Associations between general and abdominal adiposity and mortality in individuals with diabetes mellitus

Relationship between weight-adjusted-waist index and all-cause and cardiovascular mortality in individuals with type 2 diabetes

AIM

To investigate the relationship between the weight-adjusted-waist index (WWI) and all-cause mortality as well as cardiovascular mortality in individuals with type 2 diabetes.

METHODS

We used data from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 and the UK Biobank database. Restricted cubic spline curves and Cox proportional hazards models were employed to assess hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality.

RESULTS

In the UK Biobank database, compared with the lowest WWI quartile, the HR for all-cause and cardiovascular death in the highest quartile was 1.846 (95% CI 1.687-2.019) and 2.118 (95% CI 1.783-2.517), respectively, in the fully adjusted model. In the NHANES database, compared with the lowest WWI quartile, the highest quartile had an HR of 1.727 (95% CI 1.378-2.163) for all-cause death and 1.719 (95% CI 1.139-2.595) for cardiovascular death in the fully adjusted model.

CONCLUSIONS

Our study indicates that WWI has a long-term synergistic negative impact on all-cause mortality and cardiovascular mortality in individuals with type 2 diabetes. The WWI is an independent predictor of mortality in individuals with type 2 diabetes.

Central obesity may affect bone development in adolescents: association between abdominal obesity index ABSI and adolescent bone mineral density

PURPOSE

Previous studies have suggested that obesity defined by body mass index(BMI) is a protective factor for bone mineral density(BMD), but have overlooked the potential influence of different types of obesity. This study aims to evaluate the correlation between abdominal obesity index A Body Shape Index(ABSI) and adolescent bone density, and analyze the relationship between abdominal obesity and bone metabolism.

METHODS

A total of 1557 adolescent participants were included in NHANES from 2007 to 2018. Calculate the ABSI using a specific formula that takes into account waist circumference and BMI. A weighted multiple linear regression model is used to evaluate the linear correlation between ABSI and BMD. Forest plots are used to analyze the correlations between subgroups, and cubic splines are limited to evaluate the nonlinear correlations and saturation effects between ABSI and BMD.

RESULTS

After adjusting for confounding factors, there was a significant linear correlation (P < 0.01) between ABSI and femoral BMD, both as a continuous variable and an ordered categorical variable. The restrictive cubic spline curve indicates a significant nonlinear correlation and saturation effect between adolescent ABSI and BMD.

CONCLUSION

Research has shown a significant negative correlation between ABSI and BMD at the four detection sites of the femur, and this correlation may vary slightly due to age, race, family income, and different detection sites. The research results indicate that compared to overall body weight, fat distribution and content may be more closely related to bone metabolism.

Gamma-glutamyl transferase and the risk of all-cause and disease-specific mortality in patients with diabetes: A nationwide cohort study

BACKGROUND

There exists a paucity of data regarding whether gamma-glutamyl transferase is associated with disease-specific mortality in patients with type 2 diabetes mellitus. This study aimed to investigate the association of serum gamma-glutamyl transferase levels with all-cause and disease-specific mortality in patients with diabetes mellitus using a Korean nationwide health-screening database.

METHODS

A total of 9 687 066 patients without viral hepatitis or liver cirrhosis who underwent health examination in 2009 were included. These patients were divided into four groups according to sex-specific quartiles of serum gamma-glutamyl transferase levels.

RESULTS

During a median follow-up period of 8.1 years, 222 242 deaths were identified. The all-cause mortality rate increased as the serum gamma-glutamyl transferase levels became higher (highest quartile vs lowest quartile: hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.55-1.59; p for trend <.001). Similar trends were observed for cardiovascular disease (HR, 1.57; 95% CI, 1.53-1.62), ischemic heart disease (HR, 1.40; 95% CI, 1.33-1.48), and stroke (HR, 1.72; 95% CI, 1.60-1.85) in the highest quartile, as compared with the lowest quartile (p for trend <.001). As the gamma-glutamyl transferase quartiles became higher, mortality rates related to cancer (HR, 1.56; 95% CI, 1.52-1.60), liver disease (HR, 9.42; 95% CI, 8.81-10.07), respiratory disease (HR, 1.55; 95% CI, 1.49-1.62), and infectious disease (HR, 1.73; 95% CI, 1.59-1.87) also increased in the highest quartile, compared with the lowest quartile (p for trend <.001).

CONCLUSIONS

Serum gamma-glutamyl transferase levels may be useful for the risk assessment of all-cause and disease-specific mortality among patients with type 2 diabetes mellitus.

Ratio of waist circumference to body mass index: A novel predictor of clinical outcome in hypertension patients

We aim to investigate the influence of waist circumference and body mass index (BMI) on all-cause death and cardiovascular-specific death in patients with hypertension. This prospective cohort study, based on waist circumference and body mass index measurements in patients with hypertension, provided risk estimates of all-cause mortality and cardiovascular events. The waist circumference-to-BMI ratio (WtBR) is an anthropometric measure integrating waist circumference and BMI. We utilized multivariable Cox regression analysis, restricted cubic spline model, Kaplan-Meier plot, random forest analysis, and sensitivity analysis to assess the relationship of WtBR with all-cause mortality. Subsequently, Fine-Gray competing risk regression models were applied to precisely evaluate the probability of cardiovascular-specific death attributed to high WtBR. The results indicate that thea deceased group showed significantly higher WtBR and lower BMI compared with the alive groups (P < .05), while no significant difference was observed in waist circumference (P = .373). When analyzed as continuous, the risk of all-cause death elevated with increasing WtBR in the adjusted model with an HR of 2.42 (95% CI, 2.06-2.85). The restricted cubic spline illustrated an elevated risk of all-cause mortality as WtBR increased (J-shaped curve). Nevertheless, WtBR showed no significant association with cardiovascular-specific death and the prediction model exhibited a reliable performance in the testing set. This study supported that WtBR, an anthropometric measure, is independently associated with all-cause death in hypertensive patients. It's advisable to routinely assess waist circumference in hypertensive patients regardless of BMI, in order to more effectively manage the risk of obesity-related health.

Predictive model for early detection of type 2 diabetes using patients' clinical symptoms, demographic features, and knowledge of diabetes

Background and Aims

With the global rise in type 2 diabetes, predictive modeling has become crucial for early detection, particularly in populations with low routine medical checkup profiles. This study aimed to develop a predictive model for type 2 diabetes using health check-up data focusing on clinical details, demographic features, biochemical markers, and diabetes knowledge.

Methods

Data from 444 Nigerian patients were collected and analysed. We used 80% of this data set for training, and the remaining 20% for testing. Multivariable penalized logistic regression was employed to predict the disease onset, incorporating waist-hip ratio (WHR), triglycerides (TG), catalase, and atherogenic indices of plasma (AIP).

Results

The predictive model demonstrated high accuracy, with an area under the curve of 99% (95% CI = 97%-100%) for the training set and 94% (95% CI = 89%-99%) for the test set. Notably, an increase in WHR (adjusted odds ratio [AOR] = 70.35; 95% CI = 10.04-493.1, p-value < 0.001) and elevated AIP (AOR = 4.55; 95% CI = 1.48-13.95, p-value = 0.008) levels were significantly associated with a higher risk of type 2 diabetes, while higher catalase levels (AOR = 0.33; 95% CI = 0.22-0.49, p < 0.001) correlated with a decreased risk. In contrast, TG levels (AOR = 1.04; 95% CI = 0.40-2.71, p-value = 0.94) were not associated with the disease.

Conclusion

This study emphasizes the importance of using distinct clinical and biochemical markers for early type 2 diabetes detection in Nigeria, reflecting global trends in diabetes modeling, and highlighting the need for context-specific methods. The development of a web application based on these results aims to facilitate the early identification of individuals at risk, potentially reducing health complications, and improving diabetes management strategies in diverse settings.

Waist to height ratio as a simple tool for predicting mortality: a systematic review and meta-analysis

BACKGROUND

The association of central obesity with higher rates of mortality is not well studied. This study evaluates the association between waist-to-height ratio (WHtR), as a measure of central obesity, with mortality.

METHODS

Documents were retrieved from PubMed, Web of Science, Scopus, and Google Scholar databases until May 2022. Data were extracted from cohort studies reporting effect size (hazard ratio (HR)) regarding the association between WHtR as a continuous (per 1 SD increment) or categorical (highest/lowest) measure and all-cause and cause-specific mortality. Screening of included studies was performed independently by two authors. Moreover, the quality assessment of included studies was performed based on the Newcastle-Ottawa assessment scale. Finally, random effect meta-analysis was performed to pool the data, and the outcomes' certainty level was assess based on the GRADE criteria.

RESULTS

Of the 815 initial studies, 20 were included in the meta-analysis. Random effect meta-analysis showed that in the general population, the all-cause mortality HRs for categorical and continuous measurements of WHtR increased significantly by 23% (HR:1.23; 95% CI: 1.04-1.41) and 16% (HR:1.16; 95% CI: 1.07-1.25), respectively. Moreover, the hazard of cardiovascular (CVD) mortality increased significantly for categorical and continuous measurements of WHtR by 39% (HR:1.39; 95% CI: 1.18-1.59) and 19% (HR:1.19; 95% CI: 1.07-1.31). The quality assessment score of all included studies was high.

CONCLUSIONS

Higher levels of WHtR, indicating central obesity, were associated with an increased hazard of CVD and all-cause mortality. This measure can be used in the clinical setting as a simple tool for predicting mortality.

