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Park J, Jung JH, Park H, Song YS, Kim SK, Cho YW, Han K, Kim KS. Association between exercise habits and incident type 2 diabetes mellitus in patients with thyroid cancer: nationwide population-based study. BMC Med 2024; 22:251. [PMID: 38886720 PMCID: PMC11184752 DOI: 10.1186/s12916-024-03472-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND We investigated the association between exercise habits before or after thyroidectomy and incident type 2 diabetes mellitus (T2DM) in patients with thyroid cancer. METHODS An observational cohort study of 69,526 thyroid cancer patients who underwent thyroidectomy for the treatment of thyroid cancer between 2010 and 2016 was performed using the Korean National Health Information Database. Regular exercise was defined as mid-term or vigorous exercise at least 1 day in a week based on a self-reported questionnaire. Patients were divided into four groups according to exercise habits before and after thyroidectomy: persistent non-exercisers, new exercisers, exercise dropouts, and exercise maintainers. RESULTS During a median follow-up of 4.5 years, 2,720 (3.91%) patients developed T2DM. The incidence of T2DM per 1,000 person years was lower in patients who performed regular exercise before or after thyroidectomy than in persistent non-exercisers (10.77 in persistent non-exerciser group, 8.28 in new exerciser group, 8.59 in exercise dropout group, and 7.61 in exercise maintainer group). Compared with the persistent non-exerciser group, the new exerciser group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.78-0.97), the exercise dropout group (HR 0.81, 95% CI 0.72-0.91), and the exercise maintainer group (HR 0.84, 95% CI 0.76-0.93) had lower risks of incident T2DM. Exercising < 1,500 MET-minutes/week in the exercise maintainer group was associated with a lower risk of incident T2DM compared with persistent non-exercisers (< 500: HR 0.80, 95% CI 0.67-0.96, P = 0.002; 500 to < 1,000: HR 0.81, 95% CI 0.71-0.93, P < 0.001; 1,000 to < 1,500: HR 0.81, 95% CI 0.69-0.94, P < 0.001). CONCLUSIONS Regular exercise before or after thyroidectomy was associated with a lower risk of incident T2DM in patients with thyroid cancer.
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Affiliation(s)
- Jiyun Park
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea
| | - Jin-Hyung Jung
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Suwon, Republic of Korea
| | - Hyunju Park
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea
| | - Young Shin Song
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soo-Kyung Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea
| | - Yong-Wook Cho
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyung-Soo Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, 59 Yatap-Ro, Bundang-Gu, Seongnam, 13496, Republic of Korea.
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2
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Kouvari M, Chrysohoou C, Damigou E, Barkas F, Kravvariti E, Liberopoulos E, Tsioufis C, Sfikakis PP, Pitsavos C, Panagiotakos D, Mantzoros CS. Non-invasive tools for liver steatosis and steatohepatitis predict incidence of diabetes, cardiovascular disease and mortality 20 years later: The ATTICA cohort study (2002-2022). Clin Nutr 2024; 43:900-908. [PMID: 38387279 DOI: 10.1016/j.clnu.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/11/2024] [Accepted: 02/04/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND & AIMS Non-alcoholic fatty liver disease (NAFLD) or, as recently renamed, metabolic dysfunction-associated steatotic liver disease (MASLD), has common metabolic pathways with diabetes and cardiovascular disease (CVD). Non-invasive tools (NITs) for liver steatosis and steatohepatitis (MASH) were studied as potential predictors of diabetes, cardiovascular disease (CVD) and mortality over a 20-year period. METHODS In 2001-02, 3042 individuals from the Attica region of Greece were recruited randomly, and were stratified by subgroups of sex, age and region to reflect the general urban population in Athens, Greece. Validated NITs for hepatic steatosis (Hepatic Steatosis Index (HIS), Fatty Liver Index (FLI), Lipid Accumulation Product (LAP), NAFLD liver fat score (NAFLD-LFS)) and steatohepatitis (Index of non-alcoholic steatohepatitis (ION), aminotransferase-creatinine-clearance non-alcoholic steatohepatitis (acNASH)) were calculated. Incidence of diabetes, CVD and mortality were recorded 5, 10 and 20 years later. RESULTS Within a 20-year observation period, the diabetes and CVD incidence was 26.3% and 36.1%, respectively. All hepatic steatosis and steatohepatitis NITs were independently associated with diabetes incidence. ION and acNASH presented independent association with CVD incidence [(Hazard Ratio (HR)per 1 standard deviation (SD) = 1.33, 95% Confidence Interval (95% CI) (1.07, 1.99)) and (HRper 1 SD = 1.77, 95% CI (1.05, 2.59)), respectively]. NAFLD-LFS which is a steatosis NIT indicating features of steatohepatitis, was linked with increased CVD mortality (HRper 1 SD = 1.35, 95% CI (1.00, 2.30)) and all-cause mortality (HRper 1 SD = 1.43, 95% CI (1.08, 2.01)). Overall, steatohepatitis NITs (i.e., ION and acNASH) presented stronger associations with the outcomes of interest compared with steatosis NITs. Clinically important trends were observed in relation to diabetes and CVD incidence progressively over time, i.e. 5, 10 and 20 years after baseline. CONCLUSIONS Easily applicable and low-cost NITs representing steatohepatitis may be early predictors of diabetes and CVD onset. More importantly, these NITs increased the attributable risk conveyed by conventional CVD risk factors by 10%. Thus, their potential inclusion in clinical practice and guidelines should be studied further.
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Affiliation(s)
- Matina Kouvari
- Department of Medicine, Devision of Endocrinology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Christina Chrysohoou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 15772, Athens, Greece
| | - Evangelia Damigou
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 17671, Athens, Greece
| | - Fotios Barkas
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110, Ioannina, Greece
| | - Evrydiki Kravvariti
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - Evangelos Liberopoulos
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 15772, Athens, Greece
| | - Petros P Sfikakis
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, 15772, Athens, Greece
| | - Christos Pitsavos
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 15772, Athens, Greece
| | - Demosthenes Panagiotakos
- Department of Nutrition and Dietetics, School of Health Sciences and Education, Harokopio University, 17671, Athens, Greece.
| | - Christos S Mantzoros
- Department of Medicine, Devision of Endocrinology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA; Department of Medicine, Boston VA Healthcare System, Boston, MA, 02215, USA.
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Bea S, Jeong HE, Filion KB, Yu OHY, Cho YM, Lee BH, Chang Y, Byrne CD, Shin JY. Outcomes of SGLT-2i and GLP-1RA Therapy Among Patients With Type 2 Diabetes and Varying NAFLD Status. JAMA Netw Open 2023; 6:e2349856. [PMID: 38153732 PMCID: PMC10755620 DOI: 10.1001/jamanetworkopen.2023.49856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/13/2023] [Indexed: 12/29/2023] Open
Abstract
Importance Nonalcoholic fatty liver disease (NAFLD) is a cardiovascular risk factor, but whether sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) are associated with reduced cardiovascular risk in patients with type 2 diabetes (T2D) and concomitant NAFLD remains uncertain. Objective To investigate the outcomes of SGLT-2i and GLP-1RA therapy among patients with T2D varied by the presence or absence of NAFLD. Design, Setting, and Participants This retrospective, population-based, nationwide cohort study used an active-comparator new-user design. Two distinct new-user active-comparator cohorts of patients aged 40 years and older who initiated SGLT-2i or GLP-1RA were propensity score matched to patients who initiated dipeptidyl peptidase-4 inhibitors (DPP-4i). The study was conducted in South Korea from January 2013 to December 2020, and data analysis was conducted from October 2022 to March 2023. Main Outcomes and Measures The main outcomes were (1) major adverse cardiovascular events (MACE), a composite end point of hospitalization for myocardial infarction, hospitalization for stroke, and cardiovascular death, and (2) hospitalization for heart failure (HHF). Cox proportional hazards models were used to estimate hazard