Usual Blood Pressure and Risk of New-Onset Diabetes: Evidence From 4.1 Million Adults and a Meta-Analysis of Prospective Studies

Neural Circuits Underlying Reciprocal Cardiometabolic Crosstalk: 2023 Arthur C. Corcoran Memorial Lecture

The interplay of various body systems, encompassing those that govern cardiovascular and metabolic functions, has evolved alongside the development of multicellular organisms. This evolutionary process is essential for the coordination and maintenance of homeostasis and overall health by facilitating the adaptation of the organism to internal and external cues. Disruption of these complex interactions contributes to the development and progression of pathologies that involve multiple organs. Obesity-associated cardiovascular risks, such as hypertension, highlight the significant influence that metabolic processes exert on the cardiovascular system. This cardiometabolic communication is reciprocal, as indicated by substantial evidence pointing to the ability of the cardiovascular system to affect metabolic processes, with pathophysiological implications in disease conditions. In this review, I outline the bidirectional nature of the cardiometabolic interaction, with special emphasis on the impact that metabolic organs have on the cardiovascular system. I also discuss the contribution of the neural circuits and autonomic nervous system in mediating the crosstalk between cardiovascular and metabolic functions in health and disease, along with the molecular mechanisms involved.

Assessment of genetic and clinical factors in T2D susceptibility among patients with hypertension

AIMS

Hypertension (HTN) and Type 2 Diabetes (T2D) often coexist, therefore understanding the relationship between both diseases is imperative to guide targeted prevention/therapy. This study aims to explore the relationship between HTN and T2D using genome-wide association study (GWAS) analysis and biochemical data to understand the implication of both clinical and genetic factors in these pathologies.

METHODS

A total of 2,876 patients were enrolled. Using GWAS and biochemical data, patients with both T2D and HTN were compared to patients with only HTN. Specificity was confirmed by testing the detected genetic variants for associations with HTN development in T2D patients, or with HTN in healthy subjects. Regression models were applied to examine the association of T2D in patients with HTN with cardiovascular risk factors. Replication was performed using UK Biobank dataset with 31,170 subjects.

RESULTS

Data showed that females with HTN are at higher risk of developing T2D due to dyslipidemia, while males faced higher risk due to high BMI (body mass index) and family history of T2D. GWAS identified Single Nucleotide Polymorphisms (SNPs) linked to T2D in patients with HTN. Notably, rs7865889, rs7756992, and rs10896290 were positively associated with T2D, whereas rs12737517 yielded negative association. Three SNPs were replicated in the UK Biobank (rs10896290, rs7865889, and rs7756992).

CONCLUSION

Incorporating clinical and genetic screening into risk assessment is important for the detection and prevention of T2D in patients with HTN. The detected SNPs (rs7865889, rs12737517, and rs10896290), especially the protective SNP (rs12737517), provide an opportunity for better diagnosis, prevention, and therapy of patients with T2D and HTN.

Fear of hypoglycemia and illness perception in type II diabetes patients

BACKGROUND

Hypoglycemia, a prevalent acute complication among individuals with type 2 diabetes (T2D), manifests with varied symptoms. Those with diabetes who have previously encountered hypoglycemic episodes commonly develop a Fear of Hyperglycemia (FOH). Illness perception (IP) significantly affects self-care behaviors and health outcomes in individuals diagnosed with T2D.

OBJECTIVE

This study examined the correlation between IP and FOH among T2D patients and predictors of FOH.

METHODS

The present study employed a descriptive-analytical design. The target population for this investigation comprised patients diagnosed T2D who sought medical care at the clinic and endocrinology departments of a hospital affiliated with Alborz University of Medical Sciences. The data collection period spanned from August 2019 to March 2021. A total of 300 individuals were included in the sample. Questionnaires were administered to measure both IP and FOH. Statistical analysis was conducted to examine the association between IP and FOH, as well as to identify the predictors of FOH.

RESULTS

The results of the study indicated a statistically significant relationship between FOH and the mean score of IP among patients with diabetes (p = 0.001, r = 0.393), suggesting a moderate positive correlation between these variables. Additionally, the duration of illness, IP, and level of education were identified as variables that predicted FOH (p < 0.05).

CONCLUSION

The numerous factors that influence FOH in individuals diagnosed with T2D highlight the necessity for strategic planning and training initiatives aimed at enhancing IP and reducing FOH within this specific population. Healthcare providers should prioritize interventions that not only address patients' concerns but also contribute to the improvement of their overall well-being. By implementing such interventions, healthcare providers can optimize diabetes management strategies and ultimately enhance patient outcomes.

A perspective on the role of physiological stresses in cancer, diabetes and cognitive disease as environmental diseases

With rapid industrialization, urbanization, and climate change, the impact of environmental factors on human health is becoming increasingly evident and understanding the complex mechanisms involved is vital from a healthcare perspective. Nevertheless, the relationship between physiological stress resulting from environmental stressors and environmental disease is complex and not well understood. Chronic exposure to environmental stressors, such as air and water contaminants, pesticides, and toxic metals, has been recognized as a potent elicitor of physiological responses ranging from systemic inflammation to immune system dysregulation causing or progressing environmental diseases. Conversely, physiological stress can exacerbate susceptibility to environmental diseases. Stress-induced alterations in immune function and hormonal balance may impair the ability to detoxify harmful substances and combat pathogens. Additionally, prolonged stress can impact lifestyle choices, leading to harmful behaviors. Understanding the link between physiological stress and environmental disease requires a systematic, multidisciplinary approach. Addressing this complex relationship necessitates the establishment of a global research network. This perspective discusses the intricate interplay between physiological stress and environmental disease, focusing on common environmental diseases, cancer, diabetes, and cognitive degeneration. Furthermore, we highlight the intricate and reciprocal nature of the connection between physiological stress and these environmental diseases giving a perspective on the current state of knowledge as well as identifying where further information is necessary. Recognizing the role of physiological stress in environmental health outcomes will aid in the development of comprehensive strategies to safeguard public health and promote ecological balance.

Progression from different blood glucose states to cardiovascular diseases: a prospective study based on multi-state model

AIMS

To quantify the trajectories from normoglycaemia to pre-diabetes, subsequently to type 2 diabetes mellitus (T2DM), cardiovascular diseases (CVD), and cardiovascular death, and the effects of risk factors on the rates of transition.

METHODS AND RESULTS

We used data from the Jinchang Cohort of 42 585 adults aged 20-88 free of coronary heart disease (CHD) and stroke at baseline. A multistate model was applied for analysing the progression of CVD and its relation to various risk factors. During a median follow-up of 7 years, 7498 participants developed pre-diabetes, 2307 developed T2DM, 2499 developed CVD, and 324 died from CVD. Among 15 postulated transitions, transition from comorbid CHD and stroke to cardiovascular death had the highest rate (157.21/1000 person-years), followed by transition from stroke alone to cardiovascular death (69.31/1000 person-years) and transition from pre-diabetes to normoglycaemia (46.51/1000 person-years). Pre-diabetes had a sojourn time of 6.77 years, and controlling weight, blood lipids, blood pressure, and uric acid within normal limits may promote reversion to normoglycaemia. Among transitions to CHD alone and stroke alone, transition from T2DM had the highest rate (12.21/1000 and 12.16/1000 person-years), followed by transition from pre-diabetes (6.81/1000 and 4.93/1000 person-years) and normoglycaemia (3.28/1000 and 2.39/1000 person-years). Age and hypertension were associated with an accelerated rate for most transitions. Overweight/obesity, smoking, dyslipidaemia, and hyperuricaemia played crucial but different roles in transitions.

CONCLUSION

Pre-diabetes was the optimal intervention stage in the disease trajectory. The derived transition rates, sojourn time, and influence factors could provide scientific support for the primary prevention of both T2DM and CVD.

Association between a mediterranean lifestyle and Type 2 diabetes incidence: a prospective UK biobank study

BACKGROUND

There is mounting evidence that the Mediterranean diet prevents type 2 diabetes, but little is known about the role of Mediterranean lifestyles other than diet and among non-Mediterranean populations. This work aimed to examine the association between a comprehensive Mediterranean-type lifestyle and type 2 diabetes incidence in a British adult population.

METHODS

We used data from 112,493 individuals free of cardiovascular disease and type 2 diabetes mellitus, aged 40-69 years, from the UK Biobank cohort, who were followed from 2009 to 2010 to 2021. The Mediterranean lifestyle was assessed through the 25-item MEDLIFE index, which comprises three blocks: (a) "Mediterranean food consumption", (b) "Mediterranean dietary habits", (c) "Physical activity, rest, social habits, and conviviality". Diabetes incidence was obtained from clinical records. Cox proportional-hazards regression models were used to analyze associations and adjusted for the main potential confounders.

RESULTS

After a median follow-up of 9.4 years, 2,724 cases of type 2 diabetes were ascertained. Compared to the first quartile of MEDLIFE adherence, the hazard ratios (95% confidence interval) for increasing quartiles of adherence were 0.90 (0.82-0.99), 0.80 (0.72-0.89) and 0.70 (0.62-0.79) (p-trend < 0.001). All three blocks of MEDLIFE were independently associated with lower risk of diabetes.

CONCLUSIONS

Higher adherence to the MEDLIFE index was associated with lower risk of type 2 diabetes in the UK Biobank. A Mediterranean-type lifestyle, culturally adapted to non-Mediterranean populations, could help prevent diabetes.

Genetic Evidence Strongly Supports Managing Weight and Blood Pressure in Addition to Glycemic Control in Preventing Vascular Complications in People With Type 2 Diabetes

OBJECTIVE

To investigate the causal association of type 2 diabetes and its components with risk of vascular complications independent of shared risk factors obesity and hypertension and to identify the main driver of this risk.

RESEARCH DESIGN AND METHODS

We conducted Mendelian randomization (MR) using independent genetic variants previously associated with type 2 diabetes, fasting glucose, HbA1c, fasting insulin, BMI, and systolic blood pressure as instrumental variables. We obtained summary-level data for 18 vascular diseases (15 for type 2 diabetes) from FinnGen and publicly available genome-wide association studies as our outcomes. We conducted univariable and multivariable MR, in addition to sensitivity tests to detect and minimize pleiotropic effects.

RESULTS

Univariable MR analysis showed that type 2 diabetes was associated with 9 of 15 outcomes; BMI and systolic blood pressure were associated with 13 and 15 of 18 vascular outcomes, respectively; and fasting insulin was associated with 4 and fasting glucose with 2. No robust association was found for HbA1c instruments. With adjustment for correlated traits in the multivariable test, BMI and systolic blood pressure, consistent causal effects were maintained, while five associations with type 2 diabetes (chronic kidney disease, ischemic heart disease, heart failure, subarachnoid hemorrhage, and intracerebral hemorrhage) were attenuated to null.

