1
|
Moosaie F, Mouodi M, Sheikhy A, Fallahzadeh A, Deravi N, Rabizadeh S, Fatemi Abhari SM, Meysamie A, Dehghani Firouzabadi F, Nakhjavani M, Esteghamati A. Association between visit-to-visit variability of glycemic indices and lipid profile and the incidence of coronary heart disease in adults with type 2 diabetes. J Diabetes Metab Disord 2021; 20:1715-1723. [PMID: 34900821 DOI: 10.1007/s40200-021-00930-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/23/2021] [Indexed: 11/28/2022]
Abstract
Coronary heart disease (CHD) is one of the major causes of mortality and morbidity in patients with type 2 diabetes mellitus. In this study, we aimed to assess the association between visit-to-visit variability of fasting blood sugar (FBS), HbA1c, blood sugar 2 h post-prandial (BS2hpp), lipid indices, creatinine, systolic and diastolic blood pressure (SBP, DBP) and incident CHD in patients with type 2 diabetes during a median follow-up of ten years. The current case-cohort study consisted of 1500 individuals with type 2 diabetes, followed up for the occurrence of CHD from 2002 to 2019. The patients had at least four annual follow-ups during which glycemic and lipid profile were measured. Co-efficient of variance (CV) for each parameter was calculated by 10-21 measurements. Cox regression analysis was performed to assess the association between CV of glycemic indices, lipid profile, blood pressure, creatinine, weight and incident CHD during the follow-up period. Hazard ratios (HR) were adjusted for the confounding variables. Glycemic indices variability (i.e., CV-HbA1c, CV-FBS, and CV-BS2hpp), were significantly higher in the group with incident CHD (P=0.034, P=0.042, and P=0.044, respectively). Hazard ratios were 1.42 (95 % CI=1.13-2.09) for CV-HbA1c, 1.37 (95 % CI=1.02-2.10) for CV-FBS, and 1.16 (95 % CI=1.01-1.63) for CV-BS2hpp (P=0.012, P=0.046, P=0.038, respectively). Creatinine was significantly higher in the group with incident CHD (P=0.036) and it was significantly associated with higher incidence of CHD (HR=1.14, 95 % CI=1.02-2.17, P=0.048). Visit to visit variability of glycemic indices of the patients with type 2 diabetes is associated with incident CHD independent of their baseline and mean values.
Collapse
Affiliation(s)
- Fatemeh Moosaie
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Marjan Mouodi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Ali Sheikhy
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Aida Fallahzadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Niloofar Deravi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Soghra Rabizadeh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | | | - Alipasha Meysamie
- Department of Community Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Dehghani Firouzabadi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, P.O. Box: 13145-784, Tehran, Iran
| |
Collapse
|
2
|
Lemaitre RN, Jensen PN, Wang Z, Fretts AM, McKnight B, Nemet I, Biggs ML, Sotoodehnia N, de Oliveira Otto MC, Psaty BM, Siscovick DS, Hazen SL, Mozaffarian D. Association of Trimethylamine N-Oxide and Related Metabolites in Plasma and Incident Type 2 Diabetes: The Cardiovascular Health Study. JAMA Netw Open 2021; 4:e2122844. [PMID: 34448864 PMCID: PMC8397925 DOI: 10.1001/jamanetworkopen.2021.22844] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Although rodent studies suggest that trimethylamine N-oxide (TMAO) influences glucose homeostasis and risk of type 2 diabetes, evidence in humans is limited. OBJECTIVE To examine the associations of serial measures of plasma TMAO and related metabolite concentrations with incident type 2 diabetes, fasting plasma insulin and glucose levels, and the Gutt insulin sensitivity index (ISI). DESIGN, SETTING, AND PARTICIPANTS This prospective cohort design assessed the association of plasma TMAO and related metabolite concentrations with diabetes outcome, whereas a cross-sectional design assessed the association with insulin and glucose levels and Gutt ISI. The participants were a cohort of older US adults from the Cardiovascular Health Study (CHS). Data from June 1989 to May 1990, from November 1992 to June 1993, and from June 1995 to June 1997 were included, with follow-up through June 2010. Levels of TMAO and related metabolites were measured in CHS plasma samples. Data were analyzed from July 2019 to September 2020. EXPOSURES Plasma concentrations of TMAO, carnitine, betaine, choline, crotonobetaine, and γ-butyrobetaine, measured by high-performance liquid chromatography and mass spectrometry. MAIN OUTCOMES AND MEASURES Linear regression for associations of TMAO and related metabolites with insulin and glucose levels and Gutt ISI, and proportional hazards regression for associations with diabetes. RESULTS The study included 4442 participants without diabetes at baseline (mean [SD] age, 73 [6] years at entry; 2710 [61%] women). In multivariable analyses, plasma TMAO, carnitine, crotonobetaine, and γ-butyrobetaine concentrations were positively associated with fasting insulin level (insulin mean geometric ratio comparing fifth with first quintiles of metabolite concentration: 1.07 [95% CI, 1.04-1.10] for TMAO; 1.07 [95% CI, 1.03-1.10] for carnitine; 1.05 [95% CI, 1.02-1.08] for crotonobetaine; and 1.06 [95% CI, 1.02-1.09] for γ-butyrobetaine). In contrast, betaine and choline concentrations were associated with greater insulin sensitivity (mean difference in Gutt ISI comparing fifth with first quintiles: 6.46 [95% CI, 4.32-8.60] and 2.27 [95% CI, 0.16-4.38], respectively). Incident diabetes was identified in 661 participants during a median 12.1 (interquartile range, 6.9-17.1) years of follow-up. In multivariable analyses, TMAO and metabolites were not significantly associated with type 2 diabetes risk (hazard ratios of diabetes comparing fifth with first quintile: 1.20 [95% CI, 0.94-1.55] for TMAO; 0.96 [95% CI, 0.74-1.24] for choline; 0.88 [95% CI, 0.67-1.15] for betaine; 1.07 [95% CI, 0.83-1.37] for carnitine; 0.79 [95% CI, 0.60-1.04] for γ-butyrobetaine; and 1.06 [95% CI, 0.83-1.35] for crotonobetaine). CONCLUSIONS AND RELEVANCE Plasma TMAO and related metabolites were not significantly associated with type 2 diabetes among older adults. The metabolites TMAO, carnitine, γ-butyrobetaine, and crotonobetaine may be associated with insulin resistance, and betaine and choline may be associated with greater insulin sensitivity, but temporality of the associations was not established.