ratios (HRs). The Wald test was applied to assess heterogeneity by NAFLD. Results After 1:1 propensity score matching, 140 438 patients were retrieved in the first cohort (SGLT-2i vs DPP-4i; mean [SD] age, 57.5 [10.3] years; 79 633 [56.7%] male) and 34 886 patients were identified in the second cohort (GLP-1RA vs DPP-4i; mean [SD] age, 59.5 [10.5] years; 17 894 [51.3%] male). Compared with DPP-4i, SGLT-2i therapy was associated with a lower risk of MACE (HR, 0.78 [95% CI, 0.71-0.85]) and HHF (HR, 0.62 [95% CI, 0.48-0.81]). GLP-1RA therapy was associated with a decreased risk of MACE (HR, 0.49 [95% CI, 0.39-0.62]) but had statistically nonsignificant findings regarding HHF (HR, 0.64 [95% CI, 0.39-1.07]). Stratified analysis by NAFLD status yielded consistent results for SGLT-2i (MACE with NAFLD: HR, 0.73 [95% CI, 0.62-0.86]; without NAFLD: HR, 0.81 [95% CI, 0.72-0.91]; HHF with NAFLD: HR, 0.76 [95% CI, 0.49-1.17]; without NAFLD: HR, 0.56 [95% CI, 0.40-0.78]) and for GLP-1RA (MACE with NAFLD: HR, 0.49 [95% CI, 0.32-0.77]; without NAFLD: HR, 0.49 [95% CI, 0.37-0.65]; HHF with NAFLD: HR, 0.82 [95% CI, 0.38-1.76]; without NAFLD: HR, 0.54 [95% CI, 0.27-1.06]). Conclusions and Relevance In this population-based cohort study, SGLT-2i therapy was associated with a decreased risk of MACE and HHF, while GLP-1RA therapy was associated with a decreased risk of MACE among patients with T2D, irrespective of baseline NAFLD status.
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Affiliation(s)
- Sungho Bea
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Kristian B. Filion
- Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Oriana HY Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
- Division of Endocrinology and Metabolism, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Young Min Cho
- Division of Endocrinology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Bon Hyang Lee
- Division of Endocrinology, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yoosoo Chang
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
| | - Christopher D. Byrne
- Nutrition and Metabolism, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Health and Care Research, Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, United Kingdom
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
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Kouvari M, Mylonakis SC, Katsarou A, Valenzuela-Vallejo L, Guatibonza-Garcia V, Kokkorakis M, Verrastro O, Angelini G, Markakis G, Eslam M, George J, Papatheodoridis G, Mingrone G, Mantzoros CS. The first external validation of the Dallas steatosis index in biopsy-proven Non-alcoholic fatty liver Disease: A multicenter study. Diabetes Res Clin Pract 2023; 203:110870. [PMID: 37567510 DOI: 10.1016/j.diabres.2023.110870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023]
Abstract
AIMS A new non-invasive tool (NIT) for non-alcoholic fatty liver disease (NAFLD) proposed in 2022 by the multi-ethnic Dallas Heart Study, i.e. the Dallas Steatosis Index (DSI), was validated herein using for the first time the gold standard i.e. liver biopsy-proven NAFLD. METHODS This is a multicenter study based on samples and data from two Gastroenterology-Hepatology Clinics (Greece and Australia) and one Bariatric-Metabolic Surgery Clinic (Italy). Overall, n = 455 patients with biopsy-proven NAFLD (n = 374) and biopsy-proven controls (n = 81) were recruited. RESULTS The ability of DSI to correctly classify participants as NAFLD or controls was very good, reaching an Area Under the Curve (AUC) = 0.887. The cut-off point that could best differentiate the presence vs. absence of NAFLD corresponded to DSI = 0.0 (risk threshold: 50% | Sensitivity: 0.88; Positive Predictive Value (PPV): 93.0%; F1-score = 0.91). DSI demonstrated significantly better performance characteristics than other liver steatosis indexes. Decision curve analysis revealed that the benefit of DSI as a marker to indicate the need for invasive liver assessment was confirmed only when higher DSI values, i.e. ≥ 1.4, were used as risk thresholds. DSI performance to differentiate disease progression was inadequate (all AUCs < 0.700). CONCLUSIONS DSI is more useful for disease screening (NAFLD vs. controls) than to differentiate diseases stages or progression. The value of any inclusion of DSI to guidelines needs to be further studied.