CONCLUSIONS

Our findings add strong evidence to support the importance of BMI and systolic blood pressure in the development of vascular complications in people with type 2 diabetes. Such findings strongly support the need for better weight and blood pressure management in type 2 diabetes, independent of glucose lowering, to limit important complications.

A comparison in women with newly diagnosed diabetes between those with and without a history of gestational diabetes: a new perspective

AIMS

Previous gestational diabetes mellitus (GDM) entails increased risk of future diabetes. We describe the characteristics of women with previous GDM and compare with no previous GDM from the cohort Diabetes in Kalmar and Kronoberg (DKK) of 1248 adults, 40% women, with new diabetes, and factors affecting age and C-peptide levels at diagnosis of diabetes.

METHODS

Age-at-diagnosis of diabetes, BMI, hypertension, hyperlipidemia, smoking, physical activity, and pre-existing myocardial infarction, stroke, or peripheral arterial insufficiency were registered at ordinary care visits close to diagnosis of diabetes, for the 43 women (9.4% of 456 from DKK with complete data for this analysis) with self-reported previous GDM (yes/no) and 86 controls without it, matched for date of diagnosis of diabetes. Blood samples were centrally analyzed for GADA and C-peptide for classification of diabetes.

RESULTS

Women with previous GDM had lower mean age-at-diagnosis of diabetes, 53.4 vs 65.0 years, lower systolic blood pressure (SBP), 131.2 vs 137.5 mmHg, and fewer had pre-existing hypertension than without previous GDM (p < 0.001-0.05). Among antibody negative women with previous GDM, BMI (p = 0.024), hypertension (p = 0.023) and hyperlipidemia (p < 0.001) were associated with higher levels of C-peptide, while physical activity was inversely associated (p = 0.035), and SBP (p = 0.02) and hypertension (p = 0.016) were associated with age-at-diagnosis of diabetes.

CONCLUSIONS

Women with previous GDM were a decade younger and had lower prevalence of hypertension at diagnosis of diabetes; C-peptide levels were associated with BMI, hypertension, and hyperlipidemia and showed a tendency to be lower, possibly indicating a phenotype with higher risk of overt cardiovascular disease later in life.

Intensive blood pressure lowering and the risk of new-onset diabetes in patients with hypertension: a post-hoc analysis of the STEP randomized trial

AIMS

The strategy of blood pressure intervention in the elderly hypertensive patients (STEP) trial reported the cardiovascular benefit of intensive systolic blood pressure (SBP) control in patients with hypertension. The association between intensive SBP lowering and the risk of new-onset diabetes is unclear. This study aimed to evaluate the effect of intensive SBP lowering on the incidence of new-onset diabetes.

METHODS AND RESULTS

Participants in STEP who had baseline fasting serum glucose (FSG) concentrations <7.0 mmol/L and no history of diabetes or hypoglycaemic medication use were included. The primary outcome was new-onset diabetes defined as the time to first occurrence of FSG concentrations ≥7.0 mmol/L. The secondary outcome was new-onset impaired fasting glucose (FSG: 5.6-6.9 mmol/L) in participants with normoglycemia. A competing risk proportional hazards regression model was used for analysis. The cohort comprised 5601 participants (mean age: 66.1 years) with a mean baseline SBP of 145.9 mmHg. Over a median follow-up of 3.42 years, 273 (9.6%) patients in the intensive SBP group (target, 110 to <130 mmHg) and 262 (9.5%) in the standard SBP group (target, 130 to <150 mmHg) developed diabetes (adjusted hazard ratio, 1.01; 95% confidence interval (CI), 0.86-1.20). The adjusted hazard ratio for the secondary outcome was 1.04 (95% CI, 0.91-1.18). The mean highest FSG concentration during the follow-up was 5.82 and 5.84 mmol/L in the intensive and standard groups, respectively.

CONCLUSION

Intensive SBP lowering is not associated with an altered risk of new-onset diabetes or impaired fasting glucose in hypertensive patients.

REGISTRATION

STEP ClinicalTrials.gov, number: NCT03015311.

Leveraging IgG N-glycosylation to infer the causality between T2D and hypertension

BACKGROUND

Observational studies demonstrated a bidirectional association between type 2 diabetes (T2D) and hypertension, whereas Mendelian randomization (MR) analyses supported the causality from T2D to hypertension but not causal from hypertension to T2D. We previously found that IgG N-glycosylation is associated with both T2D and hypertension, and thus IgG N-glycosylation might link the causality between them.

METHODS

We carried out a genome-wide association study (GWAS) to identify IgG N-glycosylation-quantitative-trait loci (QTLs) integrating GWAS for T2D and hypertension and then performed bidirectional univariable and multivariable MR analyses to infer the causal association among them. The inverse-variance-weighted (IVW) analysis was performed as the primary analysis, followed by some sensitivity analyses to explore the stability of the results.

RESULTS

Six putatively causal IgG N-glycans for T2D and four for hypertension were identified in the IVW method. Genetically predicted T2D increased the risk of hypertension (odds ratio [OR] = 1.177, 95% confidence interval (95% CI) = 1.037-1.338, P = 0.012) and vice versa (OR = 1.391, 95% CI = 1.081-1.790, P = 0.010). Multivariable MR showed that T2D remained at risk effect with hypertension ([OR] = 1.229, 95% CI = 1.140-1.325, P = 7.817 × 10^-8) after conditioning on T2D-related IgG-glycans. Conversely, hypertension was associated with higher T2D risk (OR = 1.287, 95% CI = 1.107-1.497, P = 0.001) after adjusting for related IgG-glycans. No evidence of horizontal pleiotropy was observed, as MR‒Egger regression provided P values for intercept > 0.05.

CONCLUSION

Our study validated the mutual causality between T2D and hypertension from the perspective of IgG N-glycosylation, further validating the "common soil" hypothesis underlying the pathogenesis of T2D and hypertension.

Intensive Blood Pressure Control and Diabetes Mellitus Incidence for Patients with Impaired Fasting Glucose: A Secondary Analysis of SPRINT

Background. Previous studies indicated that intensive blood pressure (BP) control (systolic BP < 120 mm·Hg) compared with standard BP control (<140 mm·Hg) was associated with an increased risk of type 2 diabetes (T2D) and impaired fasting glucose (IFG) among hypertensive patients with normoglycemia. However, the impact of intensive BP control on the incidence of T2D for those with IFG is still unknown. Methods. This was a secondary analysis of the SPRINT (Systolic Blood Pressure Intervention Trial) of the study. We included participants with IFG at randomization, which was defined as fasting blood glucose (FBG) between 100 and 125 mg/dL. The primary outcome was incident T2D, defined as events of reaching FBG ≥ 126 mg/dL, participant self-report T2D at annual examination, or a record of hypoglycemic medications at follow-up. The secondary outcome was incident IFG reversion (IFGR), defined as the time to first FBG back to normoglycemia (<100 mg/dl) among participants without incident T2D. Cox proportional hazards models were used to compare the cumulative incidence of outcomes between the two BP control groups. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Results. A total of 3310 participants were included in our primary outcome analysis (median age 67 years, 29% female). There were 293 participants who developed T2D among the intensive BP control group and 256 participants who developed T2D among the standard BP control group, resulting in 56.87 (50.36–63.39) versus 49.33 (43.29–55.37) events per 1000 person-years of treatment (HR 1.18 [95% CI, 1.00–1.40], $P=0.052$ ). After excluding 549 participants who developed T2D, 2761 participants were included in our secondary outcome analysis with 559 participants who developed IFGR among the intensive BP control group and 632 participants who developed IFGR among the standard BP control group, resulting in 141.20 (129.50–152.91) versus 158.20 (145.86,170.53) events per 1000 person-years of treatment (HR 0.9 [95% CI, 0.8–1.01], $P=0.067$ ). Conclusions. Our study found that in comparison to the standard BP control for hypertensive patients with IFG, intensive BP control was associated with a small increased risk of new-onset T2D, though it did not reach statistical significance. This kind of impact should be considered when implementing the strategy, especially for those with high risks of developing T2D. This trial is registered with NCT01206062.

Systolic Blood Pressure and Cardiovascular Risk in Patients With Diabetes: A Prospective Cohort Study

BACKGROUND

Whether the association between systolic blood pressure (SBP) and risk of cardiovascular disease is monotonic or whether there is a nadir of optimal blood pressure remains controversial. We investigated the association between SBP and cardiovascular events in patients with diabetes across the full spectrum of SBP.

METHODS

A cohort of 49 000 individuals with diabetes aged 50 to 90 years between 1990 and 2005 was identified from linked electronic health records in the United Kingdom. Associations between SBP and cardiovascular outcomes (ischemic heart disease, heart failure, stroke, and cardiovascular death) were analyzed using a deep learning approach.

RESULTS

Over a median follow-up of 7.3 years, 16 378 cardiovascular events were observed. The relationship between SBP and cardiovascular events followed a monotonic pattern, with the group with the lowest baseline SBP of <120 mm Hg exhibiting the lowest risk of cardiovascular events. In comparison to the reference group with the lowest SBP (<120 mm Hg), the adjusted risk ratio for cardiovascular disease was 1.03 (95% CI, 0.97-1.10) for SBP between 120 and 129 mm Hg, 1.05 (0.99-1.11) for SBP between 130 and 139 mm Hg, 1.08 (1.01-1.15) for SBP between 140 and 149 mm Hg, 1.12 (1.03-1.20) for SBP between 150 and 159 mm Hg, and 1.19 (1.09-1.28) for SBP ≥160 mm Hg.

CONCLUSIONS

Using deep learning modeling, we found a monotonic relationship between SBP and risk of cardiovascular outcomes in patients with diabetes, without evidence of a J-shaped relationship.

Association of Cardiovascular Health Score With Early- and Later-Onset Diabetes and With Subsequent Vascular Complications of Diabetes

BACKGROUND Little attention has been paid to how well the American Heart Association's cardiovascular health (CVH) score predicts early-onset diabetes in young adults. We investigated the association of CVH score with early- and later-onset diabetes and with subsequent complications of diabetes. METHODS AND RESULTS Our sample included 4547 Black and White adults in the CARDIA (Coronary Artery Risk Development in Young Adults) study without diabetes at baseline (1985-1986; aged 18-30 years) with complete data on the CVH score at baseline, including smoking, body mass index, physical activity, diet quality, total cholesterol, blood pressure, and fasting blood glucose. Incident diabetes was determined based on fasting glucose, 2-hour postload glucose, hemoglobin A1c, or self-reported medication use throughout 8 visits for 30 years. Multinomial logistic regression was used to assess the association between CVH score and diabetes onset at age <40 years (early onset) versus age ≥40 years (later onset). Secondary analyses assessed the association between CVH score and risk of complications (coronary artery calcium, clinical cardiovascular disease, kidney function markers, diabetic retinopathy, and diabetic neuropathy) among a subsample with diabetes. We identified 116 early- and 502 later-onset incident diabetes cases. Each 1-point higher CVH score was associated with lower odds of developing early-onset (odds ratio [OR], 0.64 [95% CI, 0.58-0.71]) and later-onset diabetes (OR, 0.78 [95% CI, 0.74-0.83]). Lower estimates of diabetic complications were observed per 1-point higher CVH score: 19% for coronary artery calcification≥100, 18% for cardiovascular disease, and 14% for diabetic neuropathy. CONCLUSIONS Higher CVH score in young adulthood was associated with lower early- and later-onset diabetes as well as diabetic complications.