Collapse
Affiliation(s)
- Rozenn N. Lemaitre
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle
| | - Paul N. Jensen
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle
| | - Zeneng Wang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Ina Nemet
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mary L. Biggs
- Department of Biostatistics, University of Washington, Seattle
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle
- Division of Cardiology, University of Washington, Seattle
| | - Marcia C. de Oliveira Otto
- Division of Epidemiology, Human Genetics and Environmental Science, School of Public Health, The University of Texas Health Science Center at Houston
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
- Kaiser Permanente Washington Health Research Institute, Seattle
| | | | - Stanley L. Hazen
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| |
Collapse
|
3
|
Rooney MR, Tang O, Pankow JS, Selvin E. Glycaemic markers and all-cause mortality in older adults with and without diabetes: the Atherosclerosis Risk in Communities (ARIC) study. Diabetologia 2021; 64:339-348. [PMID: 32990802 PMCID: PMC7855037 DOI: 10.1007/s00125-020-05285-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
AIMS/HYPOTHESIS There is controversy regarding the performance of HbA1c in old age. We evaluated the prognostic value of HbA1c and other glycaemic markers (fructosamine, glycated albumin, fasting glucose) with mortality risk in older adults (66-90 years). METHODS This was a prospective analysis of 5636 participants (31% with diagnosed diabetes, mean age 76, 58% female, 21% black) in the Atherosclerosis Risk in Communities (ARIC) study, baseline 2011-2013. We used Cox regression to examine associations of glycaemic markers (modelled in categories) with mortality risk, stratified by diagnosed diabetes status. RESULTS During a median of 6 years of follow-up, 983 deaths occurred. Among older adults with diabetes, 30% had low HbA1c (<42 mmol/mol [<6.0%]) and 10% had high HbA1c (≥64 mmol/mol [≥8.0%]); low (HR 1.32 [95% CI 1.04, 1.68]) and high (HR 1.86 [95% CI 1.32, 2.62]) HbA1c were associated with mortality risk vs HbA1c 42-52 mmol/mol (6.0-6.9%) after demographic adjustment. Low fructosamine and glycated albumin were not associated with mortality risk. Both low and high fasting glucose were associated with mortality risk. After further adjustment for lifestyle and clinical risk factors, high HbA1c (HR 1.81 [95% CI 1.28, 2.56]), fructosamine (HR 1.96 [95% CI 1.43-2.69]), glycated albumin (HR 1.81 [95% CI 1.33-2.47]) and fasting glucose (HR 1.81 [95% CI 1.24, 2.66]) were associated with mortality risk. Low HbA1c and fasting glucose were no longer significantly associated with mortality risk. Among participants without diabetes, associations of glycaemic markers with mortality risk were less robust. CONCLUSIONS/INTERPRETATION Elevated HbA1c, fructosamine, glycated albumin and fasting glucose were associated with risk of mortality in older adults with diabetes. Low HbA1c and fasting glucose may be markers of poor prognosis but are possibly confounded by health status. Our findings support the clinical use of HbA1c in older adults with diabetes. Graphical abstract.
Collapse
Affiliation(s)
- Mary R Rooney
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
| | - Olive Tang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
4
|
Mukamal KJ, Siscovick DS, de Boer IH, Ix JH, Kizer JR, Djoussé L, Fitzpatrick AL, Tracy RP, Boyko EJ, Kahn SE, Arnold AM. Metabolic Clusters and Outcomes in Older Adults: The Cardiovascular Health Study. J Am Geriatr Soc 2019; 66:289-296. [PMID: 29431855 DOI: 10.1111/jgs.15205] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND/OBJECTIVES Few studies have the requisite phenotypic information to define metabolic patterns that may inform our understanding of the pathophysiology and consequences of diabetes in older adults. We sought to characterize clusters of older adults on the basis of shared metabolic features. DESIGN Population-based prospective cohort study. SETTING Four U.S. Cardiovascular Health Study field centers. PARTICIPANTS Individuals aged 65 and older taking no glucose-lowering agents (N = 2,231). MEASUREMENTS K-means cluster analysis of 11 metabolic parameters (fasting and postload serum glucose and plasma insulin, fasting C-peptide, body mass index, C-reactive protein (CRP), estimated glomerular filtration rate (eGFR), albuminuria, carboxymethyl lysine (an advanced glycation end-product), procollagen III N-terminal propeptide (a fibrotic marker)) and their associations with incident cardiovascular disease, diabetes, disability, and mortality over 8 to 14.5 years of follow-up and with measures of subclinical cardiovascular disease. RESULTS A 6-cluster solution provided robust differentiation into distinct, identifiable clusters. Cluster A (n = 739) had the lowest glucose and insulin and highest eGFR and the lowest rates of all outcomes. Cluster B (n = 419) had high glucose and insulin and intermediate rates of most outcomes. Cluster C (n = 118) had the highest insulin. Cluster D (n = 129) had the highest glucose with much lower insulin. Cluster E (n = 314) had the lowest eGFR and highest albuminuria. Cluster F (n = 512) had the highest CRP. Rates of CVD, mortality, and subclinical atherosclerosis were highest in clusters C, D, and E and were similar to rates in participants with treated diabetes. Incidence of disability was highest in Cluster C. CONCLUSION Clustering according to metabolic parameters identifies distinct phenotypes that are strongly associated with clinical and functional outcomes, even at advanced age.
