosed earliest in life have the most aggressive course of disease and the highest risk of complications. These characteristics might contribute to distinctive responses to glucose-lowering medications. Incretin-based agents are particularly effective for lowering glucose levels in these populations; they enhance incretin-augmented insulin secretion and suppress glucagon secretion. Sodium-glucose cotransporter 2 inhibitors might also lower blood levels of glucose especially effectively among Asian people, while α-glucosidase inhibitors are better tolerated in east Asian populations versus other populations. Further research is needed to better characterize and address the pathophysiology and phenotypes of T2DM in Indian and Chinese populations, and to further develop individualized treatment strategies.

Association of retinopathy severity with cardiovascular and renal outcomes in patients with type 1 diabetes: a multi-state modeling analysis

This study aimed to assess the impact of diabetic retinopathy (DR) severity on the incidence of major adverse cardiac events (MACE) and end-stage renal disease (ESRD) in T1D patients. Patients diagnosed with T1D between 1999 and 2013 were identified from patient-level data of Taiwan’s National Health Insurance Research database. A total of 1135 patients were included and classified into mild DR (n = 454), severe DR (n = 227), or non-DR (n = 454) by using propensity score matching. Multi-state model analyses, an extension of competing risk models with adjustment for transition-specific covariates for prediction of subsequent MACE and ESRD, were performed. MACE and ESRD risks were significantly higher in the severe DR patients; a 2.97-fold (1.73, 5.07) and 12.29-fold (6.50, 23.23) increase in the MACE risk among the severe DR patients compared to the mild DR and DR-free patients, respectively; and, a 5.91-fold (3.50, 9.99) and 82.31-fold (29.07, 233.04) greater ESRD risk of severe DR patients than that of the mild DR and DR-free groups, respectively (p < 0.001). Severity of DR was significantly associated with the late diabetes-related vascular events (i.e., MACE, ESRD) among T1D patients.

Barriers and enablers to diabetic eye screening attendance: An interview study with young adults with type 1 diabetes

AIM

The aim of this study was to identify barriers and enablers of diabetic eye screening (DES) attendance amongst young adults with diabetes living in the United Kingdom.

METHODS

Semistructured qualitative interviews with adults aged 18-34 years with diabetes. Participants were purposively sampled to aim for representation across gender, geographical locations, diabetes type, years since diabetes diagnosis and patterns of attendance (i.e. regular attenders, occasional non-attenders, regular non-attenders). Data were collected and analysed using the Theoretical Domains Framework (TDF) to explore potential individual, sociocultural and environmental influences on attendance. Data were analysed using a combined deductive and inductive thematic analysis approach. Barriers/enablers were mapped to behaviour change techniques (BCTs) to identify potential strategies to increase attendance.

RESULTS

Key barriers to attendance reported by the sample of 29 study participants with type 1 diabetes, fell within the TDF domains: [Knowledge] (e.g. not understanding reasons for attending DES or treatments available if diabetic retinopathy is detected), [Social Influences] (e.g. lack of support following DES results), [Social role and Identity] (e.g. not knowing other people their age with diabetes, feeling 'isolated' and being reluctant to disclose their diabetes) and [Environmental Context and Resources] (e.g. lack of appointment flexibility and options for rescheduling). Enablers included: [Social Influences] (e.g. support of family/diabetes team), [Goals] (e.g. DES regarded as 'high priority'). Many of the reported barriers/enablers were consistent across groups. Potential BCTs to support attendance include Instructions on how to perform the behaviour; Information about health consequences; Social support (practical) and Social comparison.

CONCLUSIONS

Attendance to diabetic eye screening in young adults is influenced by a complex set of interacting factors. Identification of potentially modifiable target behaviours provides a basis for designing more effective, tailored interventions to help young adults regularly attend eye screening and prevent avoidable vision loss.

Clinical Profile of Long-Term Survivors and Nonsurvivors with Type 1 Diabetes in India

Objective: To compare the clinical profile of long-term survivors and nonsurvivors with type 1 diabetes (T1D) in India. Research Design and Methods: This is a retrospective study of 76 individuals with T1D who had survived for at least 40 years ("survivors") and 51 individuals with T1D who had died with shorter duration of diabetes ("non-survivors"), from diabetes clinics in different cities of India. Prevalence of complications in both groups and causes of death of the nonsurvivors were analyzed. Retinopathy was diagnosed by retinal photography; chronic kidney disease (CKD) by urinary albumin excretion (micro-or macroalbuminuria) and estimated glomerular filtration rate; peripheral vascular disease (PVD) by doppler measurement of ankle-brachial pressure index; coronary artery disease (CAD) based on history of myocardial infarction or coronary revascularization, and neuropathy by biothesiometry. Results: Mean glycated hemoglobin (8.4% ± 1.5% vs. 10.7% ± 2.2%, P < 0.001), serum low-density lipoprotein cholesterol (91 ± 29 mg/dL vs. 107 ± 22 mg/dL, P = 0.004), and systolic blood pressure (135 ± 16 mmHg vs. 153 ± 37 mmHg, P = 0.003) were lower, and high-density lipoprotein cholesterol (51 ± 11 mg/dL vs. 43 ± 15 mg/dL, P = 0.002) higher, among survivors compared to nonsurvivors. Diabetic retinopathy, CKD, neuropathy, PVD, and CAD were more frequent among nonsurvivors. CAD [25.5%] and renal failure [23.5%] were the most frequent causes of death. Conclusions: In this first report of long-term survivors with T1D from India, we report that survivors had better glycemic and blood pressure control, more favorable lipid profiles and lower prevalence of complications compared to nonsurvivors. However, there could be other protective factors as well, which merit further studies.

Youth prediabetes and type 2 diabetes: Risk factors and prevalence of dysglycaemia

BACKGROUND

The American Diabetes Association recommends risk-based screening for dysglycaemia (prediabetes and type 2 diabetes) in youth with overweight/obesity plus ≥1 risk factor. However, evidence for these recommendations is lacking.