Association of changes in body mass index and waist circumference with cardiovascular risk in non-alcoholic fatty liver disease: A nationwide study

BACKGROUND

We investigated whether changes in body mass index (BMI) and waist circumference (WC) are associated with cardiovascular risk in patients with NAFLD using a nationwide dataset.

METHODS

Using the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS) data in Korea, a total of 19,057 subjects who underwent two consecutive medical check-ups (2009-2010 and 2011-2012) and who had a fatty-liver index (FLI) value of ≥ 60 were included in the analysis. Cardiovascular events were defined as the occurrence of stroke or transient ischemic attack, coronary heart disease, and cardiovascular death.

RESULTS

After multivariable adjustment, the risk of cardiovascular events was significantly lower in subjects with decreases in both BMI and WC (HR, 0.83; 95% CI, 0.69-0.99) and those with increased BMI and decreased WC (HR, 0.74; 95% CI, 0.59-0.94) when compared with those who showed increases in both BMI and WC. The effect of cardiovascular risk reduction among the group with increased BMI but decreased WC was particulary pronounced among those who had metabolic syndrome during the second check-up (HR, 0.63; 95% CI 0.43-0.93, p for interaction 0.02).

CONCLUSIONS

Changes in BMI and WC were significantly associated with cardiovascular risk in NAFLD patients. NAFLD patients with increased BMI and decreased WC had the lowest cardiometabolic risk.

Hypoglycemia and Cardiovascular Disease: Exploring the Connections

It has long been known that administering insulin or insulin secretagogues to treat diabetes has the unfavorable side effect of hypoglycemia. Because hypoglycemia can disrupt normal brain function, it can have a profound impact on people's lives. Studies have shown a connection between hypoglycemia and a higher risk of death and cardiovascular disease. Through experimental studies, numerous potential reasons for the start of cardiovascular events have been discovered. In addition, studies on people have demonstrated that hypoglycemia can result in ventricular arrhythmias. According to recent studies, a number of factors may affect the relationship between hypoglycemia, cardiovascular events, and mortality. Confounding factors may explain the apparent correlation, at least in part. People with comorbidities may experience more hypoglycemia, increasing their risk of mortality. Those who have type 1 or type 2 diabetes, however, seem to be more susceptible to the negative effects of hypoglycemia on the cardiovascular system. When choosing appropriate glucose-lowering treatments and setting glycemic objectives with patients, clinicians should be aware of this risk.

Depression score mediate the association between a body shape index and infertility in overweight and obesity females, NHANES 2013-2018

BACKGROUND

Overweight and obese females demonstrate a significantly increased risk of anovulatory infertility. This study aims to investigate whether depression score could mediate the association between a body shape index (ABSI) and infertility, especially in overweight and obese population.

METHODS

We included 5431 adult female Americans from the National Health and Nutrition Examination Survey (NHANES, 2013-2018) database. ABSI manifested the body shape using waist circumference, weight, and height. Infertility or fertility status was defined by interviewing female participants aged ≥ 18 through the reproductive health questionnaires. Depression symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) with total scores between 0 and 27. To investigate the association of infertility with ABSI and other individual components, survey-weighted multivariable logistic regression was performed. Mediation analysis of PHQ-9 score was conducted to disentangle the pathways that link ABSI to infertility among the NHANES participants.

RESULTS

596 (10.97%) females were categorized with having infertility among 5431 participants. Participants with infertility showed higher ABSI and PHQ-9 score, appearing greater population proportion with depression symptoms. In the multivariable logistic regression model, ABSI (adjusted odds ratio = 0.14, 95% CI: 0.04 to 0.50) and PHQ-9 (adjusted odds ratio = 1.04, 95% CI: 1.01 to 1.07) were positively associated with infertility. PHQ-9 score was estimated to mediate 0.2% (P = 0.03) of the link between ABSI and infertility in all individuals, but to mediate 13.5% (P < 0.01) of the ABSI-infertility association in overweight and obese adult females.

CONCLUSION

The association between ABSI and infertility seems to be mediated by depression symptoms scored by PHQ-9, especially in those adult females with overweigh and obesity. Future studies should be implemented to further explore this mediator in ABSI-infertility link.

Association of gamma-glutamyl transferase concentrations with all-cause and cause-specific mortality in Chinese adults with type 2 diabetes

BACKGROUND

Evidence links gamma-glutamyl transferase (GGT) to mortality in the general population. However, the relationship of GGT with all-cause and cause-specific mortality risk has been little explored in type 2 diabetes mellitus (T2DM) patients.

METHODS

We recruited 20 340 community-dwelling T2DM patients between 2013 and 2014 in Jiangsu, China. Cox regression models were used to assess associations of GGT with all-cause and specific-cause mortality. Restricted cubic splines were used to analyze dose-response relationships between GGT and mortality. Stratified analysis was conducted to examine potential interaction effects by age, sex, smoking status, body mass index (BMI), diabetes duration, and dyslipidemia.

RESULTS

During a median follow-up period of 7.04 years (interquartile range: 6.98-7.08), 2728 deaths occurred, including 902 (33.09%) due to cardiovascular disease (CVD), and 754 (27.58%) due to cancer. GGT concentrations were positively associated with all-cause, CVD, and cancer mortality. Multivariable hazard ratios (HRs) for the highest (Q5) vs. the lowest quintile (Q1) were 1.63 (95% confidence intervals [CI]: 1.44-1.84) for all-cause mortality, 1.87 (95% CI: 1.49-2.35) for CVD mortality, and 1.43 (95% CI: 1.13-1.81) for cancer mortality. Effect modification by BMI and dyslipidemia was observed for all-cause mortality (both p for interaction <.05), and HRs were stronger in the BMI <25 kg/m2 group and those without dyslipidemia.

CONCLUSIONS

Our findings suggest that, in Chinese T2DM patients, elevated serum GGT concentrations were associated with mortality for all-cause, CVD, and cancer, and further research is needed to elucidate the role of obesity, nonalcoholic fatty liver disease, and lipids in this association.

Body mass index versus surrogate measures of central adiposity as independent predictors of mortality in type 2 diabetes

BACKGROUND

An "obesity paradox" for mortality has been shown in chronic disorders such as diabetes, and attributed to methodological bias, including the use of body mass index (BMI) for obesity definition. This analysis investigated the independent association of BMI versus surrogate measures of central adiposity with all-cause mortality in individuals with type 2 diabetes.

METHODS

The Renal Insufficiency And Cardiovascular Events Italian Multicentre Study is a prospective cohort study that enrolled 15,773 patients in 19 Italian centres in 2006-2008. Exposures were BMI and the surrogate measures of central adiposity waist circumference (WC), waist-to-height ratio (WHtR), and A Body Shape Index (ABSI). Vital status was retrieved on 31 October 2015 for 15,656 patients (99.3%), RESULTS: Age- and sex-adjusted hazard ratios and 95% confidence intervals were significantly higher in BMI-based underweight (1.729 [1.193-2.505), P = 0.004), moderately obese (1.214 [1.058-1.392), P = 0.006) and severely obese (1.703 [1.402-2.068), P < 0.0001), lower in overweight (0.842 [0.775-0.915), P < 0.0001) and similar in mildly obese (0.950 [0.864-1.045), P = 0.292), compared to normal-weight individuals. When further adjusting for smoking, physical activity (PA), and comorbidities, risk was lower also in mildly obese versus normal-weight patients. The BMI-mortality relationship did not change after sequentially excluding ever smokers, individuals with comorbidities, and those died within two years from enrollment and when analyzing separately participants below and above the median age. Conversely, a paradox relationship was observed among inactive/moderately inactive, but not moderately/highly active patients. Mortality risk adjusted for age, gender, smoking, PA and comorbidities was significantly higher in the highest tertile of WC (1.279 [1.089-1.501], P = 0.003), WHtR (1.372 [1.165-1.615], P < 0.0001), and ABSI (1.263 [1.067-1.495], P = 0.007) versus the lowest tertile. However, risk was lower in the intermediate versus lowest tertile for WC (0.823 [0.693-0.979], P = 0.028), similar for WHtR, and higher, though not significantly, for ABSI.

CONCLUSIONS

An "overweight paradox" remained after controlling for age, smoking, and comorbidities, arguing against a collider bias or reverse causation. However, it could be partly explained by confounding from PA level, possibly through its impact on lean mass and cardiorespiratory fitness. No obesity paradox was observed with WHtR and especially ABSI, which predicted mortality risk associated with central adiposity better than WC. Trial registration ClinicalTrials.gov, NCT00715481, 15 July, 2008.

The influence of metabolic syndrome in heart valve intervention. A multi-centric study

BACKGROUND

The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients.

METHODS

Patients from 10 cardiac units who underwent isolated valve intervention (mitral± $\pm $  tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded.

RESULTS

From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications.

CONCLUSION

MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.

Association Between Obesity and Cardiovascular Disease in Elderly Patients With Diabetes: A Retrospective Cohort Study

CONTEXT

Some studies have suggested that patients with type 2 diabetes mellitus (T2DM) concomitant with obesity have better clinical outcomes than normal-weight patients with T2DM.

OBJECTIVE

We evaluated associations among obesity, cardiovascular disease (CVD) events, and mortality in elderly patients with T2DM without CVD.

