The association between blood glucose value and long-term mortality

Associations of fasting plasma glucose with all-cause mortality and cardiovascular events in older Chinese diabetes patients: A population-based cohort study

AIMS/INTRODUCTION

Our aim was to investigate the optimal fasting glucose (FPG) range in Chinese older adults with type 2 diabetes, and to clarify whether the optimal range varies according to the control of risk factors.

MATERIALS AND METHODS

The baseline survey for the cohort study began in 2018, with follow up ending in 2022. Our study enrolled 59,030 older diabetes patients with no history of cardiovascular disease (CVD). Participants were divided into nine groups based on their baseline glycemic status. The association between FPG and the risk of adverse outcomes was mainly estimated by multivariate Cox proportional risk models and restricted spline analysis.

RESULTS

During the 4-year follow-up period, a total of 5,637 deaths and 4,904 CVD events occurred. The associations of FPG with mortality and CVD events showed J-shaped curves. Among all-cause deaths, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.50 (95% confidence interval [CI] 1.31-1.71) and 1.84 (95% CI 1.67-2.02). Among CVD, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.31 (95% CI 1.13-1.53) and 1.71 (95% CI 1.54-1.89), respectively. The optimal FPG ranges of all-cause mortality and CVD were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. For participants with at least two risk factors, the optimal FPG levels were higher than those with fewer risk factors.

CONCLUSIONS

In older Chinese diabetes patients, the FPG ranges related to the minimum death and CVD event rates were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. Patients with more cardiovascular risk factors had higher optimal blood glucose ranges than those with fewer risk factors.

Association Between Fasting Blood Glucose and All-Cause Mortality in a Rural Chinese Population: 15-Year Follow-Up Cohort Study

INTRODUCTION

The worldwide prevalence of diabetes has been increasing for decades; diabetes can lead to serious health problems and even death, but the effects of maintaining low fasting blood glucose (FBG) remain controversial. The purpose of this study was to investigate the relationship between FBG levels and all-cause mortality in a long-term follow-up cohort and to find a relatively safe range of FBG levels.

METHODS

This study included 17,902 adults from a community-based cohort study in rural China who were prospectively followed from 2003 to 2018. Generalized estimating equations were used to evaluate the association between FBG and all-cause mortality, adjusting for pertinent covariates and auto-correlations among siblings.

RESULTS

A total of 1053 (5.9%) deaths occurred during 15 years of follow-up. There was a significant U-shaped association between all-cause mortality and FBG. Compared with the reference group (FBG of 5.6 - < 6.1 mmol/l), the risk of death among individuals with FBG levels < 5.6 mmol/l significantly increased by 38% (OR 1.34; 95% CI 1.13-1.59), while the risk of death among individuals with FBG ≥ 6.1 mmol/l or participants with a self-reported history of diabetes significantly increased by 51% (OR 1.49; 95% CI 1.20-1.85). Additionally, the U-shaped association remained steady in any stratification of risk factors.

CONCLUSION

Our study showed a significant U-shaped relationship between FBG levels and risk of all-cause mortality in this rural Chinese population. When FBG was within the range of 5.6 - < 6.1 mmol/l, the risk of all-cause mortality was the lowest.

Impact of low fasting plasma glucose on mortality in the general population

BACKGROUND

While the association between hypoglycaemia and poor outcomes in diabetes is well established, it is unclear whether such an association is generalizable to those without diabetes.

METHODS

A total of 8497 participants free of cardiovascular disease and diabetes from the Third National Health and Nutrition Examination Survey were included. We examined the relationship between baseline low (<80 mg/dL) and high (⩾126 mg/dL) fasting plasma glucose compared to normal levels (80-99 mg/dL).

RESULTS

Over a median follow-up of 14 years, 2101 deaths occurred, of which 570 were due to cardiovascular disease. In a model adjusted for sociodemographic and cardiovascular disease risk factors, individuals with low fasting plasma glucose were at increased risk of cardiovascular disease and all-cause mortality [hazard ratio = 1.79 (95% confidence interval = 1.04-3.08) and hazard ratio = 1.35 (95% confidence interval = 1.02-1.78), respectively], compared to those with normal fasting plasma glucose. These associations were stronger among men than women for both cardiovascular disease mortality and all-cause mortality.

CONCLUSION

Low fasting plasma glucose in individuals without diabetes is a risk factor for cardiovascular disease and all-cause mortality, especially in men.

The association between fasting plasma glucose and all-cause and cause-specific mortality by gender: The rural Chinese cohort study

BACKGROUND

To evaluate the association between fasting plasma glucose (FPG) and mortality by gender.