OBJECTIVES

Examine the association between the number of risk factors and the prevalence of dysglycaemia in youth with overweight/obesity at initial presentation.

METHODS

In a paediatric obesity registry, youth (>10 and <20 years old, body mass index ≥85th percentile) were categorized into four groups according to number of risk factors (1, 2, 3 and ≥4). Based on oral glucose tolerance test, participants were classified into normal glucose tolerance or dysglycaemia.

RESULTS

Of 635 youth, 31.5% had prediabetes and 6.1% had type 2 diabetes. The prevalence of dysglycaemia was 23.1% with 1 risk factor and increased to 44.9% with ≥4 risk factors (p = 0.025). Dyslipidaemia, family history of type 2 diabetes and maternal history of gestational diabetes were significantly associated with dysglycaemia. Fasting and 2-h insulin, 2-h glucose increased (all p < 0.0001) and ALT increased (p = 0.001) with increasing risk factors. Insulin sensitivity and β-cell function deteriorated significantly with increasing risk factors.

CONCLUSION

Screening for dysglycaemia in youth with obesity and any additional risk factor is warranted to target early management.

One-year trends from the LANDMARC trial: A 3-year, pan-India, prospective, longitudinal study on the management and real-world outcomes of type 2 diabetes mellitus

Introduction

Longitudinal data on management and progression of type 2 diabetes mellitus (T2DM) in India are scarce. LANDMARC (CTRI/2017/05/008452), first‐of‐its‐kind, pan‐India, prospective, observational study aimed to evaluate real‐world patterns and management of T2DM over 3 years.

Methods

Adults (≥25 to ≤60 years old at T2DM diagnosis; diabetes duration ≥2 years at enrolment; controlled/uncontrolled on ≥2 anti‐diabetic agents) were enrolled. The first‐year trends for glycaemic control, therapy and diabetic complications, including those from metropolitan and non‐metropolitan cities are reported here.

Results

Of 6236 enrolled participants, 5654 completed 1 year in the study. Although the overall mean glycated haemoglobin (HbA1c) improved by 0.5% (baseline: 8.1%) at 1 year, only 20% of the participants achieved HbA1c <7%. Participants from metropolitan and non‐ metropolitan cities showed similar decrease in glycaemic levels (mean change in HbA1c: −0.5% vs. −0.5%; p = .8613). Among diabetic complications, neuropathy was the predominant complication (815/6236, 13.1% participants). Microvascular complications (neuropathy, nephropathy and retinopathy) were significantly (p < .0001) higher in non‐metropolitan than metropolitan cities. Hypertension (2623/6236, 78.2%) and dyslipidaemia (1696/6236, 50.6%) continued to be the most commonly reported cardiovascular risks at 1 year. After 1 year, majority of the participants were taking only oral anti‐diabetic drugs (OADs) (baseline: 4642/6236 [74.4%]; 1 year: 4045/6013 [67.3%]), while the proportion of those taking insulin along with OADs increased (baseline: 1498/6236 [24.0%] vs. 1 year: 1844/6013 [30.7%]). Biguanides and sulfonylureas were the most used OADs. The highest increase in use was seen for dipeptidyl peptidase‐IV inhibitors (baseline: 3047/6236 [48.9%]; 1 year: 3529/6013 [58.7%]). Improvement in all glycaemic parameters was significantly (p < .0001) higher in the insulin vs. the insulin‐naïve subgroups; in the insulin‐naïve subgroup, no statistical difference was noted in those who received >3 vs. ≤3 OADs.

Conclusions

First‐year trends of the LANDMARC study offer insights into real‐world disease progression, suggesting the need for controlling risk factors and timely treatment intensification in people with T2DM.

Demographic and clinical characteristics of a population-based pediatric cohort of type 1 and type 2 diabetes in Western Australia (1999-2019)

OBJECTIVES

To determine demographic and clinical characteristics of youth diagnosed with type 1 (T1D) or type 2 (T2D) diabetes aged ≤15 years from 1999 to 2019 in Western Australia, and examine time to first diagnosis of diabetes complications.

METHODS

A retrospective cohort study was conducted of patients identified from the population-based, prospective Western Australian Children's Diabetes Database and longitudinal data extracted for available demographic and clinical variables. Patients were followed from diagnosis to transition to adult services, death, or December 31, 2019. Cox proportional hazards regression models were used to analyse time to first diagnosis of hypertension, high cholesterol or microalbuminuria, after adjusting for sex, age at diagnosis, time period of diagnosis, hemoglobin A1_c , and body max index Z-score.

RESULTS

2438 eligible patients were identified (2209 [91%] T1D: 229 [9%] T2D). The mean age at diagnosis was lower in patients with T1D (8.5 [±4.0] vs. 12.7 [±2.0] years). A higher proportion of patients with T2D were female (58% vs. 47%) and of Aboriginal ethnicity (59% vs. 2%). The median HbA1c (interquartile range) at diagnosis was lower 8.9% [6.7, 11.5] (74 mmol/mol [50, 102]) versus 11.6% [10.1, 13.3] (103 mmol/mol [87, 122]) and mean body max index Z-score higher (2.05 [±0.66] vs. 0.37 [±0.95]), in patients with T2D compared to T1D. Patients with T2D had a higher risk of hypertension, high cholesterol, and microalbuminuria (aHR 3.39 [95%CI:2.04, 5.63], 2.69 [95%CI:1.21, 5.98], and 19.79 [95%CI:10.99, 35.64] respectively).

Urinary C-peptide/creatinine ratio: A useful biomarker of insulin resistance and refined classification of type 2 diabetes mellitus

BACKGROUND

The urinary C-peptide/creatinine ratio (UCPCR) is low in patients with type 1 diabetes mellitus, but it has not been well characterized in patients with type 2 diabetes mellitus (T2DM). We aimed to measure the UCPCRs in patients with T2DM and explore the relationships among UCPCR, insulin resistance (IR), and chronic vascular complications of diabetes.