Collapse
Affiliation(s)
- Kenneth J Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David S Siscovick
- Department of Medicine, University of Washington, Seattle, Washington.,New York Academy of Medicine, New York, New York
| | - Ian H de Boer
- Department of Medicine, University of Washington, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington
| | - Joachim H Ix
- Veterans Affairs San Diego Healthcare System, San Diego, California.,School of Medicine, University of California, San Diego, California
| | - Jorge R Kizer
- Department of Medicine, Albert Einstein College of Medicine, New York, New York.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York
| | - Luc Djoussé
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Boston Veterans Affairs Healthcare System, Boston, Massachusetts
| | - Annette L Fitzpatrick
- Department of Epidemiology, University of Washington, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington
| | - Russell P Tracy
- Department of Pathology, College of Medicine, University of Vermont, Burlington, Vermont.,Department of Biochemistry, College of Medicine, University of Vermont, Burlington, Vermont
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington.,Department of Epidemiology, University of Washington, Seattle, Washington.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Steven E Kahn
- Department of Medicine, University of Washington, Seattle, Washington.,Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Alice M Arnold
- Department of Biostatistics, University of Washington, Seattle, Washington
| |
Collapse
|
5
|
Lau L, Lew J, Borschmann K, Thijs V, Ekinci EI. Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review. J Diabetes Investig 2019; 10:780-792. [PMID: 30220102 PMCID: PMC6497593 DOI: 10.1111/jdi.12932] [Citation(s) in RCA: 191] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 08/29/2018] [Accepted: 09/03/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS/INTRODUCTION Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) the prevalence of diabetes in acute stroke patients through a meta-analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose-based tests in predicting stroke outcomes. MATERIALS AND METHODS Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta-analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out. RESULTS A total of 66 eligible articles met inclusion criteria. A meta-analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26-31). The rate was higher in ischemic (33%, 95% confidence interval 28-38) compared with hemorrhagic stroke (26%, 95% confidence interval 19-33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies. CONCLUSIONS Approximately one-third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high-risk population.
Collapse
Affiliation(s)
- Lik‐Hui Lau
- Department of EndocrinologyAustin HealthMelbourneVictoriaAustralia
| | - Jeremy Lew
- Department of EndocrinologyAustin HealthMelbourneVictoriaAustralia
| | - Karen Borschmann
- The Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental HealthUniversity of MelbourneMelbourneVictoriaAustralia
- Department of NeurologyAustin HealthMelbourneVictoriaAustralia
| | - Elif I Ekinci
- Department of EndocrinologyAustin HealthMelbourneVictoriaAustralia
- Department of MedicineAustin HealthUniversity of MelbourneMelbourneVictoriaAustralia
| |
Collapse
|
6
|
Graves KY, Nowakowski ACH. Childhood Socioeconomic Status and Stress in Late Adulthood: A Longitudinal Approach to Measuring Allostatic Load. Glob Pediatr Health 2017; 4:2333794X17744950. [PMID: 29226194 PMCID: PMC5714076 DOI: 10.1177/2333794x17744950] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/20/2017] [Indexed: 01/31/2023] Open
Abstract
Objectives: This study examines how the effects of childhood socioeconomic status (SES) may carry on into late adulthood. Methods: We examine how childhood SES affects both perceived stress and allostatic load, which is a cumulative measure of the body’s biologic response to chronic stress. We use the National Social Life, Health, and Aging Project, Waves 1 and 2, and suggest a novel method of incorporating a longitudinal allostatic load measure. Results: Individuals who grew up in low SES households have higher allostatic load scores in late adulthood, and this association is mediated mostly by educational attainment. Discussion: The longitudinal allostatic load measure shows similar results to the singular measures and allows us to include 2 time points into one outcome measure. Incorporating 2 separate time points into one measure is important because allostatic load is a measure of cumulative physiological dysregulation, and longitudinal data provide a more comprehensive measure.
Collapse
Affiliation(s)
- Katelyn Y Graves
- School of Physician Assistant Practice/Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Alexandra C H Nowakowski
- Department of Geriatrics/Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Orlando Regional Campus, Orlando, FL, USA
| |
Collapse
|
7
|
Palta P, Huang ES, Kalyani RR, Golden SH, Yeh HC. Hemoglobin A 1c and Mortality in Older Adults With and Without Diabetes: Results From the National Health and Nutrition Examination Surveys (1988-2011). Diabetes Care 2017; 40:453-460. [PMID: 28223299 PMCID: PMC5864101 DOI: 10.2337/dci16-0042] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/24/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hemoglobin A1c (HbA1c) level has been associated with increased mortality in middle-aged populations. The optimal intensity of glucose control in older adults with diabetes remains uncertain. We sought to estimate the risk of mortality by HbA1c levels among older adults with and without diabetes. RESEARCH DESIGN AND METHODS We analyzed data from adults aged ≥65 years (n = 7,333) from the Third National Health and Nutrition Examination Survey (NHANES III) (1998-1994) and Continuous NHANES (1999-2004) and their linked mortality data (through December 2011). Cox proportional hazards models were used to examine the relationship of HbA1c with the risk of all-cause and cause-specific (cardiovascular disease [CVD], cancer, and non-CVD/noncancer) mortality, separately for adults with diabetes and without diabetes. RESULTS Over a median follow-up of 8.9 years, 4,729 participants died (1,262 from CVD, 850 from cancer, and 2,617 from non-CVD/noncancer causes). Compared with those with diagnosed diabetes and an HbA1c <6.5%, the hazard ratio (HR) for all-cause mortality was significantly greater for adults with diabetes with an HbA1c >8.0%. HRs were 1.6 (95% CI 1.02, 2.6) and 1.8 (95% CI 1.3, 2.6) for HbA1c 8.0-8.9% and ≥9.0%, respectively (P for trend <0.001). Participants with undiagnosed diabetes and HbA1c >6.5% had a 1.3 (95% CI 1.03, 1.8) times greater risk of all-cause mortality compared with participants without diabetes and HbA1c 5.0-5.6%. CONCLUSIONS An HbA1c >8.0% was associated with increased risk of all-cause and cause-specific mortality in older adults with diabetes. Our results support the idea that better glycemic control is important for reducing mortality; however, in light of the conflicting evidence base, there is also a need for individualized glycemic targets for older adults with diabetes depending on their demographics, duration of diabetes, and existing comorbidities.