METHODS

This retrospective observational study from 2009 to 2017, with a mean follow-up of 7.26 years, included 249 903 elderly (≥ 65 years) patients with T2DM and no preexisting CVD from the Korean National Health Information Database. We categorized subjects according to body mass index (BMI) and waist circumference (WC) and analyzed a composite of stroke, myocardial infarction, and all-cause death using Cox proportional hazards regression analysis, adjusting for baseline covariates.

RESULTS

The incidence rate of composite primary outcomes was 30.95/1000 person-years. The primary outcome risk had an L-shaped and a U-shaped association with BMI and WC, respectively. In the multivariable Cox proportional hazard models, the risk of primary composite outcomes in the highest BMI group (≥ 30 kg/m2; hazard ratio [HR] = 0.824; 95% CI, 0.794-0.855) was lower than in the normal BMI group (≥ 18.5 and < 23 kg/m2). Conversely, that in the highest WC group (≥ 100 cm/≥ 95 cm; men/women; HR = 1.434; 95% CI, 1.384-1.486) was higher than in the normal WC group (< 90 cm/< 85 cm; men/women).

CONCLUSION

Our study with elderly patients with diabetes results suggest that while BMI is an inadequate risk indicator for outcomes related to obesity, WC is a suitable alternative.

Association of Sarcopenia and A Body Shape Index With Overall and Cause-Specific Mortality

AIM

This observational study aimed to examine the association between the A Body Shape Index (ABSI) and/or sarcopenia and total, cardiovascular, and cancer mortality.

METHODS

The associations of sarcopenia and ABSI with all-cause, cardiovascular, and cancer mortality were assessed in 4,488 participants from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) who were followed up until December 31, 2015. Models were analyzed separately for men and women and adjusted for age, race, and other confounding factors. ABSI was assessed as a continuous measurement by quartile for men and women. Population attributable fractions (PAFs) were calculated to assess mortality caused by sarcopenia and/or ABSI in the study population.

RESULTS

When ABSI was assessed as a continuous variable, the ABSI quartile showed a linear trend for total (p = 0.0001), cardiovascular (p = 0.04), and cancer (p = 0.02) mortality in men and for total (p = 0.06) and cardiovascular (p = 0.06) mortality in women. The hazard ratios (HRs) of the fourth ABSI quartile were 1.51 [95% confidence interval (CI): 1.20-1.89] in men and 1.23 (95% CI: 0.93-1.64) in women, compared with those in the first quartile. When ABSI was assessed by quartile, the appendicular skeletal mass index (ASMI) was lower in the groups with high ABSI. When high ABSI was combined with sarcopenia, the HRs of all-cause mortality were 2.05 (95% CI: 1.60-2.62) in men and 1.51 (95% CI: 1.19-1.92) in women. In the subpopulation (sarcopenia group or higher ABSI), the PAFs of mortality due to sarcopenia were 26.16% (95% CI: 12.68-37.56) in men and 21.89% (95% CI: 5.64-35.35) in women, and the PAF of mortality due to higher ABSI was 23.70% (95% CI: 12.11-33.77) in men.

CONCLUSION

The ABSI value was significantly associated with all-cause and cardiovascular mortality, and the co-existence of higher ABSI values and sarcopenia can contribute to a more significant death risk in comparison with high ABSI values or sarcopenia. Moreover, the ABSI values in combination with the ASMI can be used to preliminarily evaluate the content and distribution of fat and muscle and to predict the risk of death in obese and sarcopenic populations.

The Role of Diet, Alcohol, BMI, and Physical Activity in Cancer Mortality: Summary Findings of the EPIC Study

Evidence on the impact of diet, alcohol, body-mass index (BMI), and physical activity on mortality due to cancer and other cancer-related outcomes is still scarce. Herein, we reviewed the contribution of the European Prospective Investigation into Cancer and Nutrition (EPIC) study to the current state of the art on the role of these factors in cancer mortality. We identified 45 studies using a rapid systematic review methodology. Dietary factors associated with reduced cancer mortality included raw vegetable intake; dietary fiber intake; the Mediterranean diet; other dietary scores; other diet patterns including low meat eaters, vegetarians/vegans, or fish eaters; dietary intake (or biomarkers) of some vitamins (e.g., vitamin D, vitamin K2, or Vitamin C); and intake of lignans. Physical activity and following healthy lifestyle recommendations also reduced cancer mortality risk. In contrast, dietary factors associated with higher cancer mortality risk included poor diet quality, consumption of alcohol and soft drinks including juice, and, to a lesser extent, intake of some fatty acids. Excess weight and obesity also increased the risk of cancer mortality. The EPIC study holds valuable information on diet and lifestyle factors and offers a unique opportunity to identify key diet-related factors for cancer mortality prevention.

Metabolic and genetic determinants for progression to severe liver disease in subjects with obesity from the UK Biobank

BACKGROUND

Obesity is among the main determinants of nonalcoholic fatty liver disease progression towards severe liver disease (SLD). However, risk factors for SLD in individuals with obesity have not been examined.

OBJECTIVES

To identify the independent risk factors for SLD among participants with obesity from the UK Biobank.

METHODS

A total of 80,224 UK Biobank participants with obesity (body mass index[BMI] > 30 kg/m²) and 242,822 without obesity, of European descent without clinical history of liver disease and liver cancer were prospectively followed for the onset of SLD, defined as a composite diagnosis of cirrhosis, decompensated liver disease, hepatocellular carcinoma and/or liver transplantation. Risk factors for incident SLD were assessed by Cox proportional hazards models. Different clinical phenotypes were derived by latent class analysis (LCA).

RESULTS

Obesity conferred a 2.6-fold increased risk for SLD that was abolished after the inclusion of waist circumference (WC) in the model. Among individuals with obesity, age (adjusted hazard ratio [aHR] 1.05, 95%CI 1.03-1.07, p = 3.9 * 10^-7), type 2 diabetes (aHR 2.18, 95%CI 1.55-3.05, p = 6.2 * 10^-6), PNPLA3 rs738409 (aHR 1.59, 95%CI 1.33-1.9, p = 3.1 * 10^-7) and WC (aHR 1.04, 95%CI 1.02-1.06, p = 8.5 * 10^-6) were independent predictors of SLD. BMI category-specific WC thresholds allowed a better risk stratification compared to traditional ones. By LCA, the clinical phenotype at highest risk for SLD was that with BMI < 35 kg/m² and WC above BMI-category specific thresholds.

CONCLUSIONS

Age, WC, type 2 diabetes, and the PNPLA3 variant are the main risk factors for SLD in individuals with obesity. WC is the principal mediator of SLD risk conveyed by increased BMI. BMI category-specific WC-thresholds may refine the SLD risk more accurately than traditional thresholds.

Impact of BMI and waist circumference on epigenome-wide DNA methylation and identification of epigenetic biomarkers in blood: an EWAS in multi-ethnic Asian individuals

BACKGROUND

The prevalence of obesity and its related chronic diseases have been increasing especially in Asian countries. Obesity-related genetic variants have been identified, but these explain little of the variation in BMI. Recent studies reported associations between DNA methylation and obesity, mostly in non-Asian populations.

METHODS

We performed an epigenome-wide association study (EWAS) on general adiposity (body mass index, BMI) and abdominal adiposity (waist circumference, WC) in 409 multi-ethnic Asian individuals and replicated BMI and waist-associated DNA methylation CpGs identified in other populations. The cross-lagged panel model and Mendelian randomization were used to assess the temporal relationship between methylation and BMI. The temporal relationship between the identified CpGs and inflammation and metabolic markers was also examined.

RESULTS

EWAS identified 116 DNA methylation CpGs independently associated with BMI and eight independently associated with WC at false discovery rate PFDR < 0.05 in 409 Asian samples. We replicated 110 BMI-associated CpGs previously reported in Europeans and identified six novel BMI-associated CpGs and two novel WC-associated CpGs. We observed high consistency in association direction of effect compared to studies in other populations. Causal relationship analyses indicated that BMI was more likely to be the cause of DNA methylation alteration, rather than the consequence. The causal analyses using BMI-associated methylation risk score also suggested that higher levels of the inflammation marker IL-6 were likely the consequence of methylation change.

CONCLUSION

Our study provides evidence of an association between obesity and DNA methylation in multi-ethnic Asians and suggests that obesity can drive methylation change. The results also suggested possible causal influence that obesity-related methylation changes might have on inflammation and lipoprotein levels.

Identification of an allosteric hotspot for additive activation of PPARγ in antidiabetic effects

Thiazolidinediones (TZDs), such as rosiglitazone (RSG), which activates peroxisome proliferator activated receptor-γ (PPARγ), are a potent class of oral antidiabetic agents with good durability. However, the clinical use of TZDs is challenging because of their side effects, including weight gain and hepatotoxicity. Here, we found that bavachinin (BVC), a lead natural product, additively activates PPARγ with low-dose RSG to preserve the maximum antidiabetic effects while reducing weight gain and hepatotoxicity in db/db mice caused by RSG monotherapy. Structural and biochemical assays demonstrated that an unexplored hotspot around Met329 and Ser332 in helix 5 is triggered by BVC cobinding to RSG-bound PPARγ, thereby allosterically stabilizing the active state of the activation-function 2 motif responsible for additive activation with RSG. Based on this hotspot, we discovered a series of new classes of allosteric agonists inducing the activity of TZDs in the same manner as BVC. Together, our data illustrate that the hotspot of PPARγ is druggable for the discovery of new allosteric synergists, and the combination therapy of allosteric synergists and TZD drugs may provide a potential alternative approach to the treatment of type 2 diabetes mellitus.