METHODS

A total of 17 248 eligible participants from a rural Chinese prospective cohort population were included. The same questionnaire interview and anthropometric and laboratory measurements were performed at both baseline (2007-2008) and follow-up (2013-2014). Participants were classified according to baseline FPG and diabetic status by sex. Restricted cubic splines and Cox proportional-hazards regression models, estimating hazard ratio (HR) and 95% confidence interval (CI), were used to assess the FPG-mortality relation.

RESULTS

During the 6-year follow-up, 618 men and 489 women died. The FPG-mortality relation was J shaped for both sexes. For men, risk of all-cause and noncardiovascular disease (CVD)/noncancer mortality was greater with low fasting glucose (LFG) than with normal fasting glucose (adjusted HR [aHR] 1.60; 95% CI, 1.05-2.43; and aHR 2.16; 95% CI, 1.15-4.05). Men with diabetes mellitus (DM) showed increased risk of all-cause (aHR 2.04; 95% CI, 1.60-2.60), CVD (aHR 1.98; 95% CI, 1.36-2.89), and non-CVD/noncancer mortality (aHR 2.62; 95% CI, 1.76-3.91). Men with impaired fasting glucose (IFG) had borderline risk of CVD mortality (aHR 1.34; 95% CI, 1.00-1.79). Women with LFG had increased risk of non-CVD/noncancer mortality (aHR 2.27; 95% CI, 1.04-4.95), and women with DM had increased risk of all-cause (aHR 1.73; 95% CI, 1.35-2.23), CVD (aHR 1.76; 95% CI, 1.24-2.50), and non-CVD/noncancer mortality (aHR 1.97; 95% CI, 1.27-3.08).

CONCLUSIONS

LFG is positively associated with all-cause mortality risk in rural Chinese men but not in women.

Fasting glucose and its association with 20-year all-cause and cause-specific mortality in Chinese general population

Objective

The aim of this study was to explore the relationship between fasting glucose levels and all-cause and cause-specific mortality in Chinese population.

Methods

The role of fasting blood glucose levels as a predictor of all-cause and cause-specific mortality was estimated in 9930 participants from four Chinese general populations with a 20-year follow-up. Multivariate Cox proportional hazard models were used to identify the relationship between fasting glucose and mortality.

Results

There were 1471 deaths after a median follow-up of 20.2 years (a total of 187,374 person-years), including 310 cardiovascular deaths, 581 cancer deaths, and 580 other-cause deaths. After adjustment for age, sex, urban or rural, northern or southern of China, types of work, education level, physical exercise, smoking status, drinking status, body mass index, systolic blood pressure, and serum total cholesterol at baseline, the hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality in the fasting blood glucose categories of <60, 60-69, 70-79, 90-99, 100-109, 110-125, and ≥126 mg/dl were 1.38 (1.04-1.84), 1.20 (1.01-1.43), 1.18 (1.03-1.36), 1.18 (0.99-1.41), 1.48 (1.16-1.88), 1.17 (0.84-1.62), and 2.23 (1.72-2.90), respectively, in contrast to the reference group (80-89 mg/dl). The HRs and 95% CIs for cardiovascular disease mortality in these groups were 2.58 (1.44-4.61), 1.41 (0.95-2.10), 1.56 (1.15-2.11), 1.29 (0.88-1.89), 1.36 (0.78-2.37), 1.05 (0.52-2.11), and 2.73 (1.64-4.56), respectively.

Conclusions

Both low and high fasting glucose were significantly associated with increased risk of all-cause and cardiovascular mortality in Chinese general population.

Low fructosamine and mortality - A long term follow-up of 215,011 non-diabetic subjects in the Swedish AMORIS study

BACKGROUND AND AIMS

Both high and low fasting glucose has been associated with an increased mortality among individuals without diabetes. This J-shaped association has also been shown for HbA1c in relation to all-cause mortality. High fructosamine is associated with increased mortality. In this study we aim to evaluate if low fructosamine is also associated with increased mortality in non-diabetic subjects.

METHODS AND RESULTS

We included 215,011 subjects from the AMORIS cohort undergoing occupational health screening or primary care in Stockholm, Sweden. Cause specific mortality was obtained from the Swedish Cause-of-Death Register by record linkage. Hazard ratios for the lowest decile of fructosamine were estimated by Cox regression for all-cause (n = 41,388 deaths) and cause-specific mortality during 25 years of follow-up. We observed gradually increased mortality with lower fructosamine in a large segment of the population. In the lowest decile of fructosamine the sex, age, social class and calendar adjusted hazard ratio was 1.20 (95% CI; 1.18-1.27) compared to deciles 2-9. This increased mortality was attenuated after adjustment for six other biomarkers (HR = 1.11 (95% CI; 1.07-1.15)). Haptoglobin, an indicator of chronic inflammation, made the greatest difference in the point estimate. In sensitivity analyses we found an association between low fructosamine and smoking and adjustment for smoking further attenuated the association between low fructosamine and mortality.