Collapse
Affiliation(s)
- Priya Palta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL
| | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sherita H Golden
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hsin-Chieh Yeh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
8
|
HbA1c and Risks of All-Cause and Cause-Specific Death in Subjects without Known Diabetes: A Dose-Response Meta-Analysis of Prospective Cohort Studies. Sci Rep 2016; 6:24071. [PMID: 27045572 PMCID: PMC4820688 DOI: 10.1038/srep24071] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 03/18/2016] [Indexed: 12/17/2022] Open
Abstract
Whether HbA1c levels are associated with mortality in subjects without known diabetes remains controversial. Moreover, the shape of the dose–response relationship on this topic is unclear. Therefore, a dose–response meta-analysis was conducted. PubMed and EMBASE were searched. Summary hazard ratios (HRs) were calculated using a random-effects model. Twelve studies were included. The summary HR per 1% increase in HbA1c level was 1.03 [95% confidence interval (CI) = 1.01–1.04] for all-cause mortality, 1.05 [95% CI = 1.02–1.07) for cardiovascular disease (CVD) mortality, and 1.02 (95% CI = 0.99–1.07) for cancer mortality. After excluding subjects with undiagnosed diabetes, the aforementioned associations remained significant for CVD mortality only. After further excluding subjects with prediabetes, all aforementioned associations presented non-significance. Evidence of a non-linear association between HbA1c and mortality from all causes, CVD and cancer was found (all Pnon-linearity < 0.05). The dose–response curves were relatively flat for HbA1c less than around 5.7%, and rose steeply thereafter. In conclusion, higher HbA1c level is associated with increased mortality from all causes and CVD among subjects without known diabetes. However, this association is driven by those with undiagnosed diabetes or prediabetes. The results regarding cancer mortality should be treated with caution due to limited studies.
Collapse
|
9
|
Grossman A, Beloosesky Y, Schlesinger A, Gafter-Gvili A, Koren-Morag N, Meyerovitch J, Weiss A. The association between glycated hemoglobin levels and mortality in non-diabetic elderly subjects. Eur J Intern Med 2016; 27:57-61. [PMID: 26520045 DOI: 10.1016/j.ejim.2015.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 10/08/2015] [Accepted: 10/14/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Glycated hemoglobin (HgbA1c) is extensively used as a screening tool for the diagnosis of diabetes mellitus (DM). Although its prognostic value among diabetics has been extensively studied, similar data among non-diabetics is scarce. The aim of this study was to evaluate the association between HgbA1c and mortality in non-diabetic elderly individuals. METHODS A review of a computerized database of a large health care organization was performed. Non-diabetic individuals≥65years old with HgbA1c levels<6.5% evaluated during the years 2002-2012 were included in the analysis. Subjects were stratified into quintiles based on HgbA1c levels. Hazard ratios (HR) for mortality were compared between the quintiles. RESULTS The cohort included 12,937 non-diabetic individuals≥65years who did not develop DM during the follow-up period. The lowest mortality rate was observed in the fourth HgbA1c quintile [HgbA1c 5.9-6.1% (41-43mmol/mol)]. Compared with the mortality rate in the fourth quintile, mortality rate was increased in the lowest (HgbA1c<5.39%, 35mmol/mol, HR 1.21 CI 1.09-1.35) and highest (HgbA1c>6.11%, 43mmol/mol, HR 1.17 CI 1.04-1.32) HgbA1c quintiles. This association persisted after adjustment for age, gender and co-morbidities. CONCLUSIONS The association between HgbA1c and all-cause mortality in non-diabetic elderly individuals has a U-shape form with the highest mortality in those with the lowest and highest HgbA1c levels.