Is the Obesity Paradox in Type 2 Diabetes Due to Artefacts of Biases? An Analysis of Pooled Cohort Data from the Heinz Nixdorf Recall Study and the Study of Health in Pomerania

AIMS/HYPOTHESIS

There is controversy on whether an obesity paradox exists in type 2 diabetes, ie, that mortality is lowest in overweight or obesity. We examined the role of potential biases in the obesity paradox.

METHODS

From two regional population-based German cohort studies - the Heinz Nixdorf Recall Study and the Study of Health in Pomerania (baseline examinations 2000-2003/1997-2001) - 1187 persons with diabetes at baseline were included (mean age 62.6 years, 60.9% males). Diabetes was ascertained by self-report of physician's diagnosis, antidiabetic medication, fasting/random glucose or haemoglobin A1c. Mortality data were assessed for up to 17.7 years. We used restricted cubic splines and Cox regression models to assess associations between body mass index (BMI) and mortality. Sensitivity analyses addressed, inter alia, exclusion of early death cases, of persons with cancer, kidney disease or with history of cardiovascular diseases, and of ever smokers. Furthermore, we examined the role of treatment bias and collider bias for the obesity paradox.

RESULTS

In spline models, mortality risk was lowest for BMI at about 31 kg/m2. Sensitivity analyses carried out one after another had hardly any impact on this result. In our cohort, persons with diabetes and BMI ≥30 kg/m2 did not have better treatment than non-obese patients, and we found that collider bias played only a minor role in the obesity paradox.

CONCLUSION

In a cohort of 1187 persons with diabetes, mortality risk was lowest in persons with moderate obesity. We cannot explain this result by a variety of sensitivity analyses.

A comparison of obesity indices in relation to mortality in type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

This prospective association study aimed to compare the relationship between each of four obesity indices and mortality risk in people with type 2 diabetes.

METHODS

The associations of BMI, waist circumference, WHR and A Body Shape Index (ABSI) with all-cause mortality were analysed in 1282 participants of the Fremantle Diabetes Study, followed for up to 20 years after baseline assessment. Models were adjusted for age and other confounders; assessments as continuous measures and by quintile were carried out for men and women separately. Sensitivity analyses were conducted to minimise reverse causality.

RESULTS

When indices were assessed as continuous variables, there were significant bivariate associations with mortality for: ABSI, which was greater in both men and women who died (p < 0.001); WHR, which was greater in women only (p = 0.033); and BMI, which was lower in women only (p < 0.001). When assessed by quintile, there were significant bivariate associations with mortality for ABSI in men and women (p < 0.001) and BMI in women only (p = 0.002). In Cox models of time to death, adjusted for age, diabetes duration, ethnicity and smoking, ABSI quintiles showed a linear trend for both men (p = 0.003) and women (p = 0.035). Men in the fifth ABSI quintile had an increased mortality risk compared with those in the first quintile (HR [95% CI]: 1.74 [1.24, 2.44]) and women in the fifth ABSI quintile had an increased mortality risk that approached statistical significance (1.42 [0.97, 2.08], p = 0.08). Men in the fifth WHR quintile had an increased mortality risk (1.47 [1.05, 2.06]). There was no association between mortality and BMI or waist circumference in either sex.

CONCLUSIONS/INTERPRETATION

ABSI was the obesity index most strongly associated with all-cause mortality in Australians with type 2 diabetes. There was no evidence for an obesity paradox with any of the assessed indices. ABSI may be a better index of central obesity than waist circumference, BMI or WHR when assessing mortality risk in type 2 diabetes.

Waist circumference as a vital sign in clinical practice: a Consensus Statement from the IAS and ICCR Working Group on Visceral Obesity

Despite decades of unequivocal evidence that waist circumference provides both independent and additive information to BMI for predicting morbidity and risk of death, this measurement is not routinely obtained in clinical practice. This Consensus Statement proposes that measurements of waist circumference afford practitioners with an important opportunity to improve the management and health of patients. We argue that BMI alone is not sufficient to properly assess or manage the cardiometabolic risk associated with increased adiposity in adults and provide a thorough review of the evidence that will empower health practitioners and professional societies to routinely include waist circumference in the evaluation and management of patients with overweight or obesity. We recommend that decreases in waist circumference are a critically important treatment target for reducing adverse health risks for both men and women. Moreover, we describe evidence that clinically relevant reductions in waist circumference can be achieved by routine, moderate-intensity exercise and/or dietary interventions. We identify gaps in the knowledge, including the refinement of waist circumference threshold values for a given BMI category, to optimize obesity risk stratification across age, sex and ethnicity. We recommend that health professionals are trained to properly perform this simple measurement and consider it as an important 'vital sign' in clinical practice.

The association between diabetes and depressive symptoms varies by quality of diabetes care across Europe

Background

Depressive symptoms are more common in adults with diabetes and may arise from the physical and psychosocial burden of disease. Better quality of diabetes care may be associated with a reduced disease burden and fewer depressive symptoms.

Methods

This cross-sectional study included 34 420 participants from 19 countries in the European Social Survey Round 7 (2014-2015). Countries were grouped into quartiles based on their quality of diabetes care as measured in the Euro Diabetes Index 2014. Individual-level depressive symptoms were measured using the 8-item Center for Epidemiologic Studies-Depression Scale. Negative binomial regression was used to compare the number of depressive symptoms between adults with and without diabetes in each quartile of diabetes care quality. Analyses included adjustment for covariates and survey weights.

Results

In countries with the highest quality of diabetes care, having diabetes was associated with only a 3% relative increase in depressive symptoms (95% CI 1.00-1.05). In countries in the second, third and fourth (lowest) quartiles of diabetes care quality, having diabetes was associated with a 13% (95% CI 1.08-1.17), 13% (1.08-1.19) and 22% (1.14-1.31) relative increase in depressive symptoms, respectively.

Conclusion

The association between diabetes and depressive symptoms appears stronger in European countries with lower quality of diabetes care. Potential pathways for this association include the financial aspects of diabetes care, access to services and differential exposure to the social determinants of heath. Further research is needed to unpack these mechanisms and improve the quality of life of people with diabetes across Europe.

Type-2 diabetes mellitus and cardiovascular disease

The global prevalence of diabetes has risen in adults from 4.7% in 1980 to 8.5% in 2014. 90–95% of adults with diabetes have Type 2 diabetes (T2D). This paper focuses on the diagnosis and treatment of T2D patients who have or are at risk for cardiovascular disease. Hyperglycemia, insulin resistance and excess fatty acids increase oxidative stress, disrupt protein kinase C signaling and increase advanced glycation end-products that result in vascular inflammation, vasoconstriction, thrombosis and atherogenesis. Intensive T2D treatment produces a ≥10% risk reduction in major macrovascular and microvascular events. Glucose-lowering therapies must be individualized. Metformin is an optimal drug for monotherapy. If hemoglobin A1c is not at goal, a sodium-glucose cotransporter-2 inhibitor or a dipeptidyl peptidase-4 inhibitor should be considered for therapy with metformin. Coronary angioplasty/stenting is recommended for diabetic patients with acute myocardial infarctions. Coronary artery bypass grafting is recommended for symptomatic diabetic patients with multivessel disease.

Adiposity and Diabetes Risk in Adults with Prediabetes: Heterogeneity of Findings Depending on Age and Anthropometric Measure

OBJECTIVE

The study aimed to evaluate the effect of age on diabetes incidence by general and central adiposity after 3-year follow-up in adults with prediabetes.

METHODS

Data were taken from a cohort of 1,184 subjects with prediabetes included in The Cohort Study in Primary Health Care on the Evolution of Patients with Prediabetes (PREDAPS). General adiposity was defined using body mass index (BMI), and central adiposity was defined with waist circumference and waist to height ratio. Data were analyzed by age groups 30 to 59 and 60 to 74 years. The association between adiposity and diabetes incidence was assessed using hazard ratios (HR).

RESULTS

Adjusting for sociodemographic characteristics, lifestyles, and metabolic parameters, diabetes HR for central adiposity based on the waist circumference clinical cutoff were 2.14 (1.12-4.09) and 1.48 (0.80-2.74) for people aged 30 to 59 and 60 to 74 years, respectively. In the model additionally adjusted for BMI, diabetes HR were 2.65 (1.24-5.65) and 1.33 (0.68-2.59), respectively. The use of a 1-SD increase rather than cutoff points did not alter this pattern. Similar findings were observed with central adiposity based on waist to height ratio.

CONCLUSIONS

The association of central adiposity with type 2 diabetes incidence was lower for people in the older age group than for those in the younger age group.

The Evidence for an Obesity Paradox in Type 2 Diabetes Mellitus

Although overweight/obesity is a major risk factor for the development of type 2 diabetes mellitus, there is increasing evidence that overweight or obese patients with type 2 diabetes mellitus experience lower mortality compared with patients of normal weight. This paradoxical finding, known as the "obesity paradox," occurs in other chronic diseases, and in type 2 diabetes mellitus is particularly perplexing given that lifestyle intervention with one goal being weight reduction is an important feature of the management of this condition. We summarize in this review the findings from clinical and epidemiologic studies that have investigated the association between overweight and obesity (usually assessed using body mass index [BMI]) and mortality in type 2 diabetes mellitus and discuss potential causes of the obesity paradox. We conclude that most studies show evidence of an obesity paradox, but important conflicting findings still exist. We also evaluate if potential bias might explain the obesity paradox in diabetes, including, for example, the presence of confounding factors, measurement error due to use of BMI as an index of obesity, and reverse causation.