METHODS

A cross-sectional study was performed of 1299 Chinese hospitalized patients with T2DM. Binary logistic regression was used to evaluate the relationships between the chronic vascular complications of diabetes and UCPCR. K-means analysis was used to allocate participants to subgroups with five to six variables (age at diagnosis, body mass index [BMI], glycosylated hemoglobin, homoeostasis model assessment 2-estimated beta-cell function (HOMA2-B), and HOMA2-insulin resistance (HOMA2-IR), with or without UCPCR).

RESULTS

UCPCR positively correlated with HOMA2-IR (r = 0.448, P < .001). After adjustment for sex, age, duration of diabetes, and other cardiovascular risk factors, UCPCR was positively associated with diabetic kidney disease (DKD) (odds ratio [OR] = 1.198, 95% CI 1.019-1.408, P = .029) and coronary heart disease (CHD) (OR = 1.312, 95% CI 1.079-1.594, P = .006). When UCPCR was added, cluster analysis using the six variables identified five subgroups of T2DM, characterized by differing age at diagnosis, BMI, beta-cell function, IR, and prevalence of vascular complications.

CONCLUSIONS

UCPCR is positively associated with IR, DKD, and CHD and represents a promising biomarker that could refine the classification of T2DM.

Health disparities in cardiometabolic risk among Black and Hispanic youth in the United States

Cardiometabolic risk factors in children and adolescents track into adulthood and are associated with increased risk of atherosclerotic cardiovascular disease. The purpose of this review is to examine the pervasive race and ethnic disparities in cardiometabolic risk factors among Black and Hispanic youth in the United States. We focus on three traditional cardiometabolic risk factors (obesity, type 2 diabetes mellitus, and dyslipidemia) as well as on the emerging cardiometabolic risk factor of non-alcoholic fatty liver disease. Additionally, we highlight interventions aimed at improving cardiometabolic health among these minority pediatric populations. Finally, we advocate for continued research on effective prevention strategies to reduce cardiometabolic risk and avert further disparities in cardiovascular morbidity and mortality.

Cardiovascular Disease in Type 1 Diabetes Mellitus: Epidemiology and Management of Cardiovascular Risk

Cardiovascular disease (CVD) is a major cause of mortality in type 1 diabetes mellitus (T1DM) patients, and cardiovascular risk (CVR) remains high even in T1DM patients with good metabolic control. The underlying mechanisms remain poorly understood and known risk factors seem to operate differently in T1DM and type 2 diabetes mellitus (T2DM) patients. However, evidence of cardiovascular risk assessment and management in T1DM patients often is extrapolated from studies on T2DM patients or the general population. In this review, we examine the existing literature about the prevalence of clinical and subclinical CVD, as well as current knowledge about potential risk factors involved in the development and progression of atherosclerosis in T1DM patients. We also discuss current approaches to the stratification and therapeutic management of CVR in T1DM patients. Chronic hyperglycemia plays an important role, but it is likely that other potential factors are involved in increased atherosclerosis and CVD in T1DM patients. Evidence on the estimation of 10-year and lifetime risk of CVD, as well as the efficiency and age at which current cardiovascular medications should be initiated in young T1DM patients, is very limited and clearly insufficient to establish evidence-based therapeutic approaches to CVD management.

Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses

AIMS/HYPOTHESIS

Few studies examine the association between age at diagnosis and subsequent complications from type 2 diabetes. This paper aims to summarise the risk of mortality, macrovascular complications and microvascular complications associated with age at diagnosis of type 2 diabetes.

METHODS

Data were sourced from MEDLINE and All EBM (Evidence Based Medicine) databases from inception to July 2018. Observational studies, investigating the effect of age at diabetes diagnosis on macrovascular and microvascular diabetes complications in adults with type 2 diabetes were selected according to pre-specified criteria. Two investigators independently extracted data and evaluated all studies. If data were not reported in a comparable format, data were obtained from authors, presented as minimally adjusted ORs (and 95% CIs) per 1 year increase in age at diabetes diagnosis, adjusted for current age for each outcome of interest. The study protocol was recorded with PROSPERO International Prospective Register of Systematic Reviews (CRD42016043593).

RESULTS

Data from 26 observational studies comprising 1,325,493 individuals from 30 countries were included. Random-effects meta-analyses with inverse variance weighting were used to obtain the pooled ORs. Age at diabetes diagnosis was inversely associated with risk of all-cause mortality and macrovascular and microvascular disease (all p < 0.001). Each 1 year increase in age at diabetes diagnosis was associated with a 4%, 3% and 5% decreased risk of all-cause mortality, macrovascular disease and microvascular disease, respectively, adjusted for current age. The effects were consistent for the individual components of the composite outcomes (all p < 0.001).

CONCLUSIONS/INTERPRETATION

Younger, rather than older, age at diabetes diagnosis was associated with higher risk of mortality and vascular disease. Early and sustained interventions to delay type 2 diabetes onset and improve blood glucose levels and cardiovascular risk profiles of those already diagnosed are essential to reduce morbidity and mortality. Graphical abstract.

Clinical profile and incidence of microvascular complications of childhood and adolescent onset type 1 and type 2 diabetes seen at a tertiary diabetes center in India

AIM

To study the clinical characteristics and incidence of microvascular complications among childhood and adolescent onset type 1 (T1DM) and type 2 diabetes (T2DM) seen at a tertiary care diabetes center in India.