Collapse
Affiliation(s)
- Alon Grossman
- Unit of Endocrinology and Metabolism, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Yichayahou Beloosesky
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Geriatrics, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Agatha Schlesinger
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Geriatrics, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Anat Gafter-Gvili
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Internal Medicine A, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Nira Koren-Morag
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Joseph Meyerovitch
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Chief Pediatrician, Community Division, Clalit Health Services, Tel Aviv, Israel; Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Avraham Weiss
- Sackler Faculty of Medicine, Tel Aviv University, Israel; Department of Geriatrics, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| |
Collapse
|
10
|
Mukai N, Ninomiya T, Hata J, Hirakawa Y, Ikeda F, Fukuhara M, Hotta T, Koga M, Nakamura U, Kang D, Kitazono T, Kiyohara Y. Association of hemoglobin A1c and glycated albumin with carotid atherosclerosis in community-dwelling Japanese subjects: the Hisayama Study. Cardiovasc Diabetol 2015; 14:84. [PMID: 26099223 PMCID: PMC4482030 DOI: 10.1186/s12933-015-0247-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/16/2015] [Indexed: 12/11/2022] Open
Abstract
Background It is not clear which glucose measure is more useful in the assessment of atherosclerosis. We investigated the associations of hemoglobin A1c (HbA1c), glycated albumin (GA), 1,5-anhydroglucitol (1,5-AG), fasting plasma glucose (FPG), and 2-hour postload glucose (PG) with carotid intima-media thickness (IMT) in community-dwelling Japanese subjects. Methods A total of 2702 subjects aged 40–79 years underwent a 75-g oral glucose tolerance test and measurements of HbA1c, GA, 1,5-AG, and carotid IMT by ultrasonography in 2007–2008. Carotid wall thickening was defined as a maximum IMT of >1.0 mm. The crude and multivariable-adjusted linear and logistic regression models were used to analyze cross-sectional associations between levels of glycemic measures and carotid IMT. Results The crude average of the maximum IMT increased significantly with rising quartiles of HbA1c, GA, FPG, and 2-hour PG levels in subjects with and without glucose intolerance (GI), while no clear association was observed for 1,5-AG. After adjustment for other confounding factors, positive trends for HbA1c, GA, and FPG (all p for trend < 0.05), but not 2-hour PG (p = 0.07) remained robust in subjects with GI, but no such associations were found in those without GI. When estimating multivariable-adjusted β values for the associations of 1 SD change in glycemic measures with the maximum IMT in subjects with GI, the magnitude of the influence of HbA1c (β = 0.021), GA (β = 0.024), and FPG (β = 0.024) was larger than that of 2-hour PG (β = 0.014) and 1,5-AG (β = 0.003). The multivariable-adjusted odds ratios for the presence of carotid wall thickening increased significantly with elevating HbA1c, GA, and FPG levels only in subjects with GI (all p for trend < 0.001). Among subjects with GI, the area under the receiver operating characteristic curve significantly increased by adding HbA1c (p = 0.04) or GA (p = 0.04), but not 1,5-AG, FPG, or 2-hour PG, to the model including other cardiovascular risk factors. Conclusions In community-dwelling Japanese subjects with GI, elevated HbA1c, GA, and FPG levels were significantly associated with increased carotid IMT, and HbA1c and GA provided superior discrimination for carotid wall thickening compared to 1,5-AG, FPG, and 2-hour PG, suggesting that HbA1c and GA are useful for assessing carotid atherosclerosis. Electronic supplementary material The online version of this article (doi:10.1186/s12933-015-0247-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Naoko Mukai
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Toshiharu Ninomiya
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Jun Hata
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yoichiro Hirakawa
- Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Fumie Ikeda
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Masayo Fukuhara
- Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Taeko Hotta
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Masafumi Koga
- Department of Internal Medicine, Kawanishi City Hospital, Hyogo, Japan.
| | - Udai Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Dongchon Kang
- Department of Clinical Chemistry and Laboratory Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Takanari Kitazono
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yutaka Kiyohara
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Department of Environmental Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| |
Collapse
|
11
|
Trivin C, Metzger M, Haymann JP, Boffa JJ, Flamant M, Vrtovsnik F, Houillier P, Stengel B, Thervet E. Glycated Hemoglobin Level and Mortality in a Nondiabetic Population with CKD. Clin J Am Soc Nephrol 2015; 10:957-64. [PMID: 25979978 DOI: 10.2215/cjn.08540814] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 02/20/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Glycated hemoglobin (HbA1c) is used to diagnose diabetes mellitus (DM) and guide its management. The association between higher HbA1c and progression to ESRD and mortality has been demonstrated in populations with DM. This study examined the association between HbA1c and these end points in a population with CKD and without DM. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In the hospital-based NephroTest cohort study, measured GFR (mGFR) was taken by (51)Cr-EDTA renal clearance and HbA1c in 1165 adults with nondialysis CKD stages 1-5 and without DM between January 2000 and December 2010. The median follow-up was 3.48 years (interquartile range, 1.94-5.82) for the competing events of ESRD and pre-ESRD mortality. Time-fixed and time-dependent Cox models were used to estimate hazard ratios (HRs) for ESRD and mortality according to HbA1c, treated continuously or in tertiles. RESULTS At inclusion, the mean mGFR was 42.2±19.9 ml/min per 1.73 m(2), and the mean HbA1c value was 5.5%±0.5%. During follow-up, 109 patients died, and 162 patients reached ESRD. Pre-ESRD mortality was significantly associated with HbA1c treated continuously: for every 1% higher HbA1c, the crude HR was 2.16 (95% confidence interval [95% CI], 1.27 to 3.68), and it was 1.85 (95% CI, 1.05 to 3.24) after adjustment for mGFR and other risk factors of death. After excluding incident diabetes over time, the updated mean of HbA1c remained significantly associated with higher mortality risk: adjusted HR for the highest (5.7%-6.4%) versus the lowest tertile (<5.3%) was 2.62 (95% CI, 1.16 to 5.91). There was no association with ESRD risk after adjustment for risk factors of CKD progression. CONCLUSIONS In a CKD cohort, HbA1c values in the prediabetes range are associated with mortality. Such values should be therefore included among the risk factors for negative outcomes in CKD populations.
Collapse
Affiliation(s)
- Claire Trivin
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material.