Waist-to-calf circumstance ratio is an independent predictor of hepatic steatosis and fibrosis in patients with type 2 diabetes

BACKGROUND AND AIM

Although a combination of central obesity and decreased skeletal muscle mass has been associated with various cardiometabolic disorders, its influence on the presence of non-alcoholic fatty liver disease (NAFLD) in type 2 diabetes (T2D) is unclear. We investigated whether waist-to-calf circumference ratio (WCR) predicts NAFLD or hepatic fibrosis in T2D.

METHODS

Patients with T2D (n = 5507) were enrolled in this study. Hepatic steatosis was diagnosed using abdominal ultrasound and predicting score. NAFLD was defined as 'hepatic steatosis absent other causes of chronic liver disease,' such as virus or alcoholism. Degree of hepatic fibrosis was calculated using non-invasive serum biomarker-based models. Insulin resistance was assessed by short insulin tolerance test.

RESULTS

The prevalence of NAFLD and obesity (BMI ≥ 25 kg/m² , Asian definition) were 46.4% and 38.9%, respectively. NAFLD prevalence was higher with increasing WCR tertiles: lowest tertile (36% in men, 28% in women) versus highest tertile (53.8% in men, 58.2% in women, both P < 0.001 after stratification by insulin resistance status. Increasing WCR tertiles were independently associated with presence of NAFLD: odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.22-1.68 and OR = 1.56, 95% CI = 1.31-1.86, in the middle and highest tertiles, respectively. Furthermore, patients with NAFLD and the highest WCR tertile had significant fibrosis (OR = 8.62, 95% CI = 1.39-53.36, P = 0.021). Also, WCR was correlated with risk of sarcopenia (OR = 3.18, 95% CI = 2.50-4.05, P < 0.001, highest tertile).

CONCLUSIONS

Higher WCR is associated with increased risk of NAFLD and hepatic fibrosis independent of insulin resistance. This suggests that WCR may be a useful index to predict high risk of hepatic steatosis in T2D.

Beneficial long-term antidiabetic actions of N- and C-terminally modified analogues of apelin-13 in diet-induced obese diabetic mice

AIMS

To investigate the chronic effects of twice-daily administration of stable apelin analogues, apelin-13 amide and pyroglutamyl (pGlu) apelin-13 amide, on metabolic variables in glucose-intolerant and insulin-resistant diet-induced obese mice fed a high-fat diet for 150 days.

METHODS

Groups of mice received twice-daily (9 am and 5 pm) injections of saline vehicle, apelin-13 amide, (pGlu)apelin-13 amide or exendin-4(1-39) for 28 days (all at 25 nmol/kg). Energy intake, body weight, non-fasting blood glucose, plasma insulin, glucose tolerance, metabolic response to feeding and insulin sensitivity, together with pancreatic hormone content and biochemical variables such as lipids and total GLP-1 were monitored. Dual-energy X-ray absorptiometry analysis and indirect calorimetry were also performed.

RESULTS

Administration of apelin-13 amide, (pGlu)apelin-13 amide or exendin-4 significantly decreased body weight, food intake and blood glucose and increased plasma insulin compared with high-fat-fed saline-treated controls (P < .05 and P < .001), Additionally, all peptide-treated groups exhibited improved glucose tolerance (oral and intraperitoneal), metabolic responses to feeding and associated insulin secretion. (pGlu)apelin-13 amide also significantly improved glycated haemoglobin and insulin sensitivity after 28 days. Both (pGlu)apelin-13 amide and exendin-4 increased bone mineral content and decreased respiratory exchange ratio, whereas only (pGlu)apelin-13 amide increased energy expenditure. All treatment groups displayed reduced circulating triglycerides and increased glucagon-like peptide-1 concentrations, although only (pGlu)apelin-13 amide significantly reduced LDL cholesterol and total body fat, and increased pancreatic insulin content.

CONCLUSION

These data indicate the therapeutic potential of stable apelin-13 analogues, with effects equivalent to or better than those of exendin-4.

Impact of obesity on mortality in patients with diabetes: Meta-analysis of 20 studies including 250,016 patients

AIMS/INTRODUCTION

The impact of body mass index on mortality among patients with diabetes remains controversial. Therefore, we carried out a meta-analysis of pertinent studies.

MATERIALS AND METHODS

We searched OVID/MEDLINE, EMBASE and Cochrane databases for all reported studies, which investigated the relationship between body mass index and mortality in patients with diabetes. Summary estimates of hazard ratios (HRs) were obtained with a random effects model. Univariate meta-regressions were carried out.

RESULTS

A total of 20 studies including 250,016 patients with diabetes were identified. The results of the present study showed a significantly reduced risk of all-cause mortality in overweight patients (HR 0.82, 95% CI: 0.74-0.91, P < 0.0001, and I2 = 91.6%) as compared with normal weight patients. The survival benefits of obesity were only observed in the elderly patients (HR 0.69, 95% CI: 0.63-0.75, P < 0.0001, and I2 = 50.4%), but not in the younger patients (HR 1.01, 95% CI: 0.84-1.20, P = 0.96, I2 = 80.1%). Furthermore, the beneficial prognostic impacts on overweight (coefficient = 0.030, P = 0.041) and obesity (coefficient = 0.032, P = 0.010) were attenuated with clinical follow-up duration.

CONCLUSIONS

The present meta-analysis showed a significantly lower risk of all-cause mortality in overweight patients with diabetes compared with normal weight patients. However, the survival benefits of obesity were only observed among the elderly patients.

Treatment patterns and clinical characteristics of patients with type 2 diabetes mellitus according to body mass index: findings from an electronic medical records database

OBJECTIVE

This study evaluated relationships between glycaemic control, body mass index (BMI), comorbidities and pharmacological treatment in patients with type 2 diabetes mellitus (T2D).

RESEARCH DESIGN AND METHODS

This was a retrospective, cross-sectional analysis of Quintiles electronic medical records research data (study period 1 October 2013-30 September 2014). Eligibility included age ≥18 years, T2D diagnosis, and at least one available BMI measurement.

RESULTS

The study included 626 386 patients (mean age, 63.8 year; 51.3% female; 78.5% white; 62.6%, BMI ≥30 kg/m2). A1c data were available for 414 266 patients. The proportion of patients with good glycaemic control (A1c ≤6.5) decreased as BMI category increased, ranging from 40.1% of patients with BMI <30% to 30.1% of patients with BMI ≥40. The proportions of patients with poor glycaemic control (A1c >8% and A1c ≥9%) increased with increasing BMI category. Oral antidiabetic drugs (OAD) were the most frequently used (54.4% of patients with A1c values). Among patients using insulin-based therapy, 50% had an A1c ≥8% and 29% had an A1c ≥9% regardless of concomitant OAD or glucagon-like peptide 1 receptor agonist use. Among patients using three or more OADs, 34.3% and 16.1% had A1c values ≥8% and ≥9%, respectively. There was no common trend observed for changes in the proportion of patients with T2D-related comorbidities according to BMI category. The most notable trend was a 7.6% net increase in the percentage of patients with hypertension from BMI <30 to BMI ≥40.

CONCLUSIONS

This large dataset provides evidence that roughly one out of four patients with T2D is not well controlled, and the prevalence of poor glycaemic control increases as BMI increases.

Association Between Weight Change, Clinical Outcomes, and Health Care Costs in Patients with Type 2 Diabetes

BACKGROUND

Previous research suggests that weight loss is associated with decreases in health care costs among individuals with type 2 diabetes mellitus (T2DM) and that weight change can affect clinical measures, including hemoglobin A1c (A1c), low-density lipoprotein cholesterol (LDLC), and blood pressure. Previous research has also demonstrated more pronounced impact of weight change among patients with T2DM who are obese and have no evidence of cardiovascular disease (CVD).

OBJECTIVES

To (a) examine the association between weight change and all-cause and diabetes-related health care costs among patients with T2DM; (b) examine the association between weight change and select clinical measures among patients with T2DM; and (c) analyze a subgroup of obese patients with no previous CVD.

METHODS

This retrospective, observational cohort study used U.S. insurance claims linked to laboratory and electronic medical records. This study included patients with T2DM aged 18 years or older who added or switched to a nonmetformin antidiabetes medication after metformin monotherapy between January 1, 2007, and June 30, 2012 (date of add/switch was the index date). The primary predictor was percentage weight change (PWC) between a weight measurement at index and a follow-up measurement 6 months later; PWC ranged from negative (weight loss) to positive (weight gain). Outcomes, measured in the 12-month period beginning at the time of follow-up weight measurement, included all-cause and diabetes-related health care costs and achievement of thresholds for A1c, blood pressure, and LDL-C. Multivariable models quantified the association between PWC (linear effect) and study outcomes.

RESULTS

A total of 1,520 patients (mean age 55 years; 47% female) were included, with 780 patients (mean age 53 years; 51% female) in the subgroup sample. Mean (SD) index weight and PWC were 224.6 (52.8) lbs and +0.2% (4.7%) in the primary analysis, and 241.3 (47.3) lbs and -0.2% (4.6%) in the subgroup sample. In adjusted analyses, decreasing PWC was associated with decreasing diabetes-specific pharmacy costs (P < 0.001) in the primary analysis sample and with decreasing all-cause pharmacy costs (P = 0.018), diabetes-specific total costs (P = 0.039), diabetes-specific medical costs (P = 0.002), and diabetes-specific pharmacy costs (P < 0.001) in the subgroup sample. PWC was not associated with all-cause total health care costs or all-cause medical costs in either sample. In adjusted analyses, decreasing PWC was also associated with increasing odds of attaining the A1c goals of < 6.5% (P < 0.001) and < 7.0% (P < 0.001) in the primary analysis sample and increasing odds of attaining the A1c goals of < 6.5% (P < 0.001), < 7.0% (P < 0.001), and < 8.0% (P = 0.010) in the subgroup sample. PWC was not associated with any of the other clinical measures in either of the study samples.