METHODS

From our electronic medical records, we retrieved clinical and biochemical details of 4555 individuals with childhood and adolescent onset diabetes (diagnosed below the age of 20 years) seen between 1992 and 2017. T1DM was diagnosed if there was history of ketoacidosis or fasting C-peptide <0.3 PMol/mL and stimulated C-peptide <0.6 PMol/mL or if insulin treatment was required from the time of diagnosis. T2DM was diagnosed based on absence of ketosis, or fasting C-peptide ≥0.6 PMol/mL and stimulated >1.0 PMoL/mL, or response to oral hypoglycemic agents for more than 2 years. We calculated the incidence rates of retinopathy (presence of at least one definite microaneurysm by retinal photography), nephropathy (urinary albumin excretion ≥30 μg/mg of creatinine) and neuropathy (vibration perception threshold ≥20 V) per 1000 person-years of follow up.

RESULTS

Among the 4555 individuals with childhood and adolescent-onset diabetes, 71.4% had T1DM, 19.5% T2DM and 9.1% other forms of diabetes. Age at first visit and duration of diabetes were significantly higher in T2DM when compared to T1DM. The age adjusted incidence of retinopathy was 52.9/1000 person years (Confidence Intervals [CI]: 42.9-62.8) in T1DM and 49.8/1000 person years (CI 30.8-68.8) in T2DM; nephropathy, 6.2 (CI 3.3-9.0) and 13.8 (CI 5.6-22.0); and neuropathy, 8.8(CI 3.6-14.0) and 24.0 (CI 9.8-38.2) in T1DM and T2DM, respectively.

CONCLUSION

The incidence of microvascular complications is high among childhood and adolescent-onset T1DM and T2DM and these calls for more aggressive control of diabetes.

Incidence and Predictors of Dysglycemia and Regression to Normoglycemia in Indian Adolescents and Young Adults: 10-Year Follow-Up of the ORANGE Study

Background: The prevalence of diabetes in youth is increasing worldwide in parallel with the obesity epidemic. This study aimed to determine the incidence rates of dysglycemia (diabetes or prediabetes) and evaluate the predictors of its progression or regression to normal glucose tolerance (NGT) in a cohort of children and adolescents studied in Chennai, South India. Methods: A longitudinal follow-up of the Obesity Reduction and Awareness of Noncommunicable Diseases through Group Education (ORANGE) cohort was performed after a median of 7.1 years (n = 845; 5928 person-years of follow-up). To determine their diabetes status at follow-up, participants underwent an oral glucose tolerance test (n = 811 with NGT and 34 with prediabetes at baseline), excluding those with diabetes at baseline. Incidence rates for dysglycemia were reported per 1000 person-years of follow-up. Cox proportional hazards model was used to estimate the predictors of progression and regression. Results: Out of 811 individuals with NGT at baseline, 115 developed dysglycemia giving an incidence rate of 20.2 per 1000 person-years (95% confidence interval: 16.8-24.2). Among those with prediabetes at baseline, 70.6% of the individuals converted to NGT and the remaining 29.4% either got converted to diabetes or remained as prediabetes. Higher age, body mass index, fasting plasma glucose, 2-hour plasma glucose (2-h PG), positive family history of diabetes, and systolic blood pressure (BP) were independent predictors of incident dysglycemia, whereas lower age, waist circumference, 2-h PG, systolic BP, and triglycerides predicted regression to normoglycemia. Conclusions: This study highlights the growing burden of dysglycemia in Asian Indian youth and emphasizes the need for targeted preventive actions.

Obesity and Diabetes: A Sword of Damocles for Future Generations

Childhood obesity is one of the most challenging problem of the 21st century. The prevalence has increased, reaching an alarming rate. Furthermore, the problem is global and is also affecting low- and middle-income countries. This global obesity epidemic explains how the roots of cardiovascular disease, the most common cause of mortality among adults, begin in childhood. Overweight and obese children are likely to stay obese into adulthood and to develop noncommunicable diseases such as diabetes and cardiovascular diseases at a younger age. Thus, prevention should be the major goal and should start early in life. The aim of this review is to present an updated framework of the current understanding of the cardiovascular and metabolic risks in obese children and adolescents and to discuss the available therapeutic options.

Association between daily sunlight exposure duration and diabetic retinopathy in Korean adults with diabetes: A nationwide population-based cross-sectional study

Purpose

To investigate the association between daily sunlight exposure duration and diabetic retinopathy in Korean adults with diabetes.

Methods

This study used data from the 2008–2011 Korea National Health and Nutrition Examination Survey. Overall, 1,089 patients with diabetes aged >40 years were included. The duration of daily sunlight exposure was assessed via health interviews. Comprehensive ophthalmic evaluations, including standard retinal fundus photography after pupil dilation, were conducted. Diabetic retinopathy was graded using the modified Airlie House Classification. Multivariate logistic regression analysis was performed to analyze the association between daily sunlight exposure duration and the diagnosis of diabetic retinopathy and non-proliferative diabetic retinopathy.

Results

The risk of diabetic retinopathy was 2.66 times higher in the group with ≥5 h of daily sunlight exposure than in the group with less exposure after adjusting for risk factors such as duration of diabetes, serum hemoglobin A1c level, hypertension, and dyslipidemia (P = 0.023). Furthermore, the risk of non-proliferative diabetic retinopathy was 3.13 times higher in the group with ≥5 h of daily sunlight exposure than in the group with less exposure (P = 0.009). In patients with diabetes for <10 years, the risks of diabetic retinopathy and non-proliferative diabetic retinopathy were 4.26 and 4.82 times higher in the group with ≥5 h of daily sunlight exposure than the group with less exposure, respectively (P < 0.05).

Conclusions

This study revealed that sunlight exposure for ≥5 h a day was significantly associated with an increased risk of diabetic retinopathy and non-proliferative diabetic retinopathy in Korean patients with diabetes. The risks were significantly higher in patients with diabetes for <10 years. Therefore, reducing daily sunlight exposure could be an early preventive strategy against diabetic retinopathy in people with diabetes.