| | - Marie Metzger
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Jean-Philippe Haymann
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Jean-Jacques Boffa
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Martin Flamant
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - François Vrtovsnik
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Pascal Houillier
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Benedicte Stengel
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | - Eric Thervet
- Due to the number of contributing authors,the affiliations are provided in the Supplemental Material
| | | |
Collapse
|
12
|
Paprott R, Schaffrath Rosario A, Busch MA, Du Y, Thiele S, Scheidt-Nave C, Heidemann C. Association between hemoglobin A1c and all-cause mortality: results of the mortality follow-up of the German National Health Interview and Examination Survey 1998. Diabetes Care 2015; 38:249-56. [PMID: 25414153 DOI: 10.2337/dc14-1787] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study examined the association of HbA1c-defined glycemic status and continuous HbA1c with all-cause mortality. RESEARCH DESIGN AND METHODS The study population comprised 6,299 participants (aged 18-79 years) of the German National Health Interview and Examination Survey 1998, who were followed up for mortality for an average of 11.6 years. Glycemic status was defined as known diabetes (self-reported diagnosis or intake of antidiabetic medication) and based on HbA1c levels according to American Diabetes Association diagnostic criteria as undiagnosed diabetes (≥6.5% [≥48 mmol/mol]), prediabetes with very high (6.0-6.4% [42-46 mmol/mol]) or high diabetes risk (5.7-5.9% [39-41 mmol/mol]), and normoglycemia (<5.7% [<39 mmol/mol]). Associations between glycemic status and mortality were examined by Cox regression adjusting for age, sex, education, lifestyle factors, anthropometric measures, and history of chronic diseases (reference: normoglycemia). Spline models were fitted to investigate associations between continuous HbA1c and mortality among participants without known diabetes. RESULTS Excess mortality risk was observed for participants with known diabetes (hazard ratio 1.41 [95% CI 1.08-1.84]) and undiagnosed diabetes (1.63 [1.23-2.17]) but not for those with high (1.02 [0.80-1.30]) or very high diabetes risk (0.87 [0.67-1.13]). Spline models revealed a U-shaped association, with lowest risk at HbA1c levels 5.4-5.6% (36-38 mmol/mol) and a significantly increased risk at ≤5.0% (≤31 mmol/mol) and ≥6.4% (≥46 mmol/mol). CONCLUSIONS Unlike known and undiagnosed diabetes, HbA1c levels in the prediabetic range were not associated with an increased mortality risk. The observed U-shaped relationship adds to existing evidence that not only high but also low HbA1c levels might be associated with all-cause mortality.
Collapse
Affiliation(s)
- Rebecca Paprott
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | | | - Markus A Busch
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Yong Du
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Silke Thiele
- Department of Food Economics and Consumption Studies, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Christa Scheidt-Nave
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Christin Heidemann
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| |
Collapse
|
13
|
Monami M, Vitale V, Lamanna C, Bartoli N, Martelli D, Zannoni S, Antenore A, Toffanello G, Marchionni N, Mannucci E. HbA1c levels and all-cause mortality in type 2 diabetic patients: epidemiological evidence of the need for personalised therapeutic targets. Nutr Metab Cardiovasc Dis 2013; 23:300-306. [PMID: 22633797 DOI: 10.1016/j.numecd.2012.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 01/12/2012] [Accepted: 01/17/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND AND AIM The aim of the present case-control study is to explore the effect of case mix on the relationship between glycated haemoglobin (HbA1c) and mortality in type 2 diabetic patients. METHODS AND RESULTS A nested case-control study data set was generated from the cohort-study data set (n = 4140 type 2 diabetic outpatients) by sampling controls from the risk sets. Cases (n = 427) were compared with an equal number of controls chosen from those members of the cohort who were at risk for the same follow-up time of the case, matched for age (±3 years), sex, body mass index (BMI) (±2 kg m(-2)), duration of diabetes (±5 years), and Charlson's Comorbidity Score (CCS) (±1). The main predefined analysis was the comparison of cases and controls for proportion of patients with each HbA1c class (<6.5%, 6.5-7.4%, 7.5-8.4% and ≥8.5%). During a mean follow-up of 5.7 ± 3.5 years, 427 deaths were recorded. The lowest risk of death was observed in the HbA1c 6.5-7.4% category; a lower HbA1c was associated with a non-significant trend towards a higher risk. The risk associated with a low (<6.5%) HbA1c was significantly greater in patients who were insulin-treated than in the rest of the sample. CONCLUSIONS The present study suggests that glycaemic targets should be individualised on the basis of the characteristics of each patient, considering age, co-morbidity and duration of diabetes. Caution should be used in prescribing insulin to reach near-normoglycaemia, particularly in older, frail patients.
Collapse
Affiliation(s)
- M Monami
- Section of Geriatric Cardiology and Medicine, Department of Cardiovascular Medicine, University of Florence, Careggi Teaching Hospital, Florence, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Mukamal KJ, Kizer JR, Djoussé L, Ix JH, Zieman S, Siscovick DS, Sibley CT, Tracy RP, Arnold AM. Prediction and classification of cardiovascular disease risk in older adults with diabetes. Diabetologia 2013; 56:275-83. [PMID: 23143166 PMCID: PMC3537882 DOI: 10.1007/s00125-012-2772-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Accepted: 10/02/2012] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS We sought to derive and validate a cardiovascular disease (CVD) prediction algorithm for older adults with diabetes, and evaluate the incremental benefit of adding novel circulating biomarkers and measures of subclinical atherosclerosis. METHODS As part of the Cardiovascular Health Study (CHS), a population-based cohort of adults aged ≥65 years, we examined the 10 year risk of myocardial infarction, stroke and cardiovascular death in 782 older adults with diabetes, in whom 265 events occurred. We validated predictive models in 843 adults with diabetes, who were followed for 7 years in a second cohort, the Multi-Ethnic Study of Atherosclerosis (MESA); here 71 events occurred. RESULTS The best fitting standard model included age, smoking, systolic blood pressure, total and HDL-cholesterol, creatinine and the use of glucose-lowering agents; however, this model had a C statistic of 0.64 and poorly classified risk in men. Novel biomarkers did not improve discrimination or classification. The addition of ankle-brachial index, electrocardiographic left ventricular hypertrophy and internal carotid intima-media thickness modestly improved discrimination (C statistic 0.68; p = 0.002) and classification (net reclassification improvement [NRI] 0.12; p = 0.01), mainly in those remaining free of CVD. Results were qualitatively similar in the MESA, with a change in C statistic from 0.65 to 0.68 and an NRI of 0.09 upon inclusion of subclinical disease measures. CONCLUSIONS/INTERPRETATION Standard clinical risk factors and novel biomarkers poorly discriminate and classify CVD risk in older adults with diabetes. The inclusion of subclinical atherosclerotic measures modestly improves these features, but to develop more robust risk prediction, a better understanding of the pathophysiology and determinants of CVD in this patient group is needed.