CONCLUSION

Low levels of fructosamine in individuals without diabetes were found to be associated with increased mortality. Smoking and chronic inflammation seem to at least partially explain this association but an independent contribution by low fructosamine cannot be excluded.

Fructosamine is a risk factor for myocardial infarction and all-cause mortality - Longitudinal experience from the AMORIS cohort

BACKGROUND AND AIMS

Glycation is linked to microvascular complications of diabetes and also to macrovascular events. Fructosamine is a biomarker of glycation but its associations to macrovascular complications are not well documented. The aim of this study was to evaluate fructosamine as a predictor of myocardial infarction and all-cause mortality in a large population based cohort.

METHODS AND RESULTS

Information on glucose and fructosamine was obtained from subjects of the AMORIS cohort (n = 338,443) followed for 19 years on average. Incident cases of myocardial infarction and death from any cause were identified from national patient and cause of death register respectively. The incidence of myocardial infarction (n = 21,526 cases) and all-cause mortality (n = 73,458 deaths) increased at a fructosamine of 2.30 mmol/L or above. For myocardial infarction, the sex-age- fasting- and entry period adjusted hazard ratio in subjects above 2.70 mmol/L vs. reference range subjects was 2.88 (95% CI: 2.70-3.07). The corresponding hazard ratio for all-cause mortality was 2.31 (95% CI: 2.21-2.41). These associations remained basically unchanged after adjustment for total cholesterol, triglycerides, albumin, social class, smoking and hypertension. When additional adjustment for glucose was performed the associations were attenuated but remained. In a sub cohort with simultaneous measurements of fructosamine, HbA1c and fasting glucose respectively similar associations were observed (n = 9746).

CONCLUSION

There is a strong association between fructosamine and myocardial infarction and death from any cause when major cardiovascular risk factors are accounted for. In addition, this association could only partly be explained by glucose levels.

J-shaped association between plasma glucose concentration and cardiovascular disease mortality over a follow-up of 32years

OBJECTIVE

We aimed at examining the association between plasma glucose (PG) concentration and cardiovascular mortality in a population sample from Switzerland over a follow-up time of 32 years.

METHODS

We analyzed 7984 men and women enrolled in the first National Research Program (NRP1A, 1977-1979) and followed up for survival until 2008. Mortality hazard ratios (HR) were calculated using adjusted Cox regression models. PG was measured in fasting state or randomly with known fasting time. Models were adjusted for age, sex, socio-demographic, lifestyle and cardiovascular risk factors.

RESULTS

PG concentrations ≥ 6.1 mmol/L were associated with increased risk of cardiovascular disease (CVD) and all-cause mortality. Compared to normal PG (3.8-4.9 mmol/L) the adjusted HR (95% CI) for CVD mortality was 1.26 (1.01-1.58) for PG ≥ 6.1-6.9 mmol/L, 1.56 (1.18-2.06) for PG ≥ 7 mmol/L, 1.67 (1.22-2.30) for known diabetes. All-cause mortality essentially showed the same patterns. All-cause mortality was increased [1.35 (1.01-1.80)] also for PG <3.8 mmol/L.

CONCLUSION

Plasma glucose remained significantly and independently associated with CVD mortality even after full follow-up. The relationship was J-shaped. In order to prevent premature death, persons with abnormal PG concentrations on both extremes should be screened and counseled for other CVD risk factors.

Fasting glucose level and the risk of incident atherosclerotic cardiovascular diseases

OBJECTIVE

Although diabetes increases the risk of cardiovascular disease (CVD) and mortality, the dose-response relationship between fasting glucose levels below those diagnostic of diabetes with cardiovascular events has not been well characterized.

RESEARCH DESIGN AND METHODS

A prospective cohort study of more than one million Koreans was conducted with a mean follow-up of 16 years. A total of 1,197,384 Korean adults with no specific medical conditions diagnosed were classified by baseline fasting serum glucose level. Associations of fasting glucose level with CVD incidence and mortality, stroke incidence and mortality, and all-cause mortality were analyzed using multivariate proportional hazards regression.

RESULTS

The relationships between fasting glucose levels and CVD risks generally followed J-shape curves, with lowest risk in the glucose range of 85-99 mg/dL. As fasting glucose levels increased to >100 mg/dL, risks for CVD, ischemic heart disease, myocardial infarction, and thrombotic stroke progressively increased, but risk for hemorrhagic stroke did not. Fasting glucose levels <70 mg/dL were associated with increased risk of all stroke (hazard ratio 1.06, 95% CI 1.01-1.11) in men and (hazard ratio 1.11, 1.05-1.17) in women.

CONCLUSIONS

Both low glucose level and impaired fasting glucose should be considered as predictors of risk for stroke and coronary heart disease. The fasting glucose level associated with the lowest cardiovascular risk may be in a narrow range.