Human induced pluripotent stem cell-derived cardiomyocytes reveal abnormal TGFβ signaling in type 2 diabetes mellitus

Diabetes mellitus is a serious metabolic condition associated with a multitude of cardiovascular complications. Moreover, the prevalence of diabetes in heart failure populations is higher than that in control populations. However, the role of cardiomyocyte alterations in type 2 diabetes mellitus (T2DM) has not been well characterized and the underlying mechanisms remain elusive. In this study, two patients who were diagnosed as T2DM were recruited and patient-specific induced pluripotent stem cells (iPSCs) were generated from urine epithelial cells using nonintegrated Sendai virus. The iPSC lines derived from five healthy subjects were used as controls. All iPSCs were differentiated into cardiomyocytes (iPSC-CMs) using the monolayer-based differentiation protocol. T2DM iPSC-CMs exhibited various disease phenotypes, including cellular hypertrophy and lipid accumulation. Moreover, T2DM iPSC-CMs exhibited higher susceptibility to high-glucose/high-lipid challenge than control iPSC-CMs, manifesting an increase in apoptosis. RNA-Sequencing analysis revealed a differential transcriptome profile and abnormal activation of TGFβ signaling pathway in T2DM iPSC-CMs. We went on to show that inhibition of TGFβ significantly rescued the hypertrophic phenotype in T2DM iPSC-CMs. In conclusion, we demonstrate that the iPSC-CM model is able to recapitulate cellular phenotype of T2DM. Our results indicate that iPSC-CMs can therefore serve as a suitable model for investigating molecular mechanisms underlying diabetic cardiomyopathies and for screening therapeutic drugs.

Insulin enhances and metformin reduces risk of colorectal carcinoma in type-2 diabetes

BACKGROUND

Identifying colorectal cancer associated risks is important for conducting a program for the survey and prevention of colorectal cancer.

AIM

To investigate the association between use of insulin or metformin with colorectal cancer (CRC) in type 2 diabetes (T2DM).

DESIGN

Population-based cohort study.

METHODS

Through analysis of National Health Insurance (NHI) database between 1998 and 2010 in Taiwan, we identified 66 324 T2DM patients aged ≥ 20 years and selected subjects without diabetes by 1: 1 randomly matching with the study cohort based on age, sex and index date. We followed up the participants until 31 December 2011 or when they withdrew from the NHI program.

RESULTS

Compared with non-diabetic subjects, the T2DM patients exhibited an increased risk of CRC [adjusted HR (aHR) = 1.56, 95% confidence interval (CI) = 1.39-1.75], after adjustment for age, sex, urbanization level, comorbidities and examinations of colonoscopy, sigmoidoscopy, or stool occult blood test. Among the T2DM patients, insulin usage increased the risk of CRC (aHR = 1.86, 95% CI = 1.58-0-2.19) after adjustment for age, sex, urbanization level, comorbidities, metformin usage and examinations; nevertheless, metformin decreased the risk of CRC (aHR = 0.65, 95% CI = 0.54-0.77) after adjustment for age, sex, urbanization level, comorbidities, insulin usage and examinations. Compared with the non-insulin cohort, the risk of CRC tended to increase with the incremental dosage of insulin exposure.

CONCLUSION

Our population-based cohort study demonstrated an association between T2DM and CRC. Among the T2DM patients, insulin use was associated with an increased risk of CRC and metformin use was associated with a decreased risk of CRC. Inability to obtain information on several potential confounding factors, such as lifestyle and dietary habits, is the major limitation of the study.

Will undocumented migrants contribute to change epidemiology, presentation and pharmacologic treatment of diabetes in Western countries?

AIMS

Migrants from countries in which health and social conditions are unsatisfactory, and their offspring, are becoming a growing component of the western population. Available health data show that their morbidity is at least comparable to that of the host country population, with a significant contribution of chronic diseases as diabetes. The possibility that diabetes shows different features in undocumented migrants is the hypothesis that we tried to investigate in this study.

METHODS

We retrospectively analysed the data of 413 patients with type 2 diabetes mellitus (T2DM): 222 patients followed in a diabetes clinic at a University Hospital and 191 undocumented migrants cared for by a Charity in Milan, Italy.

RESULTS

We found that the onset of the disease was earlier in migrants; they showed a significant lower body mass index (BMI) and had lower socioeconomic conditions. They had a worse glycaemic control. The pattern of complications was also different between the two groups, with cardiovascular complications more frequent in Italians. Finally, also pharmacologic treatment differed significantly.

CONCLUSIONS

Age of onset, clinical manifestations and complications of T2DM in undocumented migrants and natives may show significant differences. This is important for both epidemiological and clinical reasons. If these preliminary observations are confirmed by larger studies, we can conclude that undocumented migrants should be screened for T2DM earlier than natives, and that therapies should be tailored to the specific features of their disease.

Altered touch perception and associated risk factors in individuals with diabetes mellitus

ABSTRACT Objective: To evaluate the prevalence of altered touch perception in the feet of individuals with diabetes mellitus and the associated risk factors. Method: Cross-sectional study with 224 individuals with diabetes mellitus conducted in an endocrinology clinic at a public hospital in Campina Grande, Paraíba. The evaluation used touch sensitivity and perception, and a descriptive and multivariate analysis with Poisson regression was performed. Results: We found the prevalence of altered touch perception to be 53.1%. The risk factors that had a significant and joint impact on its occurrence were: female gender; previous ulcer; diabetes mellitus type 2; burning sensation, cracks, fissures, calluses, and Charcot foot. Conclusions: This study found a high prevalence of altered perception of touch, and this should support the planning of actions aimed at preventing the problem. The study showed the relevance of the phenomenon as a nursing diagnosis that could be included in NANDA-International.

Maternal vs paternal diabetes: The parental history is different in younger onset versus older onset type 2 diabetes

BACKGROUND

A number of previous studies exploring family history of type 2 diabetes have reported a predominance of maternal diabetes. These studies have not explicitly compared parental history of diabetes across the spectrum of disease onset from youth to later adulthood.