Effect Modification by Age and Gender in the Correlation Between Diabetes Mellitus, Hypertension, and Obesity

BACKGROUND

Literature has reported differences in the epidemiology or natural history of non-communicable diseases among both the male and female sexes. Stratification of multimorbidity burden based on sex is crucial to identify and implement targeted prevention and control interventions for chronic diseases.

OBJECTIVES

To determine the burden of hypertension, type-2 diabetes mellitus, and obesity; and to compare the related multimorbidity among male and female patients.

METHODS

The study was a retrospective analysis of 375 802 medical records from primary care centers. Data was extracted from March 2022 to March 2023. A multivariate probit estimation methodology was employed using a 3-equations multivariate multiple probit model to jointly estimate the association of a person's sex with the diagnosis of the 3 chronic conditions: obesity, diabetes, and hypertension. A multinomial logistic regression analysis was conducted to allow each unique combination of these 3 chronic diseases.

RESULTS

Females had a relatively higher proportion of obesity (58.1% vs 41.2%), obesity and diabetes only (58.9% vs 41.1%), obesity and hypertension (63.6% vs 36.4%), and joint diagnosis with 3 conditions (65.7% vs 34.3%). Females' participants consistently had a significantly higher likelihood of diagnosis compared with males except for diabetes (OR = 0.59, 95% CI: 0.56-0.62) and the combination of only diabetes and hypertension (OR = 0.67, 95% CI: 0.61-0.74). The likelihood of other combinations ranged from 1.04 (95% CI: 0.98-1.10) for only hypertension to 2.30 (95% CI: 2.10-2.53) for the joint diagnosis of all 3 conditions. An increased likelihood of a single or combined occurrence of 3 chronic conditions was observed with increased age.

CONCLUSION

The multimorbidity distribution for diabetes mellitus, hypertension, and obesity differs significantly among male and female patients. The overall burden of morbidity, and mortality, however, tends to rise after 46 years of age, with the highest burden among individuals above 60 years of age.

Blood pressure-independent renoprotective effects of small interference RNA targeting liver angiotensinogen in experimental diabetes

BACKGROUND AND PURPOSE

Small interfering RNA (siRNA) targeting liver angiotensinogen lowers blood pressure, but its effects in hypertensive diabetes are unknown.

EXPERIMENTAL APPROACH

To address this, TGR (mRen2)27 rats (angiotensin II-dependent hypertension model) were made diabetic with streptozotocin over 18 weeks and treated with either vehicle, angiotensinogen siRNA, the AT₁ antagonist valsartan, the ACE inhibitor captopril, valsartan + siRNA or valsartan + captopril for the final 3 weeks. Mean arterial pressure (MAP) was measured via radiotelemetry.

KEY RESULTS

MAP before treatment was 153 ± 2 mmHg. Diabetes resulted in albuminuria, accompanied by glomerulosclerosis and podocyte effacement, without a change in glomerular filtration rate. All treatments lowered MAP and cardiac hypertrophy, and the largest drop in MAP was observed with siRNA + valsartan. Treatment with siRNA lowered circulating angiotensinogen by >99%, and the lowest circulating angiotensin II and aldosterone levels occurred in the dual treatment groups. Angiotensinogen siRNA did not affect renal angiotensinogen mRNA expression, confirming its liver-specificity. Furthermore, only siRNA with or without valsartan lowered renal angiotensin I. All treatments lowered renal angiotensin II and the reduction was largest (>95%) in the siRNA + valsartan group. All treatments identically lowered albuminuria, whereas only siRNA with or without valsartan restored podocyte foot processes and reduced glomerulosclerosis.

CONCLUSION AND IMPLICATIONS

Angiotensinogen siRNA exerts renoprotection in diabetic TGR (mRen2)27 rats and this relies, at least in part, on the suppression of renal angiotensin II formation from liver-derived angiotensinogen. Clinical trials should now address whether this is also beneficial in human diabetic kidney disease.

The gestational diabetes future diabetes prevention study (GODDESS): A partially randomised feasibility controlled trial

OBJECTIVES

To assess the feasibility of an ante- and post-natal lifestyle intervention for women with gestational diabetes mellitus (GDM) to reduce type 2 diabetes risk.

DESIGN

A partially randomised patient preference feasibility trial.

SETTING

Diabetes antenatal clinics in two inner-London hospitals, UK.

PARTICIPANTS

Pregnant women ≥18 years with a GDM diagnosis and pre-pregnancy body mass index of ≥25kg/m2.

INTERVENTION

Participants in the intervention group were offered four motivational interview-based sessions (two antenatally and two postnatally, at 3 and 6 months postpartum), a WhatsApp support group, a FitBit and electronic self-help resources.

OUTCOME MEASURES

Recruitment; retention; intervention dose received; data completion; adaptions; proportion achieving ≥5% weight loss; weight change, blood glucose; blood pressure; diet, physical activity, breastfeeding and depression. Clinical outcomes were measured at baseline and 6 months postpartum.

RESULTS

50 participants were recruited from 155 eligible women (32% recruitment rate). Thirty-four were recruited to the intervention group (23 following randomisation (RI-group) and 11 based on preference (PI-group)); and 16 to the control group (13 randomised (RC-group) and 3 preference (PC-group)). Attrition was 44% (n = 22/50). Forty-six percent (n = 6) of the intervention group (25% (n = 2) of the RI-group and 80% (n = 4) of the PI-group) achieved ≥5% weight loss compared to 8% (n = 1) in the control group (95% confidence interval (CI) -0.69 to 0.07). Mean weight change was -2.1kg±9.0 in the intervention group (0kg±5.4 in the RI-group and -5.4kg±13.0 in the PI-group) compared to +4.4kg±4.9 in the control group (RC +4.4kg ±5.3 and PC +4.7kg ±3.1, 95% CI -12.4 to 0.2).

CONCLUSIONS

Recruitment was feasible, but strategies to improve retention are needed. The findings suggest the intervention can support women with GDM to lose weight. The observed weight loss was primarily in women who preferred the intervention. Therefore, future trials may need to adopt a preference design and consider factors associated with preference.

TRIAL REGISTRATION

Trial registration: ISRCTN52675820 https://www.isrctn.com/ISRCTN52675820?q=ISRCTN52675820&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search.

Diet, Lifestyle Behaviours and Other Risk Factors Associated With Type 2 Diabetes Beyond Body Mass Index: A Mendelian Randomization Study

OBJECTIVES

Our aim in this study was to identify promising targets for the prevention of type 2 diabetes in addition to weight loss. We conducted a Mendelian randomization (MR) study to investigate the body mass index (BMI)-independent associations of 16 risk factors, including diet, lifestyle behaviours and others, with type 2 diabetes.

METHODS

We selected genetic variants as instrumental variables for diet, sleep traits, smoking, physical activity, education and blood pressure (BP) from European-descent genome-wide association studies (GWASs). Summary statistics for type 2 diabetes were derived from a recent GWAS with 74,124 European cases and 824,006 European controls. The inverse-variance weighted MR method was used to assess the associations of the risk factors with type 2 diabetes, followed by validation of robustness using different MR methods in sensitivity analyses.

RESULTS

Genetically predicted insomnia (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.06 to 1.15), smoking initiation (OR, 1.14; 95% CI, 1.06 to 1.21), educational level (OR, 0.69; 95% CI, 0.65 to 0.74), hypertension (OR, 6.50; 95% CI, 3.13 to 13.50), systolic BP (OR, 1.02; 95% CI, 1.02 to 1.03) and diastolic BP (OR, 1.03; 95% CI, 1.02 to 1.03) had BMI-independent effects on type 2 diabetes risk. In addition, alcohol dependence (OR, 1.10; 95% CI, 1.05 to 1.16; BMI-adjusted OR, 1.04; 95% CI, 0.98 to 1.09) and vegetarian diet (OR, 0.50; 95% CI, 0.33 to 0.74; BMI-adjusted OR, 0.78; 95% CI, 0.57 to 1.06) appeared to be correlated with type 2 diabetes via a BMI-mediated pathway. Sensitivity analyses further confirmed the relationship between these factors and type 2 diabetes.

CONCLUSIONS

In this systematic MR study, insomnia, smoking, education and BP had BMI-independent causal effects on the risk of type 2 diabetes, whereas alcohol dependence and vegetarian diet were associated with type 2 diabetes through BMI.

Identification of the risk factors of type 2 diabetes and its prediction using machine learning techniques

This study identified the risk factors for type 2 diabetes (T2D) and proposed a machine learning (ML) technique for predicting T2D. The risk factors for T2D were identified by multiple logistic regression (MLR) using p-value (p<0.05). Then, five ML-based techniques, including logistic regression, naïve Bayes, J48, multilayer perceptron, and random forest (RF) were employed to predict T2D. This study utilized two publicly available datasets, derived from the National Health and Nutrition Examination Survey, 2009-2010 and 2011-2012. About 4922 respondents with 387 T2D patients were included in 2009-2010 dataset, whereas 4936 respondents with 373 T2D patients were included in 2011-2012. This study identified six risk factors (age, education, marital status, SBP, smoking, and BMI) for 2009-2010 and nine risk factors (age, race, marital status, SBP, DBP, direct cholesterol, physical activity, smoking, and BMI) for 2011-2012. RF-based classifier obtained 95.9% accuracy, 95.7% sensitivity, 95.3% F-measure, and 0.946 area under the curve.

Exploring the risk factors of impaired fasting glucose in middle-aged population living in South Korean communities by using categorical boosting machine

Objective

This epidemiological study (1) identified factors associated with impaired fasting glucose using 3,019 subjects (≥30 years old and <60 years old) without diabetes mellitus from national survey data and (2) developed a nomogram that could predict groups vulnerable to impaired fasting glucose by using machine learning.