Non-linear contribution of glucose measures to cardiovascular diseases and mortality: reclassifying the Framingham's risk categories: a decade follow-up from the Tehran lipid and glucose study

BACKGROUND

We investigated non-linear contribution of fasting plasma glucose (FPG) and 2-hour post-challenge plasma glucose (2h-PCPG) to the risk of CVD and mortality. We hypothesized that glucose measures improve risk-stratification made by the Framingham's general CVD risk algorithm.

METHODS

Among participants aged ≥ 30 (n=8071), not taking glucose-lowering agents, 6169 (3477 women) remained eligible. Non-linear contribution of FPG and 2h-PCPG to incident CVD and mortality were assessed using Cox models incorporating restricted cubic splines functions. Risk reclassification improvement conferred by FPG and 2h-PCPG was examined using an extended version of net reclassification index (NRI) that takes into account the censoring nature of survival data.

RESULTS

We documented 465 incident CVD events (402 CHD), 212 deaths from any cause (94 CVD deaths). Excluding the contribution of the 2h-PCGP to mortality (that was linear) dose-response relationships between glucose measures and CVD and mortality were curvilinear with nadirs below which decreasing levels of glucose were unlikely to offer any benefit. These nadirs were assigned to FPG of 4.9-5.3 and 2h-PCPG of 6.0 mmol.l(-1). Glucose measures added to the predictive ability of the Framingham's general CVD risk algorithm with cutpoint-free NRIs ranging from 19 to 54%.

CONCLUSION

Glucose measures contributed to the risk of CVD and mortality in a curvilinear fashion, we observed increased risk below glucose thresholds currently used to define diabetes, supporting criteria for the diagnosis of impaired fasting glycemia and impaired glucose tolerance. Glucose measures were observed to add to predictive ability of the predictive model which included established cardiovascular risk factors.

Cardiovascular and total mortality in men and women with different blood pressure levels--A 26-year follow-up

AIM

Our aim was to study different levels of high blood pressure and normal blood pressure (reference) to calculate the hazard ratios (HRs) for cardiovascular and total mortality in men and women with adjustments for many covariates.

METHODS

A health-screening program was offered to a population-based sample in Stockholm County to estimate healthcare needs (a proxy for co-morbidity). Blood pressure measurements (mmHg systolic/diastolic) were available for 2280 participants (74%). Mortality was followed up for 26 years.

RESULTS

HRs with confidence intervals (CI) were calculated. The HR for all-cause mortality in those with very high blood pressure, > or =160 and/or 95, was 1.93 (1.38-2.70) in men and 2.29 (1.42-3.69) in women. High blood pressure (> or = 140 and/or 90 but <160 and 95 cmHg) and prehypertension (> or = 130 and/or 85 but <140 and 90) were significant in women but not in men. Diagnosed hypertension with antihypertensive treatment adjusted for blood pressure level was non-significant in all models.

CONCLUSION

Very high blood pressure was an independent risk factor for both total and cardiovascular mortality in both men and women after adjustments for all covariates including healthcare need. Hypertension seems just as important to treat in individuals with co-morbidities.

The association between BMI value and long-term mortality

OBJECTIVES

To study total mortality in different categories of BMI values, with adjustments for important covariates in a population-based 26-year mortality follow-up. Special interest will be given to gender differences and low BMI values.

METHODS

From a stratified sample in 1969 of 32 185 individuals aged 18-64 years from Stockholm County, 2422 underwent a health examination, with complete data obtained for 1020 subjects. BMI was classified as underweight (<20), normal (20-24.9), overweight (25-29.9) or obesity (> or =30). Participants were followed up in the National Cause of Death Register until the end of 1996. Multivariate analysis was performed by Cox regression for men and women separately, with different models, with step-wise adjustment for age, care need category, heart rate, hypertension, blood glucose, alcohol intake and smoking, with hazard ratios (HR) and 95% confidence interval (CI) and with normal weight as reference.

RESULTS

Among men, the age-adjusted HR was 1.68 (95% CI 1.10-2.57) for underweight and 1.62 (95% CI 1.08-2.43) for obesity, and among women it was 0.93 (95% CI 0.58-1.51) for underweight and 1.88 (95% CI 1.26-2.82) for obesity. In men, the significantly increased mortality remained when also adjusting for care need category, but not when adjusting for other factors, whereas the opposite was found regarding obesity. For women, underweight was significantly associated with decreased mortality when adjusting for smoking and for all factors together, whereas obesity was associated with increased mortality when adjusting for the different factors except for all factors together.

CONCLUSIONS

Underweight was associated with higher mortality among men, but not when adjusting for covariates, whereas underweight was associated with lower mortality among women when adjusting for smoking.