METHODS

Family history data from 11,467 patients with type 2 diabetes were extracted from the RPA Diabetes Centre database. Parental histories of diabetes were compared across a range of age of diagnosis strata (15-<30, 30-<40, 40-<50, 50-<60 and 60-<70 years). For the young-onset group (diagnosed between 15 and 30 years of age), associations between parental history of diabetes and the presence of cardio-metabolic risk factors and diabetic complications were also explored.

RESULTS

For the total cohort and within each age of diagnosis strata, more individuals reported maternal history than paternal history of diabetes. The young-onset group demonstrated the highest prevalence of any parental history of diabetes (60.7%), the highest combined maternal and paternal history (15.8%) and the smallest differential between maternal (25.1%) and paternal (19.7%) history of diabetes. Within the young-onset group, no significant association between parental history and cardio-metabolic risk factors or diabetic complications were identified after a median of 15.0 years of diabetes exposure.

CONCLUSION

Overall, our results demonstrate a consistent maternal excess of diabetes which could be consistent with an underlying epigenetic effect. However, the differential between maternal and paternal history is significantly lower in the young-onset group. Earlier emergence of type 2 diabetes may therefore reflect a different interaction and impact of genetic and environmental factors.

Phenotypic characteristics and risk factors in a multi-ethnic cohort of young adults with type 2 diabetes

Background: Early onset of type 2 diabetes (T2DM) is associated with prolonged exposure to hyperglycaemia and increased propensity to chronic complications. The aim of this study was to characterize and compare the phenotypic characteristics and risk factors in a multi-ethnic cohort of young adults with type 2 diabetes (T2DMY). Methods: One hundred young adults (White European [WE], South Asian [SA] and African-Caribbean [AC]) diagnosed with T2DM before the age of 40 years were recruited. Demographics, family history, diabetes related complications, co-morbidities, anthropometry (body mass index [BMI], body composition), physical activity and biochemistry (HbA1c, lipid profile, liver and renal function) and autoantibodies (anti GAD, anti islet cell) were collected for all participants. Data were analysed for the most represented ethnic groups: (WE, N = 36 and SA, N = 53) using SPSS version 23. Results: Mean (± standard deviation) age at diagnosis was 32.5 ± 5.5 years and mean diabetes duration was 7.7 ± 3.8 years. Overweight/obesity was present in 95% of participants, history of maternal diabetes in 68%, deprivation 75%, low physical activity 40%, polycystic ovarian disease 29% (in females), acanthosis nigricans 12% and non-alcoholic fatty liver 11%. There was considerable clustering of risk factors within the cohort with over 75% of all subjects having three or more of the above risk factors and 52% required insulin within 3 years of diagnosis. Two-thirds of the patients had evidence of at least one diabetes related microvascular complication. Conclusion: T2DMY is characterized by a high burden of commonly associated risk factors for both the disease and its long-term complications.

Premature death and risk of cardiovascular disease in young-onset diabetes: a 23-year follow-up of the Da Qing Diabetes Study

OBJECTIVE

This study aimed to investigate premature mortality and the risk of cardiovascular disease (CVD) in Chinese adults with diabetes diagnosed before the age of 45 years.

METHODS

A total of 519 participants with normal glucose tolerance (NGT) and 630 with newly diagnosed diabetes mellitus (DM) were recruited in 1986 in the Da Qing Diabetes Study. In 2009, the participants were followed up to assess mortality and CVD events. The subjects were stratified into four subgroups according to age and diabetes status: age <45 years with NGT (NGT_<45y), age <45 years with DM (DM_<45y), age ≥45 years with NGT (NGT_≥45y), and age ≥45 years with DM (DM_≥45y). The risk of death and CVD events in patients with young-onset DM and elder subjects with NGT were compared to show the extent of premature death and CVD in the DM participants.

RESULTS

During the 23-year follow-up, 26 (10.40%) participants in NGT_<45y, 72 (34.12%) in DM_<45y, 74 (30.58%) in NGT_≥45y, and 266 (68.73%) in DM_≥45y died, including 13 (5.20%), 36 (17.06%), 24 (9.92%), and 128 (33.07%) death attributed to CVD. The corresponding rates of CVD events were 56 (22.40%), 90 (42.65%), 89 (36.78), and 213 (55.04%). It also showed that the risk of all-cause death (HR 1.23, 95% CI 0.88-1.71) or CVD events (HR 1.25, 95% CI 0.93-1.69) did not differ significantly between the DM_<45y and NGT_≥45y groups after adjusting for sex, smoking, body mass index, systolic blood pressure, total cholesterol and previous history of CVD. Of note, participants in the DM_<45y group had an higher risk of CVD mortality compared with that in the NGT_≥45y group (HR 1.76, 95% CI 1.04-2.98), although the mean age in the former group was 12 years lesser than that in the latter group (39.01 ± 5.00 vs 51.45 ± 5.14).

CONCLUSIONS

Young-onset diabetes is a risk factor for the premature death and cardiovascular disease. Early prevention and intensive treatment are warrented in patients with young-onset diabetes.

Cardiometabolic risk in obese children

Obesity in childhood remains a significant and prevalent public health concern. Excess adiposity in youth is a marker of increased cardiometabolic risk (CMR) in adolescents and adults. Several longitudinal studies confirm the strong association of pediatric obesity with the persistence of adult obesity and the future development of cardiovascular disease, diabetes, and increased risk of death. The economic and social impact of childhood obesity is further exacerbated by the early onset of the chronic disease burden in young adults during their peak productivity years. Furthermore, rising prevalence rates of severe obesity in youth from disadvantaged and/or minority backgrounds have prompted the creation of additional classification schemes for severe obesity to improve CMR stratification. Current guidelines focus on primary obesity prevention efforts, as well as screening for clustering of multiple CMR factors to target interventions. This review summarizes the scope of the pediatric obesity epidemic, the new severe obesity classification scheme, and examines the association of excess adiposity with cardiovascular and metabolic risk. We will also discuss potential questions for future investigation.