Methods

This study analyzed 3,019 adults between 30 and 65 years old who completed blood tests, physical measurements, blood pressure measurements, and health surveys. Impaired fasting glucose, a dependent variable, was classified into normal blood glucose (glycated hemoglobin<5.7% and fasting blood glucose ≤ 100mg/dl) and impaired fasting glucose (glycated hemoglobin is 5.7-6.4% and fasting blood glucose is 100-125mg/dl). Explanatory variables included socio-demographic factors, health habit factors, anthropometric factors, dietary habit factors, and cardiovascular disease risk factors. This study developed a model for predicting impaired fasting glucose by using logistic nomogram and categorical boosting (CatBoost).

Results

In this study, the top eight variables with a high impact on CatBoost model output were age, high cholesterol, WHtR, BMI, drinking more than one shot per month for the past year, marital status, hypertension, and smoking.

Conclusion

It is necessary to improve lifestyle and continuously monitor subjects at the primary medical care level so that we can detect non-diabetics vulnerable to impaired fasting glucose living in the community at an early stage and manage their blood glucose.

Association of mean arterial pressure with 5-year risk of incident diabetes in Chinese adults：a secondary population-based cohort study

OBJECTIVE

Hypertension predicts the development of diabetes. However, there are still lacking high-quality studies on the correlation between mean arterial pressure (MAP) and incident diabetes. We aimed to explore the relationship between MAP and diabetes in Chinese adults.

DESIGN

This is a secondary retrospective cohort study and the data were downloaded from the 'DATADRYAD' database (www.Datadryad.org).

PARTICIPANTS

The study included 210 418 adults without diabetes at baseline between 2010 and 2016 across 32 sites and 11 cities in China.

SETTING

The target-independent and dependent variables were MAP measured at baseline and diabetes occurred during follow-up. Cox proportional hazards regression was used to explore the relationship between MAP and diabetes.

PRIMARY OUTCOME MEASURES

The outcome was incident diabetes, which was defined as fasting blood glucose ≥7.00 mmol/L and/or self-reported diabetes during follow-up. Patients were censored either at the time of the diagnosis or at the last visit, whichever comes first.

RESULTS

3927 participants developed diabetes during a 5-year follow-up. After adjusting covariates, MAP positively correlated with diabetes (HR=1.008, 95% CI 1.005 to 1.011, p<0.001), and the absolute risk difference was 0.02%. E-value analysis and multiple imputations were used to explore the robustness of the results. The relationship between MAP and diabetes was also non-linear, and the inflection point of MAP was 100.333 mm Hg. Subgroup analysis revealed a stronger association between MAP and diabetes in people with age (≥30,<50 years old), fasting plasma glucose <6.1 mmol/L and drinking. Additionally, receiver operating characteristic (ROC) curves showed the predictive performance of MAP for diabetes was similar to systolic blood pressure (SBP) (area under the curve (AUC)=0.694 with MAP vs AUC=0.698 with SBP).

CONCLUSIONS

MAP is an independent predictor for a 5-year risk of incident diabetes among Chinese adults. The relationship between MAP and diabetes is also non-linear. When MAP is below 100.333 mm Hg, MAP is closely positively related to diabetes.

Hamid A, Ugusman A. Effects of Piper sarmentosum Roxb. on hypertension and diabetes mellitus: A systematic review and meta-analysis

Hypertension and diabetes mellitus are among the most prevalent diseases affecting people from all walks of life. Medicinal herbs have garnered interest as potential agents for the prevention and treatment of diabetes mellitus and hypertension due to their multiple beneficial effects. Piper sarmentosum Roxb. (PS) is an edible medicinal plant that has been traditionally used in Asia for treating hypertension and diabetes mellitus. This review is aimed to provide comprehensive information from the literature on the effects of PS on hypertension and diabetes mellitus. A computerized database search was performed on Scopus, PubMed and Web of Science databases with the following set of keywords: Piper sarmentosum AND diabetes mellitus OR diabetic OR diabetes OR hyperglyc*emia OR blood glucose OR HbA1c OR glycated h*emoglobin OR h*emoglobin A1c OR hyperten* OR blood pressure. A total of 47 articles were screened and 14 articles published between the years 1998 until 2021 were included for data extraction, comprising of six articles on antihypertensive and eight articles on antidiabetic effects of PS. These studies consist of two in vitro studies and eleven in vivo animal studies. Meta-analysis of three studies on hypertension showed that PS versus no treatment significantly lowered the systolic blood pressure with mean difference (MD) -39.84 mmHg (95% confidence interval (CI) -45.05, -34.62; p < 0.01), diastolic blood pressure with MD -26.68 mmHg (95% CI -31.48, -21.88; p < 0.01), and mean arterial pressure with MD -30.56 mmHg (95% CI -34.49, -26.63; p < 0.01). Most of the studies revealed positive effects of PS against hypertension and diabetes mellitus, suggesting the potential of PS as a natural source of antidiabetic and antihypertensive agents.

Long-term variability and change trend of systolic blood pressure and risk of type 2 diabetes mellitus in middle-aged Japanese individuals: findings of the Aichi Workers' Cohort Study

Studies have reported that short-term blood pressure (BP) variability (BPV) is associated with type 2 diabetes mellitus (T2DM) incidence, but the association with long-term BPV remains unclear. The present study investigated the associations of long-term BPV as well as the time trend of BP changes over time with the incidence of T2DM. This study followed a cohort of 3017 Japanese individuals (2446 male, 571 female) aged 36-65 years from 2007 through March 31, 2019. The root-mean-square error (RMSE) and the slope of systolic BP (SBP) change regressed on year were calculated individually using SBP values obtained from 2003 to baseline (2007). A multivariable Cox proportional hazard model was applied to estimate hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) for tertiles of SBP RMSE and continuous SBP slopes adjusted for age, sex, smoking status, regular exercise, sodium intake, family history of diabetes, sleep disorder, body mass index (BMI), SBP, and fasting blood glucose (FBG) at baseline, and BMI slope from 2003 to 2007. The highest RMSE tertile compared to the lowest was associated with a significantly higher incidence of T2DM after adjusting for covariates (HR: 1.79, 95% CI: 1.15, 2.78). The slope was also significantly associated with T2DM incidence until baseline SBP and FBG were adjusted (HR: 1.03, 95% CI: 0.99, 1.07). In conclusion, long-term SBP variability was significantly associated with an increased incidence of T2DM independent of baseline age, sex, BMI, SBP, FBG, lifestyle factors and BMI slope from 2003 until baseline.

Unravelling the Distinct Effects of Systolic and Diastolic Blood Pressure Using Mendelian Randomisation

A true discrepancy between the effect of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on cardiovascular (CV) outcomes remains unclear. This study performed two-sample Mendelian randomization (MR) using genetic instruments that exclusively predict SBP, DBP or both to dissect the independent effect of SBP and DBP on a range of CV outcomes. Genetic predisposition to higher SBP and DBP was associated with increased risk of coronary artery disease (CAD), myocardial infarction (MI), stroke, heart failure (HF), atrial fibrillation (AF), chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM). Genetically proxied SBP exclusively was associated with CAD (OR 1.18, 95% CI: 1.03–1.36, per 10 mmHg), stroke (1.44[1.28–1.62]), ischemic stroke (1.49[1.30–1.69]), HF (1.41[1.20–1.65]), AF (1.28[1.15–1.43]), and T2DM (1.2[1.13–1.46]). Genetically proxied DBP exclusively was associated with stroke (1.21[1.06–1.37], per 5 mmHg), ischemic stroke (1.24[1.09–1.41]), stroke small-vessel (1.35[1.10–1.65]) and CAD (1.19[1.00–1.41]). Multivariable MR using exclusive SBP and DBP instruments showed the predominant effect of SBP on CAD (1.23[1.05–1.44], per 10 mmHg), stroke (1.39[1.20–1.60]), ischemic stroke (1.44[1.25–1.67]), HF (1.42[1.18–1.71]), AF (1.26[1.10–1.43]) and T2DM (1.31[1.14–1.52]). The discrepancy between effects of SBP and DBP on outcomes warrants further studies on underpinning mechanisms which may be amenable to therapeutic targeting.

Diabetes Mellitus among Adult Outpatients Visiting a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Diabetes mellitus is a chronic metabolic disease characterised by elevated blood sugar levels and is a pandemic of public health importance. Screening programs can help reduce morbidity and mortality by preventing or delaying complications. This study aimed to find out the prevalence of diabetes mellitus among adult outpatients visiting a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted among outpatients visiting a tertiary care centre between 1 January 2019 to 31 December 2019. Ethical approval was obtained from the Ethical Review Board (Registration number: 408/2020 P). Patients with unknown history of diabetes participating in free random blood sugar examinations were included in the study. Systematic random sampling was used. Point estimate and 95% Confidence Interval were calculated.

Results

Among 385 adult outpatients, 17 (4.42%) (2.37-6.47, 95% Confidence Interval) had diabetes. The mean random blood sugar level of the diabetic patients was 281.41±57.49 mg/dl.

Conclusions

The prevalence of diabetes mellitus among adult outpatients was similar to previous studies conducted in similar settings. Random blood sugar test in hospital outpatient settings is feasible to identify people with diabetes mellitus.

Keywords

diabetes mellitus; hospital; Nepal; outpatient.

Association between serum manganese levels and diabetes in chinese adults with hypertension

Manganese (Mn) is an essential trace metal element that is associated with diabetes; however, the results of previous studies are inconsistent. Furthermore, few studies have been conducted in a hypertensive population. The purpose of this study is to explore the relationship between manganese and diabetes in a population with hypertension. A cross‐sectional study was conducted, including 2575 hypertensive individuals from 14 provinces in China. Serum manganese concentrations were measured by the inductively coupled plasma mass spectrometry (ICP‐MS) method. And logistic regression models were used to analyze the association between serum manganese and the risk of diabetes. The prevalence of diabetes was 27.0% in this hypertensive population. In logistic regression models, the odds ratios (95% confidence interval) for diabetes in tertile subgroups were 1.40 (1.12, 1.76) and 1.32 (1.05, 1.65) for tertiles 1 and tertiles 3, respectively, compared to tertile 2 (reference). Additionally, an interaction between sex and manganese was observed. The odds ratios (95% confidence interval) for diabetes were 1.29 (0.95, 1.75) and 0.96 (0.70, 1.31) for tertiles 1 and tertiles 3 among males, and 1.44 (1.01, 2.04) and 1.81 (1.29, 2.55) for tertiles 1 and tertiles 3 among females, respectively, compared to tertile 2. In conclusion, a U‐shaped association between serum manganese and diabetes was observed in a Chinese population with hypertension, and the association was modified by sex.

Adherence to a Healthy Sleep Pattern and Incidence of Cardiometabolic Multimorbidity Among Hypertensive Patients: A Prospective Study of UK Biobank

Study Objectives

To investigate whether a healthy sleep pattern would reduce the risk of cardiometabolic multimorbidity (CMM) among hypertensives.