CONCLUSIONS

This real-world study suggests that among patients with T2DM, weight loss over a short-term (6-month) period is associated with positive impact on attainment of A1c goals and decreased diabetes-specific pharmacy costs over the subsequent 12 months. In the subset of patients who were obese and had no previus CVD, weight loss over the 6-month period was also associated with decreased all-cause pharmacy costs, diabetes-specific medical costs, and diabetes-specific total health care costs. Future research is warranted to examine whether these associations change over longer-term periods of follow-up.

DISCLOSURES

This study was sponsored by AstraZeneca and Bristol-Myers Squibb. Truven Health Analytics received funding from Bristol-Myers Squibb and AstraZeneca to conduct this study. Mukherjee is an employee of Bristol-Myers Squibb. Bell and Sternhufvud are employees of AstraZeneca. Johnston, Stott-Miller, and McMorrow are employees of Truven Health Analytics. Nancy Smith is a consultant to Bristol-Myers Squibb and is employed by GreenKey Resources. Study concept was created by Mukherjee, Sternhufvud, Bell, and Johnston. Stott-Miller and McMorrow took the lead in data collection, along with Johnston, with data interpretation performed by Mukherjee, Sternhufvud, Smith, Stott-Miller, and Johnston. The manuscript was written by Mukherjee, Johnston, and Stott-Miller, along with Sternhufvud and Smith, and revised by Mukherjee, Smith, and Johnston, along with Sternhufvud and Stott-Miller.

Nonlinear association of BMI with all-cause and cardiovascular mortality in type 2 diabetes mellitus: a systematic review and meta-analysis of 414,587 participants in prospective studies

AIMS/HYPOTHESIS

The relationship between BMI and mortality has been extensively investigated in the general population; however, it is less clear in people with type 2 diabetes. We aimed to assess the association of BMI with all-cause and cardiovascular mortality in individuals with type 2 diabetes mellitus.

METHODS

We searched electronic databases up to 1 March 2016 for prospective studies reporting associations for three or more BMI groups with all-cause and cardiovascular mortality in individuals with type 2 diabetes mellitus. Study-specific associations between BMI and the most-adjusted RR were estimated using restricted cubic splines and a generalised least squares method before pooling study estimates with a multivariate random-effects meta-analysis.

RESULTS

We included 21 studies including 24 cohorts, 414,587 participants, 61,889 all-cause and 4470 cardiovascular incident deaths; follow-up ranged from 2.7 to 15.9 years. There was a strong nonlinear relationship between BMI and all-cause mortality in both men and women, with the lowest estimated risk from 31-35 kg/m² and 28-31 kg/m² (p value for nonlinearity <0.001) respectively. The risk of mortality at higher BMI values increased significantly only in women, whilst lower values were associated with higher mortality in both sexes. Limited data for cardiovascular mortality were available, with a possible inverse linear association with BMI (higher risk for BMI <27 kg/m²).

CONCLUSIONS/INTERPRETATION

In type 2 diabetes, BMI is nonlinearly associated with all-cause mortality with lowest risk in the overweight group in both men and women. Further research is needed to clarify the relationship with cardiovascular mortality and assess causality and sex differences.

Body Mass Index-Related Mortality in Patients with Type 2 Diabetes and Heterogeneity in Obesity Paradox Studies: A Dose-Response Meta-Analysis

Objective

We conducted a systematic review and meta-analysis of studies to quantify the association between body mass index (BMI) and the risks of all-cause and cardiovascular mortality in patients with type 2 diabetes.

Methods

We included studies assessing the impact of BMI on all-cause and cardiovascular mortality in patients with type 2 diabetes. Data were combined using a random-effects dose-response model.

Results

Sixteen cohort studies on all-cause mortality (n = 445,125) and two studies on cardiovascular mortality (n = 92,841) were evaluated in the meta-analysis. A non-linear association was observed between BMI and all-cause mortality among patients with type 2 diabetes. With a BMI nadir of 28–30 kg/m², the risk of all-cause mortality displayed a U-shaped increase. With a BMI nadir of 29–31 kg/m², the risk of cardiovascular mortality exhibited a gradual non-linear increase for BMI > 31 kg/m². Subgroup analyses suggested that study location, diabetes duration, and smoking history may have contributed to heterogeneity among the studies.

Conclusions

An obesity paradox exists for patients with type 2 diabetes with respect to all-cause and cardiovascular mortality. Study location, diabetes duration, and smoking history might contribute to heterogeneity among obesity paradox studies of patients with type 2 diabetes.

A cellular model for the investigation of depot specific human adipocyte biology

Upper-body adiposity is associated with increased metabolic disease risk, while lower-body adiposity is paradoxically protective. Efforts to understand the underlying mechanisms require appropriate and reproducible in vitro culture models. We have therefore generated immortalised (_im) human preadipocyte (PAD) cell lines derived from paired subcutaneous abdominal and gluteal adipose tissue. These cell lines, denoted _imAPAD and _imGPAD display enhanced proliferation and robust adipogenic capacities. Differentiated _imAPAD and _imGPAD adipocytes synthesize triglycerides de novo and respond lipolytically to catecholamine-stimulation. Importantly the cells retain their depot-of-origin 'memory' as reflected by inherent differences in fatty acid metabolism and expression of depot-specific developmental genes. These features make these cell lines an invaluable tool for the in vitro investigation of depot-specific human adipocyte biology.

Exploring the non-linear association between BMI and mortality in adults with and without diabetes: the US National Health Interview Survey

AIMS

To assess the non-linear relationship between BMI and mortality and to determine the BMI values with the lowest mortality risk in adults with and without diabetes.

METHODS

This observational study assessed the relationship between BMI and mortality with flexible parametric survival models using data from the US National Health Interview Survey. Participants included 25 458 adults with diabetes and 315 939 adults without diabetes, aged 18-84 years at baseline surveys, conducted from 1997 to 2009. Mortality status data were obtained from the linked mortality data up to 2011.

RESULTS

We observed a U-shaped relationship between BMI and mortality in both adults with and without diabetes. With the BMI 25-29.9 kg/m² group as reference, hazard ratios (95% CI) of mortality for those with BMI < 18.5, 18.5-24.9, 30-34.9, 35-39.9 and ≥ 40 kg/m² were 2.67 (2.12, 3.35), 1.26 (1.18, 1.35), 1.04 (0.98, 1.12), 1.12 (1.02, 1.22) and 1.37 (1.24, 1.51), respectively, for adults with diabetes, adjusting for age, sex, race and survey year. The corresponding hazard ratios for adults without diabetes were 2.97 (2.78, 3.17), 1.27 (1.23, 1.30), 1.07 (1.03, 1.12), 1.36 (1.27, 1.45), and 1.77 (1.62, 1.92), respectively. The BMI values associated with the lowest mortality were 29.1 kg/m² for adults with diabetes and 26.7 kg/m² for those without diabetes.

CONCLUSIONS

Regardless of the presence of diabetes, there is a U-shaped relationship between BMI and mortality. The BMI values associated with the lowest mortality were above the current 'normal' range for adults with and without diabetes.

The association of substituting carbohydrates with total fat and different types of fatty acids with mortality and weight change among diabetes patients

BACKGROUND

Substitution of carbohydrates with fat in a diet for type 2 diabetes patients is still debated.

OBJECTIVE

This study aimed to investigate the association between dietary carbohydrate intake and isocaloric substitution with (i) total fat, (ii) saturated fatty acids (SFA), (iii) mono-unsaturated fatty acids (MUFA) and (iv) poly-unsaturated fatty acids (PUFA) with all-cause and cardiovascular (CVD) mortality risk and 5-year weight change in patients with type 2 diabetes.

METHODS

The study included 6192 patients with type 2 diabetes from 15 cohorts of the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at recruitment with country-specific food-frequency questionnaires. Cox and linear regression were used to estimate the associations with (CVD) mortality and weight change, adjusting for confounders and using different methods to adjust for energy intake.

RESULTS

After a mean follow-up of 9.2 y ± SD 2.3 y, 791 (13%) participants had died, of which 268 (4%) due to CVD. Substituting 10 g or 5 energy% of carbohydrates by total fat was associated with a higher all-cause mortality risk (HR 1.07 [1.02-1.13]), or SFAs (HR 1.25 [1.11-1.40]) and a lower risk when replaced by MUFAs (HR 0.89 [0.77-1.02]). When carbohydrates were substituted with SFAs (HR 1.22 [1.00-1.49]) or PUFAs (HR 1.29 [1.02-1.63]) CVD mortality risk increased. The 5-year weight was lower when carbohydrates were substituted with total fat or MUFAs. These results were consistent over different energy adjustment methods.

CONCLUSIONS

In diabetes patients, substitution of carbohydrates with SFAs was associated with a higher (CVD) mortality risk and substitution by total fat was associated with a higher all-cause mortality risk. Substitution of carbohydrates with MUFAs may be associated with lower mortality risk and weight reduction. Instead of promoting replacement of carbohydrates by total fat, dietary guideline should continue focusing on replacement by fat-subtypes; especially SFAs by MUFAs.