Early-onset diabetes: an epidemic in China

Although type 2 diabetes is a disease often associated with aging, the global prevalence of early-onset diabetes has been increasing due to man's sedentary lifestyle, low-physical activity, obesity, and some nonmodifiable risk factors. Many studies have found that individuals with early-onset type 2 diabetes were at higher risk of developing vascular complications than those with late-onset diabetes. Individuals with early-onset diabetes are usually unwilling to visit hospital and have more confidence in their health, which results in poor glycemic control and the delayed detection of diabetes-related complications. Few studies have focused on the treatment and prevention of complications in specific population of individuals with early-onset type 2 diabetes. Therefore, focusing on this particular population is critical for the government and academic societies. Screening for T2DM is imminent for young adults with a family history of diabetes, obesity, markers of insulin resistance, or alcohol consumption. More data are definitely required to establish a reasonable risk model to screen for early-onset diabetes.

The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control

BACKGROUND

The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics.

OBJECTIVE

To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata.

METHODS

We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables.

RESULTS

The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities.

CONCLUSIONS

Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted.

DISCLOSURES

This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.

Nomogram for prediction of non-proliferative diabetic retinopathy in juvenile-onset type 1 diabetes: a cohort study in an Asian population

The need for screening for retinopathy in patients with type 1 diabetes mellitus (T1DM) has been emphasised, but diagnostic delays were reported when screening was done at fixed intervals. To establish an individualised risk-prediction model to assist screening non-proliferative diabetic retinopathy (NPDR) in T1DM, we performed a retrospective cohort study enrolling participants in the Chang Gung Juvenile Diabetes Eye Study. There were 413 patients with 12 381 records analysed from 2005 to 2015. A time-dependent Cox proportional hazard analysis was used to evaluate the risks of NPDR development and a nomogram with risk-stratification indicators was established based on the results. During 97 months of follow-up, 43 of 413 patients (10.4%) developed NPDR. Male sex (HR: 0.4, 95% CI: 0.19–0.85), age 5–14 years at onset of T1DM (6.38, 2.41–16.87), duration of diabetes (1.57, 1.41–1.75), and hemoglobin A1c level (1.56, 1.35–1.80) were independently associated with NPDR. Using the nomogram offers a quick method in the clinical setting to interpret the risk of NPDR development. Based on its weighting, each of the independent factors is allocated a score, and the total points indicate the probabilities of NPDR occurring within 6 months, 1 year, and 3 years.

Predictors of vascular complications among type 2 diabetes mellitus patients at University of Gondar Referral Hospital: a retrospective follow-up study

BACKGROUND

Type 2 Diabetes Mellitus is a serious metabolic disease that is often associated with vascular complications. There are 1.9 million people living with Diabetes in Ethiopia; diabetes mellitus is found to be the ninth leading cause of death related to its complications. Although the rate of vascular complications continues to rise, there is limited information about the problem. This study aimed to estimate the incidence and predictors of vascular complications among type 2 diabetes mellitus patients at University of Gondar Referral Hospital.

METHODS

Institution based retrospective follow-up study was conducted at University of Gondar Referral Hospital with 341 newly diagnosed type 2 DM patients from September 2005 to March 2017 and the data were collected by reviewing their records. Schoenfeld residuals test and interaction of each covariate with time were used to check proportional hazard assumption. The best model was selected by using Akaike Information Criteria (AIC). Hazards ratio (HR) with its respective 95% confidence interval were reported to show strength of association.

RESULT

The selected patients were followed retrospectively for a median follow up time of 81.50 months (Inter quartile range (IQR) = 67.2-103.3). The mean age (± Standard deviation (SD)) of patients at baseline was 51.7(SD: ±11.5 years) and 57.48% were females. The incidence rate of vascular complications was 40.6 cases/ 1000 person years of observation. The significant predictors for vascular complications where found to be male sex (Adjusted hazard ratio (AHR) = 0.50, 95% CI: 0.27, 0.94), having hypertension at baseline(AHR = 3.99, 95% CI: 1.87, 8.56), positive protein urea at base line (AHR = 1.69, 95% CI: 1.03, 2.78), high density lipoprotein cholesterol(HDL-C) level ≥ 40 mg per deciliter (mg/dl) (AHR = 0.43, 95% CI: 0.24, 0.77), low density lipoprotein cholesterol(LDL-C) level > 100 mg/dl (AHR = 3.05, 95% CI: 1.47, 6.35) and triglyceride > 150 mg/dl (AHR = 2.74, 95% CI: 1.28, 5.84).

CONCLUSION

The incidence of vascular complications among type 2 diabetes patients remains a significant public health problem. Hypertension at baseline, LDL-C > 100 mg/dl, triglyceride > 150 mg/dl, HDL-C ≥ 40 mg/dl and male sex were significant predictors of vascular complication. In the light of these findings targeted interventions should be given to diabetes patients with hypertension comorbidity and dyslipidemia at follow up clinics.

Mortality in youth-onset type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth study

AIMS

To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20 years from the SEARCH for Diabetes in Youth study.

METHODS

We included 8358 individuals newly-diagnosed with type 1 (n = 6840) or type 2 (n = 1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study.

RESULTS

During 44,893 person-years (PY) of observation (median follow-up = 5.3 years), 41 individuals died (91.3 deaths/100,000 PY); 26 with type 1 (70.6 deaths/100,000 PY) and 15 with type 2 (185.6 deaths/100,000 PY) diabetes. The expected mortality rate was 70.9 deaths/100,000 PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19 year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4).