Collapse
Affiliation(s)
- K J Mukamal
- Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 1309 Beacon Street, Brookline, MA 02446, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Zieman SJ, Kamineni A, Ix JH, Barzilay J, Djoussé L, Kizer JR, Biggs ML, de Boer IH, Chonchol M, Gottdiener JS, Selvin E, Newman AB, Kuller LH, Siscovick DS, Mukamal KJ. Hemoglobin A1c and arterial and ventricular stiffness in older adults. PLoS One 2012; 7:e47941. [PMID: 23118911 PMCID: PMC3484154 DOI: 10.1371/journal.pone.0047941] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 09/24/2012] [Indexed: 11/19/2022] Open
Abstract
Objective Arterial and ventricular stiffening are characteristics of diabetes and aging which confer significant morbidity and mortality; advanced glycation endproducts (AGE) are implicated in this stiffening pathophysiology. We examined the association between HbA1c, an AGE, with arterial and ventricular stiffness measures in older individuals without diabetes. Research Design & Methods Baseline HbA1c was measured in 830 participants free of diabetes defined by fasting glucose or medication use in the Cardiovascular Health Study, a population-based cohort study of adults aged ≥65 years. We performed cross-sectional analyses using baseline exam data including echocardiography, ankle and brachial blood pressure measurement, and carotid ultrasonography. We examined the adjusted associations between HbA1c and multiple arterial and ventricular stiffness measures by linear regression models and compared these results to the association of fasting glucose (FG) with like measures. Results HbA1c was correlated with fasting and 2-hour postload glucose levels (r = 0.21; p<0.001 for both) and positively associated with greater body-mass index and black race. In adjusted models, HbA1c was not associated with any measure of arterial or ventricular stiffness, including pulse pressure (PP), carotid intima-media thickness, ankle-brachial index, end-arterial elastance, or left ventricular mass (LVM). FG levels were positively associated with systolic, diastolic and PP and LVM. Conclusions In this sample of older adults without diabetes, HbA1c was not associated with arterial or ventricular stiffness measures, whereas FG levels were. The role of AGE in arterial and ventricular stiffness in older adults may be better assessed using alternate AGE markers.
Collapse
Affiliation(s)
- Susan J. Zieman
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Aruna Kamineni
- Group Health Research Institute, Group Health, Seattle, Washington, United States of America
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, and Veterans Affairs San Diego Healthcare System, La Jolla, California, United States of America
| | - Joshua Barzilay
- Division of Endocrinology, Kaiser-Permanente, Tucker, Georgia, United States of America
| | - Luc Djoussé
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, and Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States of America
| | - Jorge R. Kizer
- Departments of Medicine and Public Health, Weill Medical College of Cornell University, New York, New York, United States of America
| | - Mary L. Biggs
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Ian H. de Boer
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Michel Chonchol
- Department of Medicine, University of Colorado Denver Health Sciences Center, Denver, Colorado, United States of America
| | - John S. Gottdiener
- Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Elizabeth Selvin
- National Institute on Aging, National Institutes of Health, Bethesda, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Anne B. Newman
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Lewis H. Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - David S. Siscovick
- Departments of Biostatistics and Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kenneth J. Mukamal
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
| |
Collapse
|
16
|
Schneider HJ, Wallaschofski H, Völzke H, Markus MRP, Doerr M, Felix SB, Nauck M, Friedrich N. Incremental effects of endocrine and metabolic biomarkers and abdominal obesity on cardiovascular mortality prediction. PLoS One 2012; 7:e33084. [PMID: 22438892 PMCID: PMC3306371 DOI: 10.1371/journal.pone.0033084] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 02/09/2012] [Indexed: 11/19/2022] Open
Abstract
Background Biomarkers may help clinicians predict cardiovascular risk. We aimed to determine if the addition of endocrine, metabolic, and obesity-associated biomarkers to conventional risk factors improves the prediction of cardiovascular and all-cause mortality. Methodology/Principal Findings In a population-based cohort study (the Study of Health in Pomerania) of 3,967 subjects (age 20–80 years) free of cardiovascular disease with a median follow-up of 10.0 years (38,638 person-years), we assessed the predictive value of conventional cardiovascular risk factors and the biomarkers thyrotropin; testosterone (in men only); insulin-like growth factor-1 (IGF-1); hemoglobin A1c (HbA1c); creatinine; high-sensitive C-reactive protein (hsCRP); fibrinogen; urinary albumin-to-creatinine ratio; and waist-to-height ratio (WHtR) on cardiovascular and all-cause death. During follow-up, we observed 339 all-cause including 103 cardiovascular deaths. In Cox regression models with conventional risk factors, the following biomarkers were retained as significant predictors of cardiovascular death after backward elimination: HbA1c, IGF-1, and hsCRP. IGF-1 and hsCRP were retained as significant predictors of all-cause death. For cardiovascular death, adding these biomarkers to the conventional risk factors changed the C-statistic from 0.898 to 0.910 (p = 0.02). The net reclassification improvement was 10.6%. For all-cause death, the C-statistic changed from 0.849 to 0.853 (P = 0.09). Conclusions/Significance HbA1c, IGF-1, and hsCRP predict cardiovascular death independently of conventional cardiovascular risk factors. These easily assessed endocrine and metabolic biomarkers might improve the ability to predict cardiovascular death.