The Obesity Paradox in Type 2 Diabetes and Mortality

The obesity paradox for survival among individuals with type 2 diabetes has been observed in some but not all studies. Conflicting evidence for the role of overweight and obesity in all-cause mortality may largely be a result of differences in study populations, epidemiological methods, and statistical analysis. For example, analyses among populations with long-term prevalent diabetes and the accrual of other chronic health conditions are more likely to observe that the sickest participants have lower body weights, and therefore, relative to normal weight, overweight and even obesity appear advantageous. Other mortality risk factors, such as smoking, also confound the relationship between body weight and survival, but this behavior varies widely in intensity and duration, making it difficult to assess and effectively adjust for in statistical models. Disentangling the potential sources of bias is imperative in understanding the relevance of excess body weight to mortality in diabetes. In this review, we summarize methodological considerations underlying the observed obesity paradox. Based on the available evidence, we conclude that the obesity paradox is likely an artifact of biases, and once these are accounted for, it is evident that compared with normal body weight, excess body weight is associated with a greater mortality risk.

Determinants of mortality in patients with type 2 diabetes: a review

We aimed to review and summarize the evidence from accomplished trials analyzing factors influencing mortality in patients with T2DM and to provide some recommendations for targets and treatment in the European region. The following databases were searched for relevant trials: PubMed and the Cochrane Library. Of 3.806 citations, 134 trials met our inclusion criteria.

RESULTS

The reduction in lifetime for 65 + -years-old patients having less than 10 years T2DM amounts to 1.8 years. Having T2DM for more than 10 years lifetime will be reduced by 2.7 years. However, the lifetime shortening factor of T2DM will even be stronger for 40 + -years-old patients at onset. Males will lose 11.6 years of life and 18.6 QUALYs. T2DM among females will reduce life by 14 QUALYs by 22 years. From a statistical point of view, the highest mortality rate will occur in an over 55-years-old European smoking and non-compliant diabetic woman with alcohol abuse living in a rural area with a low level of education and a low socio-economic status. Furthermore, other co-morbidities such as cardiovascular diseases, gout, and depression affect mortality. Additionally, mortality will increase with a BMI over 35 and also with a BMI under 20-25. This refers to the obesity paradox indicating a higher mortality rate among normal weight patients with T2DM compared to overweight patients with T2DM. HbA1c-levels between 6.5 % and 7 % are associated with the lowest impact on mortality.

Imbalanced insulin action in chronic over nutrition: Clinical harm, molecular mechanisms, and a way forward

The growing worldwide prevalence of overnutrition and underexertion threatens the gains that we have made against atherosclerotic cardiovascular disease and other maladies. Chronic overnutrition causes the atherometabolic syndrome, which is a cluster of seemingly unrelated health problems characterized by increased abdominal girth and body-mass index, high fasting and postprandial concentrations of cholesterol- and triglyceride-rich apoB-lipoproteins (C-TRLs), low plasma HDL levels, impaired regulation of plasma glucose concentrations, hypertension, and a significant risk of developing overt type 2 diabetes mellitus (T2DM). In addition, individuals with this syndrome exhibit fatty liver, hypercoagulability, sympathetic overactivity, a gradually rising set-point for body adiposity, a substantially increased risk of atherosclerotic cardiovascular morbidity and mortality, and--crucially--hyperinsulinemia. Many lines of evidence indicate that each component of the atherometabolic syndrome arises, or is worsened by, pathway-selective insulin resistance and responsiveness (SEIRR). Individuals with SEIRR require compensatory hyperinsulinemia to control plasma glucose levels. The result is overdrive of those pathways that remain insulin-responsive, particularly ERK activation and hepatic de-novo lipogenesis (DNL), while carbohydrate regulation deteriorates. The effects are easily summarized: if hyperinsulinemia does something bad in a tissue or organ, that effect remains responsive in the atherometabolic syndrome and T2DM; and if hyperinsulinemia might do something good, that effect becomes resistant. It is a deadly imbalance in insulin action. From the standpoint of human health, it is the worst possible combination of effects. In this review, we discuss the origins of the atherometabolic syndrome in our historically unprecedented environment that only recently has become full of poorly satiating calories and incessant enticements to sit. Data are examined that indicate the magnitude of daily caloric imbalance that causes obesity. We also cover key aspects of healthy, balanced insulin action in liver, endothelium, brain, and elsewhere. Recent insights into the molecular basis and pathophysiologic harm from SEIRR in these organs are discussed. Importantly, a newly discovered oxide transport chain functions as the master regulator of the balance amongst different limbs of the insulin signaling cascade. This oxide transport chain--abbreviated 'NSAPP' after its five major proteins--fails to function properly during chronic overnutrition, resulting in this harmful pattern of SEIRR. We also review the origins of widespread, chronic overnutrition. Despite its apparent complexity, one factor stands out. A sophisticated junk food industry, aided by subsidies from willing governments, has devoted years of careful effort to promote overeating through the creation of a new class of food and drink that is low- or no-cost to the consumer, convenient, savory, calorically dense, yet weakly satiating. It is past time for the rest of us to overcome these foes of good health and solve this man-made epidemic.

Measures of body adiposity and visceral adiposity index as predictors of metabolic syndrome among Thai women with PCOS

AIM

To evaluate the relationship between measures of body adiposity and visceral adiposity index (VAI) and risk of metabolic syndrome (MS) and to identify the optimal cut-off points of each measurement in Thai polycystic ovary syndrome (PCOS).

METHODS

A cross-sectional study was completed physical examination, fasting plasma glucose, lipid profiles of 399 PCOS and 42 age-matched normal controls. Body mass index (BMI), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and VAI were calculated. Associations between different measures and MS were evaluated and the receiver-operating characteristic (ROC) curve was performed to determine appropriate cut-off points for identifying MS.

RESULTS

Percentage of MS in PCOS was 24.6%, whereas none MS in controls. Previously recommended cut-off values for body adiposity and VAI were significantly associated with MS. ROC curve analysis of the only PCOS showed newly obtained optimal cut-off points for BMI and VAI of ≥28 kg/m(2) (AUC = 0.90) and >5.6 (AUC = 0.94), respectively. Values found to be more accurate than the original ones. VAI was the best predictor, followed by BMI and WHtR.

CONCLUSION

All body adiposity and VAI parameters can predict the risk of MS. Optimal values for Thai PCOS were ≥28 kg/m(2) for BMI, ≥0.85 for WHR, ≥0.5 for WHtR and >5.6 for VAI.

Interactions between adipose tissue and the immune system in health and malnutrition

Adipose tissue provides the body with a storage depot of nutrients that is drained during times of starvation and replenished when food sources are abundant. As such, it is the primary sensor for nutrient availability in the milieu of an organism, which it communicates to the body through the excretion of hormones. Adipose tissue regulates a multitude of body functions associated with metabolism, such as gluconeogenesis, feeding and nutrient uptake. The immune system forms a vital layer of protection against micro-organisms that try to gain access to the nutrients contained in the body. Because infections need to be resolved as quickly as possible, speed is favored over energy-efficiency in an immune response. Especially when immune cells are activated, they switch to fast, but energy-inefficient anaerobic respiration to fulfill their energetic needs. Despite the necessity for an effective immune system, it is not given free rein in its energy expenditure. Signals derived from adipose tissue limit immune cell numbers and activity under conditions of nutrient shortage, whereas they allow proper immune cell activity when food sources are sufficiently available. When excessive fat accumulation occurs, such as in diet-induced obesity, adipose tissue becomes the site of pathological immune cell activation, causing chronic low-grade systemic inflammation. Obesity is therefore associated with a number of disorders in which the immune system plays a central role, such as atherosclerosis and non-alcoholic steatohepatitis. In this review, we will discuss the way in which adipose tissue regulates activity of the immune system under healthy and pathological conditions.

Diabetes and onset of natural menopause: results from the European Prospective Investigation into Cancer and Nutrition

STUDY QUESTION

Do women who have diabetes before menopause have their menopause at an earlier age compared with women without diabetes?

SUMMARY ANSWER

Although there was no overall association between diabetes and age at menopause, our study suggests that early-onset diabetes may accelerate menopause.

WHAT IS KNOWN ALREADY

Today, more women of childbearing age are being diagnosed with diabetes, but little is known about the impact of diabetes on reproductive health.

STUDY DESIGN, SIZE, DURATION

We investigated the impact of diabetes on age at natural menopause (ANM) in 258 898 women from the European Prospective Investigation into Cancer and Nutrition (EPIC), enrolled between 1992 and 2000.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Determinant and outcome information was obtained through questionnaires. Time-dependent Cox regression analyses were used to estimate the associations of diabetes and age at diabetes diagnosis with ANM, stratified by center and adjusted for age, smoking, reproductive and diabetes risk factors and with age from birth to menopause or censoring as the underlying time scale.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, no association between diabetes and ANM was found (hazard ratio (HR) = 0.94; 95% confidence interval (CI) 0.89-1.01). However, women with diabetes before the age of 20 years had an earlier menopause (10-20 years: HR = 1.43; 95% CI 1.02-2.01, <10 years: HR = 1.59; 95% CI 1.03-2.43) compared with non-diabetic women, whereas women with diabetes at age 50 years and older had a later menopause (HR = 0.81; 95% CI 0.70-0.95). None of the other age groups were associated with ANM.