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Affiliation(s)
- Matina Kouvari
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophia C Mylonakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Angeliki Katsarou
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Laura Valenzuela-Vallejo
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Michail Kokkorakis
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | | | - Georgios Markakis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Georgios Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | | | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Medicine, Boston VA Healthcare System, Boston, MA, USA.
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Mantovani A, Morieri ML, Palmisano L, Masulli M, Cossu E, Baroni MG, Bonomo K, Cimini FA, Cavallo G, Buzzetti R, Mignogna C, Leonetti F, Bacci S, Trevisan R, Pollis RM, Aldigeri R, Cas AD, de Kreutzenberg SV, Targher G. Hepatic steatosis with significant fibrosis is associated with an increased 10-year estimated risk of cardiovascular disease in adults with type 1 diabetes mellitus. Cardiovasc Diabetol 2023; 22:204. [PMID: 37563618 PMCID: PMC10416459 DOI: 10.1186/s12933-023-01945-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND We assessed whether hepatic steatosis with or without significant fibrosis (determined by validated non-invasive biomarkers) is associated with an increased 10-year estimated risk for cardiovascular disease (CVD) in people with type 1 diabetes mellitus (T1DM). METHODS We conducted a retrospective, multicenter, cross-sectional study involving 1,254 adults with established T1DM without pre-existing CVD. We used the hepatic steatosis index (HSI) and fibrosis (FIB)-4 index for non-invasively detecting hepatic steatosis (defined as HSI > 36), with or without coexisting significant fibrosis (defined as FIB-4 index ≥ 1.3 or < 1.3). We calculated the Steno type 1 risk engine and the atherosclerotic CVD (ASCVD) risk score to estimate the 10-year risk of developing a first fatal or nonfatal CVD event. RESULTS Using the Steno type 1 risk engine, a significantly greater proportion of patients with hepatic steatosis and significant fibrosis (n = 91) had a high 10-year estimated CVD risk compared to those with hepatic steatosis alone (n = 509) or without steatosis (n = 654) (75.8% vs. 23.2% vs. 24.9%, p < 0.001). After adjustment for sex, BMI, diabetes duration, hemoglobin A1c, chronic kidney disease, and lipid-lowering medication use, patients with hepatic steatosis and significant fibrosis had an increased 10-year estimated risk of developing a first fatal or nonfatal CVD event (adjusted-odds ratio 11.4, 95% confidence interval 3.54-36.9) than those without steatosis. We observed almost identical results using the ASCVD risk calculator. CONCLUSIONS The 10-year estimated CVD risk is remarkably greater in T1DM adults with hepatic steatosis and significant fibrosis than in their counterparts with hepatic steatosis alone or without steatosis.
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Affiliation(s)
- Alessandro Mantovani
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy
| | - Mario Luca Morieri
- Metabolic Diseases, Department of Medicine, University of Padua, Padua, Italy
| | - Luisa Palmisano
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Maria Masulli
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Efisio Cossu
- Diabetology Unit, Policlinico Universitario of Cagliari, Cagliari, Italy
| | - Marco Giorgio Baroni
- Department of Clinical Medicine, Life, Health and Environmental Sciences, University of Aquila, L'Aquila, Italy
- Neuroendocrinology and Metabolic Diseases, IRCCS Neuromed, Pozzilli, Italy
| | - Katia Bonomo
- Diabetes and Metabolic Diseases Unit, San Luigi Gonzaga University Hospital, Turin, Italy
| | | | - Gisella Cavallo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | | | - Carmen Mignogna
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Frida Leonetti
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy
| | - Simonetta Bacci
- Section of Endocrinology, Department of Medicine, IRCCS Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - Roberto Trevisan
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | | | - Raffaella Aldigeri
- Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria, Parma, Italy
| | - Alessandra Dei Cas
- Division of Nutritional and Metabolic Sciences, Azienda Ospedaliero-Universitaria, Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Giovanni Targher
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona, Verona, Italy.
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, VR, Italy.
- Section of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata, Piazzale Stefani, 1, Verona, 37126, Italy.
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