Methods

This is a prospective cohort analysis from the UK Biobank. A total of 69 524 hypertensives without a history of diabetes mellitus, coronary heart disease, or stroke at baseline were enrolled. Five dimensions of healthy sleep at baseline including early chronotype, sleep 7–8 h/d, free of insomnia, no snoring, and no frequent excessive daytime sleepiness were used to generate a healthy sleep score ranging from 0 to 5 (one point was given for each dimension of healthy sleep). A higher score indicated a healthier sleep pattern. We set five groups corresponding to the healthy sleep score of 5, 4, 3, 2, and 0–1, respectively. The primary outcome was the incidence of overall CMM among enrolled hypertensives. We assessed the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) by Fine-Gray subdistribution hazard models.

Results

We found the full-adjusted HR (95% CI) for overall CMM was 0.93 (0.91–0.95) for a 1-point increase in the healthy sleep score. Compared to hypertensives with a healthy sleep score of 0–1, those with a score of 5 had a 27% lower risk of overall CMM, and 37%, 23%, and 20% lower risks of diabetes mellitus, coronary heart disease, and stroke, respectively, after adjusting for sociodemographic characteristic, lifestyle, and clinical factors.

Conclusions

Our results indicated that a healthy sleep pattern was associated with lower risks of CMM outcomes among hypertensives.

Effect of age and sex on the associations between potential modifiable risk factors and both type 2 diabetes and impaired fasting glycaemia among West African adults

Background

Type 2 diabetes mellitus (T2DM) is becoming one of the leading causes of morbidity and mortality worldwide, including among Africans. Knowledge of the association between traditional risk factors and both diabetes and pre-diabetes, and whether these differ by age and sex, is important for designing targeted interventions. However, little is known about these associations for African populations.

Methods

The study used data from WHO STEPS surveys, comprising 15,520 participants (6,774 men and 8,746 women) aged 25–64 years, from 5 different West African countries, namely Burkina Faso (4,711), Benin (3,816), Mali (1,772), Liberia (2,594), and Ghana (2,662). T-test and chi-square tests were used to compare differences in the prevalence of traditional risk factors for both sexes. Multinomial logistic regression was conducted to ascertain the relative risks (RR) and 95% confidence intervals (CI) for both T2DM and impaired fasting glucose (IFG) relating to each risk factor, including obesity [defined by BMI, waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR)], high blood pressure (HBP), fruit and vegetable consumption, physical inactivity, alcohol consumption, and smoking. Models for each of these traditional risk factors and interactions with age and sex were fitted.

Results

Factors associated with T2DM and IFG were age, obesity [defined by BMI, WC, WHtR, and WHR], HBP, smoking, physical inactivity, and fruit and vegetable consumption (p < 0.05). Analysis of interaction effects showed few significant differences in associations between risk factors and T2DM according to age or sex. Significant interaction with age was observed for HBP*age and T2DM [RR; 1.20, 95% CI: (1.01, 1.42)) (p = 0.04)], WHtR*age and T2DM [RR; 1.23, 95% CI: (1.06, 1.44) (p = 0.007)] and WHR*age and IFG [RR: 0.79, 95% CI: (0.67, 0.94) (p = 0.006)]. Some interactions with age and sex were observed for the association of alcohol consumption and both IFG and T2DM, but no clear patterns were observed.

Conclusion

The study found that with very few exceptions, associations between traditional risk factors examined and both IFG and T2DM did not vary by age or sex among the West African population. Policies and public health intervention strategies for the prevention of T2DM and IFG should target adults of any age or sex in West Africa.

Short-term effects of modest salt reduction combined with DASH diet on changing salt eating habits in hypertensive patients with type II diabetes

OBJECTIVE

Excessive salt intake is currently the foremost universal risk factor for controllable chronic disease. This study evaluated the short-term effects of a modest salt intake reduction combined with the Chinese Modified Dietary Approaches to Stop Hypertension (CM-DASH) diet on sodium and potassium intake, mean arterial pressure (MAP), and pulse pressure (PP) in hypertensive patients with type II diabetes.

METHODS

Sixty-one participants were randomized to the intervention group (52% low-sodium salt and DASH) and control group (normal salt and DASH). An 8-week dietary intervention was applied. Daily salt intake, blood pressure (BP), and drug use were recorded every week. Twenty-four-hour urine, casual urine, and blood samples were measured at baseline, the 4th week, and the end of the intervention.

RESULTS

Fifty-nine patients (25 men) completed the entire study. Sodium intake decreased by 1259.66 (792.76, 1726.56)/705.80 (149.21, 1262.39) mg/day after 4 weeks (intervention: P < .001; control: P = .015). Potassium intake increased by 641.14 (73.31, 1208.96)/43.43 (-259.66, 346.53) mg/day (intervention: P = .028); MAP decreased by 9.06 (6.69, 11.43)/7.16 (4.03, 10.28) mmHg (both: P < .001); PP decreased by 7.97 (3.05, 12.88)/5.74 (2.55,8.94) mmHg (intervention: P = .002; control: P = .001) after 8 weeks. However, the difference between the two groups was not statistically significant.

CONCLUSION

Modest salt reduction and the CM-DASH diet for hypertensive patients with type II diabetes can achieve short-term salt reduction effects. The effect on changing salt-eating habits needs to be investigated with an extended follow-up.

Diabetes Mellitus and Its Risk Factors among Migrant Workers in Kuwait

The prevalence of diabetes mellitus (DM) is growing enormously worldwide, and actions need to be taken in order to minimize the burden of diabetes mellitus and reduce its complications. Since two-thirds of Kuwait's population are expatriates, the prevalence of and factors associated with diabetes among migrant workers was assessed as it has a significant impact on migrant workers' quality of life, health, and productivity. The data used in this study was for all migrant workers who attended Shuaiba Industrial Medical Center (SIMC) for physical examination in the year 2018. Univariate and multivariate regression were used to assess the relationship between diabetes mellitus and the other independent factors where odds ratios with confidence intervals were delineated. Information for a total of 3477 participants was recorded in the dataset for 2018. Of the total participants, 10.1% had diabetes mellitus. About 49% of the participants were overweight. The largest age group of participants was between 31 and 40 years of age. A small percentage of the participants were diagnosed with hypertension at 11.8%. Additionally, 76.1% of the participants reported themselves as non-smokers. Diabetes was positively associated with age, hypertension, and nationalities. However, no association was found between BMI and smoking tobacco. This is the first study in SIMC to assess DM and its associated risk factor among migrants, since migrant workers are neglected subpopulations that need our focus and attention to achieve justice and fairness. The findings revealed that the prevalence of DM among our study population was considerably lower. However, a healthy lifestyle, including a healthy diet and being physically active, need to be introduced to prevent any further damage.

Risk factors for hypertension and diabetes comorbidity in a Korean population: A cross-sectional study

BACKGROUND

Hypertension and diabetes are risk factors for severe cardiovascular disease and are prevalent comorbidities. No studies have examined the associations of various risk factors related to anthropometry, bone mineral density and body composition of specific body regions with hypertension and diabetes comorbidity (HDC). This study explored the association between HDC and various risk factors related to specific body regions.

METHOD

A total of 7,978 subjects (3,451 men and 4,527 women) aged ≥ 50 years were included in the analysis. A binary logistic regression analysis based on complex sample data analysis was conducted to examine associations between the normal and diabetes groups, between the normal and hypertension groups, and between the normal and HDC groups.

RESULTS

Among Korean adults aged ≥ 50 years, 11.27% of men and 10.05% of women had both diabetes and hypertension. The HDC prevalence was higher in men than in women. In men, waist-to-height ratio (WHtR, adjusted OR = 1.63 [1.22-2.18], adjusted p<0.001) exhibited a more significant association with HDC than other indices, left leg fat mass (adjusted OR = 0.61 [0.45-0.81], adjusted p = 0.0009) and right leg fat mass (adjusted OR = 0.60 [0.45-0.81], adjusted p = 0.0007) displayed strong negative associations with diabetes, and left leg lean mass (adjusted OR = 0.77 [0.67-0.89], adjusted p = 0.0002) and trunk fat mass (adjusted OR = 1.28 [1.07-1.52], adjusted p = 0.0062) were significantly associated with hypertension. In women, left leg fat mass (adjusted OR = 0.29 [0.22-0.39], adjusted p<0.0001) and right leg fat mass (adjusted OR = 0.32 [0.23-0.45], adjusted p<0.0001) exhibited strong negative associations with HDC, waist circumference (WC) (adjusted OR = 2.15 [1.40-3.30], adjusted p = 0.0005) showed a stronger association with diabetes than did other indices, and WC (adjusted OR = 1.39 [1.11-1.74], adjusted p = 0.0040) and WHtR (adjusted OR = 1.39 [1.09-1.76], adjusted p = 0.0075) were significantly associated with hypertension.

DISCUSSION

HDC was more strongly associated with fat and lean mass than diabetes and hypertension. The association between HDC and body fat variables was more robust in women than in men.

Interaction of Hypertension and Insulin Resistance Exacerbates the Occurrence of Diabetes Mellitus in Healthy Individuals

OBJECTIVE

Hypertension and type 2 diabetes are common complications. Patients with hypertension often show insulin resistance. The purpose of this study was to investigate the correlations between different blood pressure levels and different degrees of insulin resistance, as well as their interactions, with newly diagnosed diabetes mellitus.

METHODS

We conducted a retrospective study on 1251 adult medical examiners who were examined in the Physical Examination Center of Zhongshan Hospital, Fudan University (Shanghai, China) during 2015. All human subjects had no history of diabetes. General clinical data, including blood pressure, fasting glucose and 2-h post-load glucose levels, and lipid profiles, were collected. HOMA-IR was separately calculated. Statistical analyses were carried out by using SPSS software (version 13.0).

RESULTS

In 1251 physical examination subjects, a total of 166 cases of newly diagnosed diabetes were detected, with a total detection rate of 13.3%. The rates of newly diagnosed diabetes in the normal blood pressure group, high-normal blood pressure group, and hypertension group were 4.9%, 10.6%, and 19.0%, respectively. Compared with the normal blood pressure group, the proportion of newly diagnosed diabetes in the hypertension group was significantly increased [OR: 2.956, 95% CI 1.736-5.032, P < 0.001]. According to the stratification of HOMA-IR level, with the first quartile group (HOMA-IR<1.21) as a reference, the risk of newly diagnosed diabetes in the fourth quartile group (HOMA-IR ≥2.68) was significantly increased. After adjusting for gender and age, for every unit increase in HOMA-IR, the risk of developing newly diagnosed diabetes increased 9.67 times [OR: 9.670, 95% CI 5.086-18.384, P < 0.001]. When hypertension was combined with insulin resistance (HOMA-IR ≥2.68), the risk of newly diagnosed diabetes was 38.32 times compared with the control group [OR: 38.315, 95% CI 9.227-159.108, P < 0.001].