CONCLUSIONS

Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

Association Between Type I and II Diabetes With Gallbladder Stone Disease

Objective: To assess the association of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) with the subsequent development of gallbladder stone disease (GSD). Setting: Cohort Study. Participants: We identified two study cohort groups to evaluate the association of T1DM and T2DM with the development of GSD. The first group comprised a T1DM cohort of 7015 patients aged ≤ 40 years and a non-diabetes cohort randomly matched with the study cohort (4:1). The second group comprised a T2DM cohort of 51,689 patients aged ≥20 years and a non-diabetes cohort randomly matched with the study cohort (1:1). All patients were studied from 1996 to the end of 2011 or withdrawal from the National Health Insurance program to determine the incidence of GSD. Results: Compared with patients without diabetes, those with T1DM had a decreased risk of GSD [adjusted hazard ratios (aHR) = 0.48, 95% confidence interval (CI) = 0.25-0.92]. Those with T2DM had an increased risk of GSD (aHR = 1.55, 95% CI = 1.41-1.69), after adjustment for age, sex, comorbidities, and number of parity. The relative risk of GSD in the T2DM cohort was higher than that in the non-diabetes cohort in each group of age, sex, and patients with or without comorbidity. However, the relative risk of GSD in the T1DM cohort was lower than that in the non-diabetes cohort only in the age group of 20-40 years. Conclusion: Our population-based cohort study reveals a strong association between T2DM and GSD. However, an inverse relationship exists between T1DM and GSD in patients aged 20-40 years.

Young onset type 2 diabetic patients might be more sensitive to metformin compared to late onset type 2 diabetic patients

It is unknown whether YOD (young onset diabetes) and LOD (late onset diabetes) require similar insulin doses for intensive insulin therapy with a metformin add-on to achieve glycemic control. We analyzed data from our two previously performed randomized, controlled open-label trials. Patients were randomized to receive either continuous subcutaneous insulin infusion (CSII) therapy or CSII combined with metformin therapy for 4 weeks. The studies concentrated on the differences in the insulin doses used for the two groups. We included 36 YOD (age < 40 yrs) and 152 LOD (age > 40 yrs) patients. YOD patients who received metformin combined with CSII therapy required significantly lower insulin doses to maintain euglycemic control compared to patients with LOD. A multivariate analysis, controlled for gender and the fasting blood concentration, was performed to determine the significance of the differences between groups, particularly with respect to the total and basal insulin doses. There was a trend toward improvement in β-cell function and insulin resistance in terms of ΔHOMA-B and ΔHOMA-IR in patients with YOD compared to those with LOD. Newly diagnosed T2D patients with YOD required significantly lower insulin doses, particularly basal insulin doses, to maintain glycemic control compared to the LOD patients.

Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR-INDIAB population-based cross-sectional study

BACKGROUND

Previous studies have not adequately captured the heterogeneous nature of the diabetes epidemic in India. The aim of the ongoing national Indian Council of Medical Research-INdia DIABetes study is to estimate the national prevalence of diabetes and prediabetes in India by estimating the prevalence by state.

METHODS

We used a stratified multistage design to obtain a community-based sample of 57 117 individuals aged 20 years or older. The sample population represented 14 of India's 28 states (eight from the mainland and six from the northeast of the country) and one union territory. States were sampled in a phased manner: phase I included Tamil Nadu, Chandigarh, Jharkhand, and Maharashtra, sampled between Nov 17, 2008, and April 16, 2010; phase II included Andhra Pradesh, Bihar, Gujarat, Karnataka, and Punjab, sampled between Sept 24, 2012, and July 26, 2013; and the northeastern phase included Assam, Mizoram, Arunachal Pradesh, Tripura, Manipur, and Meghalaya, with sampling done between Jan 5, 2012, and July 3, 2015. Capillary oral glucose tolerance tests were used to diagnose diabetes and prediabetes in accordance with WHO criteria. Our methods did not allow us to differentiate between type 1 and type 2 diabetes. The prevalence of diabetes in different states was assessed in relation to socioeconomic status (SES) of individuals and the per-capita gross domestic product (GDP) of each state. We used multiple logistic regression analysis to examine the association of various factors with the prevalence of diabetes and prediabetes.

FINDINGS

The overall prevalence of diabetes in all 15 states of India was 7·3% (95% CI 7·0-7·5). The prevalence of diabetes varied from 4·3% in Bihar (95% CI 3·7-5·0) to 10·0% (8·7-11·2) in Punjab and was higher in urban areas (11·2%, 10·6-11·8) than in rural areas (5·2%, 4·9-5·4; p<0·0001) and higher in mainland states (8·3%, 7·9-8·7) than in the northeast (5·9%, 5·5-6·2; p<0·0001). Overall, 1862 (47·3%) of 3938 individuals identified as having diabetes had not been diagnosed previously. States with higher per-capita GDP seemed to have a higher prevalence of diabetes (eg, Chandigarh, which had the highest GDP of US$ 3433, had the highest prevalence of 13·6%, 12.8-15·2). In rural areas of all states, diabetes was more prevalent in individuals of higher SES. However, in urban areas of some of the more affluent states (Chandigarh, Maharashtra, and Tamil Nadu), diabetes prevalence was higher in people with lower SES. The overall prevalence of prediabetes in all 15 states was 10·3% (10·0-10·6). The prevalence of prediabetes varied from 6·0% (5·1-6·8) in Mizoram to 14·7% (13·6-15·9) in Tripura, and the prevalence of impaired fasting glucose was generally higher than the prevalence of impaired glucose tolerance. Age, male sex, obesity, hypertension, and family history of diabetes were independent risk factors for diabetes in both urban and rural areas.

INTERPRETATION

There are large differences in diabetes prevalence between states in India. Our results show evidence of an epidemiological transition, with a higher prevalence of diabetes in low SES groups in the urban areas of the more economically developed states. The spread of diabetes to economically disadvantaged sections of society is a matter of great concern, warranting urgent preventive measures.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.