Collapse
Affiliation(s)
- Harald Jörn Schneider
- Institute of Clinical Chemistry and Laboratory Medicine, Ernst Moritz Arndt University Greifswald, Greifswald, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Lapolla A, Mosca A, Fedele D. The general use of glycated haemoglobin for the diagnosis of diabetes and other categories of glucose intolerance: still a long way to go. Nutr Metab Cardiovasc Dis 2011; 21:467-475. [PMID: 21641782 DOI: 10.1016/j.numecd.2011.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 01/31/2011] [Accepted: 02/06/2011] [Indexed: 12/16/2022]
Abstract
Glycated haemoglobin (HbA(1c)) is considered the 'gold standard' for monitoring metabolic control in diabetes. An International Expert Committee recently recommended HbA(1c) as a better method than measurement of glucose to use in the diagnosis of diabetes, based on its strong association with microvascular complications, a lower day-to-day variability and ease of use, not necessarily in the fasting state. These recommendations have been embraced by the American Diabetes Association (ADA), which stated in its Standards of Medical Care in Diabetes 2010 that "A(1c), fasting plasma glucose or the 2 h 75 g oral glucose tolerance test (OGTT) are appropriate for testing diabetes and assessing the risk of future diabetes," and that "a confirmed A(1c) ≥ 6.5% is diagnostic for diabetes." Measuring HbA(1c) has several advantages over glucose measurements, but its exclusive use should only be considered if the test is conducted under standardised conditions and its limitations are taken into due account. The impact of its use on the epidemiology of diabetes and other categories of glucose intolerance, as seen from recent reports, is also discussed.
Collapse
Affiliation(s)
- A Lapolla
- Dipartimento di Scienze Mediche e Chirurgiche, Cattedra di Malattie del Metabolismo, Università degli Studi di Padova, Padova, Italy.
| | | | | |
Collapse
|
18
|
Bibliography. Current world literature. Adrenal cortex. Curr Opin Endocrinol Diabetes Obes 2011; 18:231-3. [PMID: 21522003 DOI: 10.1097/med.0b013e3283457c7d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
19
|
Carson AP, Fox CS, McGuire DK, Levitan EB, Laclaustra M, Mann DM, Muntner P. Low hemoglobin A1c and risk of all-cause mortality among US adults without diabetes. Circ Cardiovasc Qual Outcomes 2010; 3:661-7. [PMID: 20923991 DOI: 10.1161/circoutcomes.110.957936] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among individuals without diabetes, elevated hemoglobin A1c (HbA1c) has been associated with increased morbidity and mortality, but the literature is sparse regarding the prognostic importance of low HbA1c. METHODS AND RESULTS National Health and Nutrition Examination Survey III (NHANES III) participants, 20 years and older, were followed up to 12 years (median follow-up, 8.8 years) for all-cause mortality. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for the association between HbA1c levels and all-cause mortality for 14 099 participants without diabetes. There were 1825 deaths during the follow-up period. Participants with a low HbA1c (<4.0%) had the highest levels of mean red blood cell volume, ferritin, and liver enzymes and the lowest levels of mean total cholesterol and diastolic blood pressure compared with their counterparts with HbA1c levels between 4.0% and 6.4%. An HbA1c <4.0% versus 5.0% to 5.4% was associated with an increased risk of all-cause mortality (HR, 3.73; 95% CI, 1.45 to 9.63) after adjustment for age, race-ethnicity, and sex. This association was attenuated but remained statistically significant after further multivariable adjustment for lifestyle, cardiovascular factors, metabolic factors, red blood cell indices, iron storage indices, and liver function indices (HR, 2.90; 95% CI, 1.25 to 6.76). CONCLUSIONS In this nationally representative cohort, low HbA1c was associated with increased all-cause mortality among US adults without diabetes. Additional research is needed to confirm these results and identify potential mechanisms that may be underlying this association.
Collapse
Affiliation(s)
- April P Carson
- Department of Epidemiology, University of Alabama at Birmingham, 35294-0022, USA.
| | | | | | | | | | | | | |
Collapse
|
20
|
Biochemical risk indices, including plasma homocysteine, that prospectively predict mortality in older British people: the National Diet and Nutrition Survey of People Aged 65 Years and Over. Br J Nutr 2010; 104:893-9. [PMID: 20398433 DOI: 10.1017/s0007114510001236] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Predictive power, for total and vascular mortality, of selected indices measured at baseline in the British National Diet and Nutrition Survey (community-living subset) of People Aged 65 Years and Over was tested. Mortality status and its primary and underlying causes were recorded for 1100 (mean age 76.7 (sd 7.5) years, 50.2% females) respondents from the baseline survey in 1994-5 until September 2008. Follow-up data analyses focussed especially on known predictors of vascular disease risk, together with intakes and status indices of selected nutrients known to affect, or to be affected by, these predictors. Total mortality was significantly predicted by hazard ratios of baseline plasma concentrations (per sd) of total homocysteine (tHcy) (95% CI) 1.19 (1.11, 1.27), pyridoxal phosphate 0.90 (0.81, 1.00), pyridoxic acid 1.10 (1.03, 1.19), alpha1-antichymotrypsin 1.21 (1.13, 1.29), fibrinogen 1.14 (1.05, 1.23), creatinine 1.20 (1.10, 1.31) and glycosylated Hb 1.23 (1.14, 1.32), and by dietary intakes of energy 0.87 (0.80, 0.96) and protein 0.86 (0.77, 0.97). Prediction patterns and significance were similar for primary-cause vascular mortality. The traditional risk predictors plasma total and HDL cholesterol were not significant mortality predictors in this age group, nor were the known tHcy-regulating nutrients, folate and vitamin B12 (intakes and status indices). Model adjustment for known risk predictors resulted in the loss of significance for some of the afore-mentioned indices; however, tHcy 1.34 (1.04, 1.73) remained a significant predictor for vascular mortality. Thus, total and primary vascular mortality is predicted by energy and protein intakes, and by biochemical indices including tHcy, independent of serum folate or vitamin B12.
Collapse
|