CONCLUSIONS

Elevated blood pressure levels and insulin resistance levels were associated with the risk of newly diagnosed diabetes. Hypertension was an independent risk factor for newly diagnosed diabetes, and the combination of hypertension with insulin resistance further increased the risk of newly diagnosed diabetes.

Stolen childhood taking a toll at young adulthood: The higher risk of high blood pressure and high blood glucose comorbidity among child brides

Despite notable progress being made in preventing child marriage, a significant proportion of women worldwide are still married before reaching adulthood. Though many aspects of child marriage have been widely studied, little is known on the later life health outcomes of child brides, let alone the critical need for healthcare during adulthood. This paper examines whether child brides at a young adult age bear a greater risk of high blood pressure (HBP) and high blood glucose (HBG) comorbidity than those who were married as adults. Using nationally representative data from India, we categorized married young adult (aged 20-34 years) women in four categories: neither HBP nor HBG, HBP only, HBG only, and both HBP and HBG. We estimated multinomial logistic regressions to obtain unadjusted and adjusted relative risk ratios in favor of these mutually exclusive outcomes for the child marriage indicator. Around 0.5% of the women in our sample had high blood pressure and high blood glucose comorbidity. While the prevalence of comorbidity was 0.4% among women who were married as adults, comorbidity was 40% higher (p < 0.000) among women who were married as children. The relative risk of the comorbidity among child brides was 1.4 (95%CI: 1.2-1.7) times that of their peers who were not married as children. The findings, thus, suggest that child brides at young adult age are at greater risk of having high blood pressure and high blood glucose comorbidity. Concerted public health efforts, therefore, are necessary to improve their long-term health and wellbeing.

Association of healthy lifestyle including a healthy sleep pattern with incident type 2 diabetes mellitus among individuals with hypertension

BACKGROUND

Evidence is limited regarding the association of healthy lifestyle including sleep pattern with the risk of complicated type 2 diabetes mellitus (T2DM) among patients with hypertension. We aimed to investigate the associations of an overall healthy lifestyle including a healthy sleep pattern with subsequent development of T2DM among participants with hypertension compared to normotension, and to estimate how much of that risk could be prevented.

METHODS

This study examined six lifestyle factors with T2DM cases among hypertension (227,966) and normotension (203,005) and their interaction in the UK Biobank. Low-risk lifestyle factors were defined as standard body mass index (BMI), drinking alcohol in moderation, nonsmoking, engaging in moderate- to vigorous-intensity physical activity, eating a high-quality diet, and maintaining a healthy sleep pattern.

RESULTS

There were 12,403 incident T2DM cases during an average of 8.63 years of follow-up. Compared to those with 0 low-risk lifestyle factors, HRs for those with 5-6 were 0.14 (95% CI 0.10 to 0.19) for hypertensive participants, 0.13 (95% CI 0.08 to 0.19) for normotensive participants, respectively (p_trend < 0.001). 76.93% of hypertensive participants were considerably less likely to develop T2DM if they adhered to five healthy lifestyle practices, increased to 81.14% if they followed 6-factors (with a healthy sleep pattern). Compared with hypertension adults, normotensive people gain more benefits if they stick to six healthy lifestyles [Population attributable risk (PAR%) 83.66%, 95% CI 79.45 to 87.00%, p for interaction = 0.0011].

CONCLUSIONS

Adherence to a healthy lifestyle pattern including a healthy sleep pattern is associated with lower risk of T2DM in hypertensives, and this benefit is even further in normotensives.

Development and Validation of Decision Rules Models to Stratify Coronary Artery Disease, Diabetes, and Hypertension Risk in Preventive Care: Cohort Study of Returning UK Biobank Participants

Many predictive models exist that predict risk of common cardiometabolic conditions. However, a vast majority of these models do not include genetic risk scores and do not distinguish between clinical risk requiring medical or pharmacological interventions and pre-clinical risk, where lifestyle interventions could be first-choice therapy. In this study, we developed, validated, and compared the performance of three decision rule algorithms including biomarkers, physical measurements, and genetic risk scores for incident coronary artery disease (CAD), diabetes (T2D), and hypertension against commonly used clinical risk scores in 60,782 UK Biobank participants. The rules models were tested for an association with incident CAD, T2D, and hypertension, and hazard ratios (with 95% confidence interval) were calculated from survival models. Model performance was assessed using the area under the receiver operating characteristic curve (AUROC), and Net Reclassification Index (NRI). The higher risk group in the decision rules model had a 40-, 40.9-, and 21.6-fold increased risk of CAD, T2D, and hypertension, respectively (p < 0.001 for all). Risk increased significantly between the three strata for all three conditions (p < 0.05). Based on genetic risk alone, we identified not only a high-risk group, but also a group at elevated risk for all health conditions. These decision rule models comprising blood biomarkers, physical measurements, and polygenic risk scores moderately improve commonly used clinical risk scores at identifying individuals likely to benefit from lifestyle intervention for three of the most common lifestyle-related chronic health conditions. Their utility as part of digital data or digital therapeutics platforms to support the implementation of lifestyle interventions in preventive and primary care should be further validated.

Unequal burden of equal risk factors of diabetes between different gender in India: a cross-sectional analysis

Many studies have supported that the burden of diabetes is shared differently by different genders due to various factors associated with it. This study aims at capturing whether women and men with a similar background, dietary and smoking habits, and biological conditions (blood pressure and body mass index (BMI)) are being affected equally or differently by diabetes. We have used cross-sectional data of NFHS-4 by covering the age group 15-49 years. Association between socio-economic background, dietary habits, biological conditions, and diabetes has been estimated using two separate multivariate logistic regression models. Results show that the overall prevalence of diabetes is higher among men (2.63%) than women (2.35%). Whereas, women belonging to urban areas (3.53%), Christian category (3.92%), richer section (3.22%), women with no schooling (2.51%), those reported never to consume pulses (2.66%) and green vegetables (2.40%) and daily consuming eggs (3.66%) and chicken or meat (3.54%) are more affected by diabetes than their men counterparts. Whereas men residing in rural areas (2.30%), belonging to the general category (3.12%), SCs (2.37%) and STs (1.72%) are more affected than their women counterparts. Results have also shown a higher prevalence of diabetes among obese men (11.46%), non-vegetarian (2.71%) and those who watch television almost every day (3.03%) as compared to their women counterparts. Regression analyses show that the richest, hypertensive, and obese women and men are significantly more likely to suffer from diabetes. This study concludes that women and men with similar socio-economic status, biological conditions, dietary and smoking habits are being affected differently by diabetes. Thus, there is a need for gender dimension in research to understand and validate the differences in the needed interventions for diabetes control in India.

Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis

BACKGROUND

Blood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. We aimed to examine this question using individual participant data from major randomised controlled trials.

METHODS

We performed a one-stage individual participant data meta-analysis, in which data were pooled to investigate the effect of blood pressure lowering per se on the risk of new-onset type 2 diabetes. An individual participant data network meta-analysis was used to investigate the differential effects of five major classes of antihypertensive drugs on the risk of new-onset type 2 diabetes. Overall, data from 22 studies conducted between 1973 and 2008, were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We included all primary and secondary prevention trials that used a specific class or classes of antihypertensive drugs versus placebo or other classes of blood pressure lowering medications that had at least 1000 persons-years of follow-up in each randomly allocated arm. Participants with a known diagnosis of diabetes at baseline and trials conducted in patients with prevalent diabetes were excluded. For the one-stage individual participant data meta-analysis we used stratified Cox proportional hazards model and for the individual participant data network meta-analysis we used logistic regression models to calculate the relative risk (RR) for drug class comparisons.

FINDINGS

145 939 participants (88 500 [60·6%] men and 57 429 [39·4%] women) from 19 randomised controlled trials were included in the one-stage individual participant data meta-analysis. 22 trials were included in the individual participant data network meta-analysis. After a median follow-up of 4·5 years (IQR 2·0), 9883 participants were diagnosed with new-onset type 2 diabetes. Systolic blood pressure reduction by 5 mm Hg reduced the risk of type 2 diabetes across all trials by 11% (hazard ratio 0·89 [95% CI 0·84-0·95]). Investigation of the effects of five major classes of antihypertensive drugs showed that in comparison to placebo, angiotensin-converting enzyme inhibitors (RR 0·84 [95% 0·76-0·93]) and angiotensin II receptor blockers (RR 0·84 [0·76-0·92]) reduced the risk of new-onset type 2 diabetes; however, the use of β blockers (RR 1·48 [1·27-1·72]) and thiazide diuretics (RR 1·20 [1·07-1·35]) increased this risk, and no material effect was found for calcium channel blockers (RR 1·02 [0·92-1·13]).

INTERPRETATION

Blood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. This evidence supports the indication for selected classes of antihypertensive drugs for the prevention of diabetes, which could further refine the selection of drug choice according to an individual's clinical risk of diabetes.

FUNDING

British Heart Foundation, National Institute for Health Research, and Oxford Martin School.

Natriuretic Peptides and Risk of Type 2 Diabetes: Results From the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) Consortium

OBJECTIVE

Natriuretic peptide (NP) concentrations are increased in cardiovascular diseases (CVDs) but are associated with a lower diabetes risk. We investigated associations of N-terminal pro-B-type NP (NT-proBNP) and midregional proatrial NP (MR-proANP) with incident type 2 diabetes stratified by the presence of CVD.

RESEARCH DESIGN AND METHODS

Based on the Biomarkers for Cardiovascular Risk Assessment in Europe (BiomarCaRE) Consortium, we included 45,477 participants with NT-proBNP measurements (1,707 developed type 2 diabetes over 6.5 years of median follow-up; among these, 209 had CVD at baseline) and 11,537 participants with MR-proANP measurements (857 developed type 2 diabetes over 13.8 years of median follow-up; among these, 106 had CVD at baseline). The associations were estimated using multivariable Cox regression models.

RESULTS

Both NPs were inversely associated with incident type 2 diabetes (hazard ratios [95% CI] per 1-SD increase of log NP: 0.84 [0.79; 0.89] for NT-proBNP and 0.77 [0.71; 0.83] for MR-proANP). The inverse association between NT-proBNP and type 2 diabetes was significant in individuals without CVD but not in individuals with CVD (0.81 [0.76; 0.86] vs. 1.04 [0.90; 1.19]; P multiplicative interaction = 0.001). There was no significant difference in the association of MR-proANP with type 2 diabetes between individuals without and with CVD (0.75 [0.69; 0.82] vs. 0.81 [0.66; 0.99]; P multiplicative interaction = 0.236).

CONCLUSIONS

NT-proBNP and MR-proANP are inversely associated with incident type 2 diabetes. However, the inverse association of NT-proBNP seems to be modified by the presence of CVD. Further investigations are warranted to confirm our findings and to investigate the underlying mechanisms.

Role of hypertension in the association of overweight and obesity with diabetes among adults in Bangladesh: a population-based, cross-sectional nationally representative survey

AIMS

Overweight and obesity (OWOB) is a modifiable risk factor for both hypertension and diabetes. However, the association between OWOB and diabetes among Bangladeshi adults and how hypertension may mediate this relationship are not well explored. This study aimed to examine (1) whether OWOB is independently associated with diabetes among Bangladeshi adults, (2) whether this association is mediated by hypertension, and (3) the effect modification by wealth status and place of residence in the relationships.

RESEARCH DESIGN AND METHODS

We used data of 9305 adults aged ≥18 years from the most recent nationally representative cross-sectional study of Bangladesh Demographic and Health Survey 2017-2018. Design-based logistic regression was used to assess the association between OWOB and diabetes, and counterfactual framework-based weighting approach was used to evaluate the mediation effect of hypertension in the OWOB-diabetes relationship. We used stratified analyses for the effect modifications.

RESULTS

The prevalence of OWOB, diabetes and hypertension was 48.5%, 11.7% and 30.3%, respectively. We observed a significant association between OWOB and diabetes and a mediating role of hypertension in the OWOB-diabetes association. The odds of diabetes was 51% higher among adults with OWOB than those without OWOB (adjusted OR: 1.51, 95% CI 1.29 to 1.77). We observed that 18.64% (95% CI 9.84% to 34.07%) of the total effect of OWOB on the higher odds of diabetes was mediated through hypertension, and the mediation effect was higher among adults from non-poor households and from both rural and urban areas.

CONCLUSIONS

Adult OWOB status is independently associated with diabetes in Bangladesh, and hypertension mediates this association. Therefore, prevention policies should target adults with both OWOB and hypertension, particularly those from non-poor households and from both rural and urban areas, to reduce the growing burden of diabetes and its associated risk.

Associations between elevated kidney and liver biomarker ratios, metabolic syndrome and all-cause and coronary heart disease (CHD) mortality: analysis of the U.S. National Health and Nutrition Examination Survey (NHANES)

BACKGROUND

We examined the relationship between ratios of select biomarkers of kidney and liver function on all-cause and coronary heart disease (CHD) mortality, both in isolation, and in combination with metabolic syndrome (MetS), among adults (20 + years, n = 10,604).

METHODS

Data was derived from the U.S. National Health and Nutrition Examination Survey (1999-2016) including public-use linked mortality follow-up files through December 31, 2015.

RESULTS

Select biomarker ratios of kidney (UACR or albuminuria and BUN-CR) and liver (AST-ALT and GGT-ALP) function in isolation and in combination with MetS were associated with all-cause and CHD mortality. Compared to individuals with neither elevated biomarker ratios nor MetS (HR = 1.00, referent), increased risk of all-cause mortality was observed in the following groups: MetS with elevated UACR (HR, 95% CI = 2.57, 1.99-3.33), MetS with elevated AST-ALT (HR = 2.22, 1.61-3.07), elevated UACR without MetS (HR = 2.12, 1.65-2.72), and elevated AST-ALT without MetS (HR = 1.71, 1.35-2.18); no other biomarker ratios were associated with all-cause mortality. For cause-specific deaths, elevated risk of CHD mortality was associated with MetS with elevated UACR (HR = 1.67, 1.05-2.67), MetS with elevated AST-ALT (HR = 2.80, 1.62-4.86), and elevated BUN-CR without MetS (HR = 2.12, 1.12-4.04); no other biomarker ratios were associated with CHD mortality.

CONCLUSION

Future longitudinal studies are necessary to examine the utility of these biomarker ratios in risk stratification for chronic disease management.

Hypertension and the Risk of All-Cause and Cause-Specific Mortality: An Outcome-Wide Association Study of 67 Causes of Death in the National Health Interview Survey

Background

Few studies have assessed the association between hypertension and risk of detailed causes of death. We investigated the association between hypertension and all-cause mortality and 67 causes of death in a large cohort.

Methods

Multivariable Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for self-reported hypertension vs. no hypertension and mortality. Adults aged ≥18 years (n = 213798) were recruited in 1997-2004 and followed through December 31, 2006.

Results

During 5.81 years of follow-up, 11254 deaths occurred. Self-reported hypertension vs. no hypertension was associated with increased risk of all-cause mortality (HR = 1.25, 95% CI: 1.19-1.31) and mortality from septicemia (HR =1.66, 1.06-2.59), other infectious parasitic diseases (HR = 2.67, 1.09-6.51), diabetes mellitus (HR = 1.97, 1.45-2.67), circulatory disease (HR = 1.49, 1.37-1.61), hypertensive heart disease (HR = 3.23, 2.00-5.20), ischemic heart disease (HR = 1.35, 1.23-1.49), acute myocardial infarction (HR = 1.50, 1.27-1.77), other chronic ischemic heart diseases (HR = 1.35, 1.17-1.56), all other forms of heart disease (HR = 1.51, 1.21-1.89), primary hypertension and renal disease (HR = 3.11, 1.82-5.30), cerebrovascular disease (HR = 1.64, 1.37-1.97), other circulatory system diseases (HR = 1.71, 1.09-2.69), other chronic lower respiratory diseases (HR = 1.39, 1.12-1.73), other chronic liver disease (HR = 1.89, 1.06-3.37), renal failure (HR = 1.91, 1.33-2.74), motor vehicle accidents (HR = 1.60, 1.07-2.37), and all other diseases (HR =1.30, 1.10-1.54), but with lower risk of uterine cancer (HR = 0.37, 95% CI: 0.15-0.90) and Alzheimer's disease (HR = 0.65, 95% CI: 0.47-0.92).

Conclusion

Hypertension was associated with increased risk of all-cause mortality and 17 out of 67 causes of death, with most of these being circulatory disease outcomes, however, some of the remaining associations are unlikely to be causal. Further studies are needed to clarify associations with less common causes of death and potential causality across outcomes.

Prevalence and determinants of diabetes and prediabetes in southwestern Iran: the Khuzestan comprehensive health study (KCHS)

BACKGROUND

The Middle East and North Africa (MENA) is postulated to have the highest increase in the prevalence of diabetes by 2030; however, studies on the epidemiology of diabetes are rather limited across the region, including in Iran.

METHODS

This study was conducted between 2016 and 2018 among Iranian adults aged 20 to 65 years residing in Khuzestan province, southwestern Iran. Diabetes was defined as the fasting blood glucose (FBG) level of 126 mg/dl or higher, and/or taking antidiabetic medications, and/or self-declared diabetes. Prediabetes was defined as FBG 100 to 125 mg/dl. Multinomial logistic regression models were used to examine the association of multiple risk factors that attained significance on the outcome.

RESULTS

Overall, 30,498 participants were recruited; the mean (±SD) age was 41.6 (±11.9) years. The prevalence of prediabetes and diabetes were 30.8 and 15.3%, respectively. We found a similar prevalence of diabetes in both sexes, although it was higher among illiterates, urban residents, married people, and smokers. Participants aged 50-65 and those with Body Mass Index (BMI) 30 kg/m² or higher were more likely to be affected by diabetes [RR: 20.5 (18.1,23.3) and 3.2 (3.0,3.6)]. Hypertension [RR: 5.1 (4.7,5.5)], waist circumference (WC) equal or more than 90 cm [RR: 3.6 (3.3,3.9)], and family history [RR: 2.3 (2.2,2.5)] were also significantly associated with diabetes. For prediabetes, the main risk factors were age 50 to 65 years [RR: 2.6 (2.4,2.8)], BMI 30 kg/m² or higher [RR: 1.9 (1.8,2.0)], hypertension and WC of 90 cm or higher [RR: 1.7 (1.6,1.8)]. The adjusted relative risks for all variables were higher in females than males, with the exception of family history for both conditions and waist circumference for prediabetes.

CONCLUSIONS

Prediabetes and diabetes are prevalent in southwestern Iran. The major determinants are older age, obesity, and the presence of hypertension. Further interventions are required to escalate diabetes prevention and diagnosis in high-risk areas across Iran.

Phenotyping the Prediabetic Population-A Closer Look at Intermediate Glucose Status and Cardiovascular Disease

Even though the new thresholds for defining prediabetes have been around for more than ten years, there is still controversy surrounding the precise characterization of this intermediate glucose metabolism status. The risk of developing diabetes and macro and microvascular disease linked to prediabetes is well known. Still, the prediabetic population is far from being homogenous, and phenotyping it into less heterogeneous groups might prove useful for long-term risk assessment, follow-up, and primary prevention. Unfortunately, the current definition of prediabetes is quite rigid and disregards the underlying pathophysiologic mechanisms and their potential metabolic progression towards overt disease. In addition, prediabetes is commonly associated with a cluster of risk factors that worsen the prognosis. These risk factors all revolve around a common denominator: inflammation. This review focuses on identifying the population that needs to be screened for prediabetes and the already declared prediabetic patients who are at a higher risk of cardiovascular disease and require closer monitoring.

Comparison of risk factors between people with type 2 diabetes and matched controls in Nairobi, Kenya

OBJECTIVE

To identify risk factors associated with type 2 diabetes (T2D) in Nairobi, Kenya.

METHODS

A case-control study comparing 70 (53% women) recently diagnosed T2D cases with age-, sex- and socioeconomic status-matched normoglycemic controls (1:1). Objectively measured data were obtained on anthropometrics, handgrip strength and physical activity (by accelerometer). Self-reported data were collected on demographic characteristics and lifestyle factors. Logistic regression models, adjusted for covariates, were used to analyse the data.

RESULTS

Each standard deviation (SD) increase in height was associated with lower odds for T2D (adjusted odds ratio (AOR) = 0.34 (95% confidence intervals [CIs] 0.17, 0.66), P = 0.0031). Fat-free mass was inversely associated with T2D (AOR = 0.42 (95% CI 0.24, 0.75), P = 0.0032, per SD increase). Grip strength was associated with a lower risk of T2D (AOR = 0.20 (95% CI 0.08, 0.45), P < 0.001, per SD increase). BMI was not associated with T2D, but higher waist-to-hip ratio was associated higher odds of T2D (AOR = 2.28 (95% CI 1.38, 3.79), P = 0.0014, per SD increase). Physical activity was not associated with T2D. Cases reported higher intakes of fruits and vegetables and a lower intake of sugar than controls.

CONCLUSIONS

Central obesity, rather than BMI, may have more utility for T2D risk stratification in Kenya, and interventions that increase muscle mass and strength, as well as support weight loss, may be useful for T2D prevention in this and other SSA populations. However, more evidence is needed to determine whether low muscle mass, strength and height are causally related to T2D risk and/or are indicators of adverse early-life environment.

A Smartphone App (TRIANGLE) to Change Cardiometabolic Risk Behaviors in Women Following Gestational Diabetes Mellitus: Intervention Mapping Approach

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common complication during pregnancy and is associated with an increased risk for the development of cardiometabolic diseases. Behavioral interventions can reduce this risk, but current solutions insufficiently address the requirements for such a program. The systematic development of a scalable mobile health (mHealth) promotion program for mothers during the first years post-GDM may contribute to solving this problem.

OBJECTIVE

The aim of this project was to systematically plan and develop a theory- and evidence-based mHealth intervention to change cardiometabolic risk behaviors in women during the first 5 years post-GDM that meets women's expected standards of commercial health apps.

METHODS

The intervention mapping steps 1 to 4 structured the systematic planning and development of the mHealth program described in this paper. Steps 1 and 2 led to a theory- and evidence-based logic model of change for cardiometabolic health. Based on this model, the prevention program was designed (step 3) and produced (step 4) in cooperation with industrial partners to ensure a high technological standard of the resulting smartphone app for the iPhone (Apple Inc). Step 4 included a user study with women during the first 5 years post-GDM once a beta version of the app ("TRIANGLE") was available. The user study comprised 2 test rounds of 1 week (n=5) and 4 weeks (n=6), respectively. The tests included validated questionnaires on user acceptance, user logs, and think-alouds with semistructured interviews.

RESULTS

The novel TRIANGLE app is among the first self-paced smartphone apps for individual habit change in the 3 lifestyle areas of physical activity, nutrition, and psychosocial well-being. The 3 core features-a challenge system, human coaching, and a library-address 11 behavioral determinants with 39 behavior change methods to support lifestyle changes. Participants in the user study showed a high acceptance, high perceived quality, and high perceived impact of the TRIANGLE app on their health behaviors. Participants tested the app regularly, used it intuitively, and suggested improvements. We then adapted the TRIANGLE app according to the insights from the user study before the full TRIANGLE program production.

CONCLUSIONS

The intervention mapping approach was feasible to plan and develop an innovative and scalable smartphone solution for women during the first 5 years post-GDM. The resulting TRIANGLE intervention has the potential to support behavior change for cardiometabolic disease prevention. However, the app needs further refinement and testing in clinical trials. Intervention mapping steps 5 (implementation plan) and 6 (evaluation plan) may support the integration of the TRIANGLE intervention into routine care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00012736; https://www.drks.de/DRKS00012736.

Epidemiological characteristics of hypertension, impaired fasting capillary glucose and their comorbidity: a retrospective cross-sectional population-based study of rural adolescents in Southeast Nigeria

OBJECTIVE

To assess the prevalence of hypertension, impaired fasting capillary glucose (IFCG) and coexistence of both as well as determinants of these conditions among rural adolescents.

DESIGN

A retrospective cross-sectional population-based study.

SETTING

Three rural communities in southeast Nigeria.

PARTICIPANTS

A total of 401 adolescents (10 - 19 years) selected through a five-stage sampling technique completed the study. Sick adolescents, pregnant and nursing adolescent mothers were excluded.

PRIMARY OUTCOME MEASURES

Prevalence and determinants of hypertension, IFCG and comorbidity of both were assessed through weight, height, blood pressure, fasting capillary glucose measurements and statistical analysis.

RESULTS

Prehypertension (10.7%), hypertension alone (12.7%), IFCG alone (11.0%), diabetes (0.2%) and hypertension with IFCG (6.2%) were prevalent among the adolescents. The adolescents aged 15 - 19 years were less likely to be affected by hypertension alone (adjusted OR (AOR)=0.36, 95% CI 0.18 to 0.74, p<0.01). The likelihood of having hypertension alone was three times higher among those who smoked any substance (AOR=3.43, 95% CI 1.34 to 8.78, p<0.05) and 2.85 times higher among those who consumed alcohol (AOR=2.85, 95% CI 1.33 to 6.10, p<0.01). Meal skipping (AOR=2.69, 95% CI 1.16 to 6.25, p<0.05), consumption of fried/baked snacks (AOR=15.46, 95% CI 1.62 to 147.37, p<0.05) and vegetables (AOR=2.27, 95% CI 1.11 to 4.66, p<0.05) were also significant risk factors of hypertension alone. Skipping meals (AOR=2.15, 95% CI 0. 93 to 4.99, p>0.05) and longer than 7 hours of night sleep (AOR=1.88, 95% CI 0.94 TO 3.73, p>0.05) increased the risk of IFCG alone by twofold. Female adolescents (AOR=0.29, 95% CI 0.10 to 0.78, p<0.05) and those who consumed fried/baked snacks (AOR=0.09, 95% CI 0.02 to 0.37, p<0.01) were less likely to have hypertension with IFPG than males and those who consumed non-fried/baked snacks, respectively.

CONCLUSION

This study reported relatively low prevalence of hypertension alone, IFCG alone, hypertension with IFCG and epidemiological characteristics that can become focus of interventions to curtail the emergence of cardiovascular events at an early age. Awareness creation through health and nutrition education is emphasised.

Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis

BACKGROUND

The effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure.

METHODS

We did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat.

FINDINGS

Data for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19·8%) of participants with previous cardiovascular disease and 14 928 (8·0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4·15 years' follow-up (Q1-Q3 2·97-4·96), 42 324 participants (12·3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31·9 (95% CI 31·3-32·5) in the comparator group and 25·9 (25·4-26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0-40·5) and 36·0 (95% CI 35·3-36·7), in the comparator and intervention groups, respectively. Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89-0·94 for partipants without previous cardiovascular disease and 0·89, 0·86-0·92, for those with previous cardiovascular disease. In stratified analyses, there was no reliable evidence of heterogeneity of treatment effects on major cardiovascular events by baseline cardiovascular disease status or systolic blood pressure categories.

INTERPRETATION

In this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high-normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Physicians communicating the indication for blood pressure lowering treatment to their patients should emphasise its importance on reducing cardiovascular risk rather than focusing on blood pressure reduction itself.

FUNDING

British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.

Differential associations of ankle and brachial blood pressures with diabetes and cardiovascular diseases: cross-sectional study

Increased brachial systolic blood-pressure (BP) predicts diabetes (T2DM) but is not fully effective. Value of absolute ankle systolic BP for T2DM compared to brachial systolic BP is not known. Our objectives were to assess independent relationships of ankle-systolic BP with T2DM and cardiovascular disease in Europeans and south Asians. Cross-sectional studies of anonymised data from registered adults (n = 1087) at inner city deprived primary care practices. Study includes 63.85% ethnic minority. Systolic BP of the left and right-brachial, posterior-tibial and dorsalis-pedis-arteries measured using a Doppler probe. Regression models' factors were age, sex, ethnicity, body mass index (BMI) and waist height ratio (WHtR). Both brachial and ankle systolic-BP increase with diabetes in Europeans and south Asians. We demonstrated that there was a significant positive independent association of ankle BP with diabetes, regardless of age and sex compared to Brachial. There was stronger negative association of ankle blood pressure with cardiovascular disease, after adjustment for BMI, WHtR and ethnicity. Additionally, we found that ankle BP were significantly associated with cardiovascular disease in south Asians more than the Europeans; right posterior tibial. Ankle systolic BPs are superior to brachial BPs to identify risks of Type 2DM and cardiovascular diseases for enhanced patient care.

Association of hypertension and incident diabetes in Chinese adults: a retrospective cohort study using propensity-score matching

BACKGROUND

Reliable quantification of the relationship between hypertension and diabetes risk is limited, especially among Chinese people. We aimed to investigate the association between hypertension and the risk of diabetes in a large cohort of the Chinese population.

METHODS

This was a retrospective propensity score-matched cohort study among 211,809 Chinese adults without diabetes at baseline between 2010 and 2016. The target independent and dependent variable were hypertension at baseline and incident diabetes during follow-up respectively. The propensity score matching using a non-parsimonious multivariable logistic regression was conducted to balance the confounders between 28,711 hypertensive patients and 28,711 non-hypertensive participants. The doubly robust estimation method was used to investigate the association between hypertension and diabetes.

RESULTS

In the propensity-score matching cohort, diabetes risk increased by 11.0% among hypertensive patients (HR = 1.110, 95% confidence interval (CI): 1.031-1.195, P = 0.00539). And diabetes risk dropped to 8.3% among hypertensive subjects after adjusting for the propensity score (HR = 1.083, 95%CI: 1.006-1.166, P = 0.03367). Compared to non-hypertensive participants with low propensity score, the risk of incident diabetes increased by 2.646 times among hypertensive patients with high propensity score (HR = 3.646, 95%CI: 2.635-5.045, P < 0.0001).

CONCLUSION

Hypertension was associated with an 11.0% increase in the risk of developing diabetes in Chinese adults. And the figure dropped to 8.3% after adjusting the propensity score. Additionally, compared to non-hypertensive participants with low propensity scores, the risk of incident diabetes increased by 2.646 times among hypertensive patients with high propensity scores.

Applying latent class analysis to risk stratification of incident diabetes among Chinese adults

OBJECTIVE

To use latent class analysis to identify unobservable subpopulations amongst the heterogeneous population and explore the relationship between subpopulations and incident diabetes among Chinese adults.

METHODS

The retrospective study included 32,312 Chinese adults without diabetes at baseline. Latent class indicators included demographic and clinical variables. The outcome was incident diabetes. The relationship between latent class and outcome was evaluated with Cox proportional hazard regression analysis.

RESULTS

After screening, the two-class latent class model best fits the population. Participants in class 2 are characterized by higher age, body mass index, systolic and diastolic blood pressure, fasting plasma glucose, total cholesterol, triglyceride, low-density lipoprotein cholesterol, serum creatinine, serum urea nitrogen, alanine aminotransferase, and a higher proportion of males, ever/current smokers and drinkers, but lower high-density lipoprotein cholesterol and a lower proportion of family history of diabetes. The risk of diabetes in class 2 was 5.451 times (HR: 6.451, 95%CI: 4.179-9.960, P < 0.00001) and 5.264 times (HR: 6.264, 95%CI: 4.680-8.385, P < 0.00001) higher than that in class 1 during 3-year and 5-year follow-up, respectively.

CONCLUSIONS

We used latent class analysis to identify two distinct subpopulations with differential risk of diabetes during 3-year and 5-year follow-up.