LIMITATIONS, REASONS FOR CAUTION

Strengths of the study include the large sample size and the broad set of potential confounders measured. However, results may have been underestimated due to survival bias. We cannot be sure about the sequence of the events in women with a late age at diabetes, as both events then occur in a short period. We could not distinguish between type 1 and type 2 diabetes.

WIDER IMPLICATIONS OF THE FINDINGS

Based on the literature, an accelerating effect of early-onset diabetes on ANM might be plausible. A delaying effect of late-onset diabetes on ANM has not been reported before, and is not in agreement with recent studies suggesting the opposite association.

STUDY FUNDING/COMPETING INTERESTS

The coordination of EPIC is financially supported by the European Commission (DG-SANCO) and the International Agency for Research on Cancer. The national cohorts are supported by Danish Cancer Society (Denmark); Ligue Contre le Cancer, Institut Gustave Roussy, Mutuelle Générale de l'Education Nationale, Institut National de la Santé et de la Recherche Médicale (INSERM) (France); German Cancer Aid, German Cancer Research Center (DKFZ) and Federal Ministry of Education and Research (BMMF) (Germany); Ministry of Health and Social Solidarity, Stavros Niarchos Foundation and Hellenic Health Foundation (Greece); Italian Association for Research on Cancer (AIRC) and National Research Council (Italy); Dutch Ministry of Public Health, Welfare and Sports (VWS), Netherlands Cancer Registry (NKR), LK Research Funds, Dutch Prevention Funds, Dutch ZON (Zorg Onderzoek Nederland), World Cancer Research Fund (WCRF), Statistics Netherlands (The Netherlands); ERC-2009-AdG 232997 and Nordforsk, Nordic Centre of Excellence programme on Food, Nutrition and Health (Norway); Health Research Fund (FIS), Regional Governments of Andalucía, Asturias, Basque Country, Murcia (no. 6236) and Navarra, ISCIII RETIC (RD06/0020) (Spain); Swedish Cancer Society, Swedish Scientific Council and Regional Government of Skåne and Västerbotten (Sweden); Cancer Research UK, Medical Research Council, Stroke Association, British Heart Foundation, Department of Health, Food Standards Agency, and Wellcome Trust (UK). None of the authors reported a conflict of interest.

Impact of regular physical activity on blood glucose control and cardiovascular risk factors in adolescents with type 2 diabetes mellitus--a multicenter study of 578 patients from 225 centres

INTRODUCTION

Regular physical activity (RPA) is a major therapeutic recommendation in children and adolescents with type 2 diabetes mellitus (T2DM). We evaluated the association between frequency of RPA and metabolic control, cardiovascular risk factors, and treatment regimes.

METHODS

The Pediatric Quality Initiative (DPV), including data from 225 centers in Germany and Austria, provided anonymous data of 578 patients (10-20 yr; mean 15.7 ± 2.1 yr; 61.9% girls) with T2DM. Patients were grouped by the frequency of their self-reported RPA per week: RPA 0, none; RPA 1, 1-2×/wk; RPA 2, >2×/wk.

RESULTS

The frequency of RPA ranged from 0 to 9×/wk (mean 1.1×/wk ±1.5). 55.7% of the patients reported no RPA (58.1% of the girls). Hemoglobin A1c (HbA1c) differed significantly among RPA groups (p < 0.002), being approximately 0.8 percentage points lower in RPA 2 compared to RPA 0. Body mass index (BMI-SDS) was higher in the groups with less frequent RPA (p < 0.00001). Multiple regression analysis revealed a negative association between RPA and HbA1c (p < 0.0001) and between RPA and BMI-SDS (p < 0.01). The association between RPA and high density lipoprotein (HDL)-cholesterol was positive (p < 0.05), while there was no association to total cholesterol, low density lipoprotein (LDL)-cholesterol or triglycerides. Approximately 80% of the patients received pharmacological treatment (oral antidiabetic drugs and/or insulin) without differences between RPA groups.

CONCLUSION

More than half of the adolescents with T2DM did not perform RPA. Increasing physical activity was associated with a lower HbA1c, a lower BMI-SDS, a higher HDL-cholesterol, but not with a difference in treatment regime. These results suggest that regular exercise is a justified therapeutic recommendation for children and adolescents with T2DM.

Isocaloric substitution of carbohydrates with protein: the association with weight change and mortality among patients with type 2 diabetes

Background

The health impact of dietary replacement of carbohydrates with protein for patients with type 2 diabetes is still debated. This study aimed to investigate the association between dietary substitution of carbohydrates with (animal and plant) protein and 5-year weight change, and all-cause and cardiovascular (CVD) mortality risk in patients with type 2 diabetes.

Methods

The study included 6,107 diabetes patients from 15 European cohorts. Patients with type 1 diabetes were excluded. At recruitment, validated country-specific food-frequency questionnaires were used to estimate dietary intake. Multivariable adjusted linear regression was used to examine the associations between dietary carbohydrate substitution with protein and 5-year weight change, and Cox regression to estimate hazard ratios (HRs) for (CVD) mortality.

Results

Annual weight loss of patients with type 2 diabetes was 0.17 (SD 1.24) kg. After a mean follow-up of 9.2 (SD 2.3)y, 787 (13%) participants had died, of which 266 (4%) deaths were due to CVD. Substitution of 10 gram dietary carbohydrate with total (ß = 187 [75;299]g) and animal (ß = 196 [137;254]g) protein was associated with mean 5-year weight gain. Substitution for plant protein was not significantly associated with weight change (β = 82 [−421;584]g). Substitution with plant protein was associated with lower all-cause mortality risk (HR = 0.79 [0.64;0.97]), whereas substitution with total or animal protein was not associated with (CVD) mortality risk.

Conclusions

In diabetes patients, substitution with plant protein was beneficial with respect to weight change and all-cause mortality as opposed to substitution with animal protein. Therefore, future research is needed whether dietary guidelines should not actively promote substitution of carbohydrates by total protein, but rather focus on substitution of carbohydrates with plant protein.

Effect of ketotifen in obese patients with type 2 diabetes mellitus

AIM

Mast cells are found to be an important contributor in obesity induced insulin resistance. We evaluate the effect of ketotifen in obese patient with type 2 diabetes (T2DM) treated with glimepiride.

METHOD

In a randomized controlled study we recruited forty-eight obese patients with T2DM from Internal Medicine Department at Tanta University Hospital, Egypt. They were classified into three groups: group 1, those who received glimepiride (GL) 3mg/d alone; group 2, those who received GL 3mg/d+ketotifen 1mg once daily; and group 3, those who received GL 3mg/d+ketotifen 1mg twice daily. Fasting blood samples were obtained before and 12weeks after treatment for biochemical analysis of glycemic and inflammatory biomarkers. Data were statistically analyzed by paired Student's t-test and one way analysis of variance; p<0.05 was considered statistically significant.

RESULTS

The obtained data suggested that the addition of ketotifen in twice daily dose has a beneficial effect on all measured parameters except adiponectin. However, glimepiride plus ketotifen once daily only affected the level of inflammatory biomarkers without any significant effect on other parameters.

CONCLUSIONS

The co-administration of ketotifen twice daily plus glimepiride improves glycemic and inflammatory process in obese patients with T2DM.

Poor mental health in severely obese patients is not explained by the presence of comorbidities

The prevalence of obesity, especially severe obesity where body mass index (BMI) exceeds 40 kg m(-2) and where the physical risks are greatest, is increasing. However, little is known about the impact of severe obesity on psychological well-being and self-rated health (SRH). We aimed to investigate this relationship in patients attending an Irish weight management clinic. SRH was measured with a single-item inventory (excellent = 1, poor = 5). Well-being was measured with the validated World Health Organization-Five Well-being Index (WHO-5), in which scores <13 indicate poor well-being. Previous studies of the Irish population have reported mean SRH = 2.56 (males) and 2.53 (females) and mean well-being = 16.96. One hundred eighty-two (46.8%) completed questionnaires were returned. The sample was representative of the clinic population with a mean age of 47.1, mean baseline BMI of 51.9 kg m(-2) and 64.3% females. Mean SRH was 3.73 in males and 3.30 in females; mean well-being was 10.27 in males and 10.52 in females. In the final multivariable models, number of medications, depression and obstructive sleep apnoea, WHO-5 and current BMI were significant predictors of SRH, and secondary level education, social support and mindfulness scores were significant predictors of psychological well-being. Number of medications was not significant. The results suggest that the poor psychological well-being seen is not explained by the presence of comorbidities and that social support and mindfulness may be important targets for improving psychological well-being. Improving psychological well-being in addition to weight loss and effective management of comorbidities may be important for improving SRH.

Pre-transplant diabetes mellitus is a risk factor for non-relapse mortality, especially infection-related mortality, after allogeneic hematopoietic SCT

Diabetes mellitus (DM) is a factor in the hematopoietic cell transplantation-comorbidity index. However, the impact of pre-transplant DM on morbidity and cause-specific non-relapse mortality (NRM) remains unclear. We performed a retrospective study with registry data that included a total of 7626 patients who underwent their first allogeneic hematopoietic SCT (HSCT) between 2007 and 2010. The median age was 44 years (range 0-88). Compared with patients without pre-transplant DM (non-DM group, n=7248), patients with pre-transplant DM (DM group, n=378) were older and were more likely to have high-risk disease, a reduced-intensity conditioning regimen and GVHD prophylaxis using tacrolimus. Multivariate analyses showed that pre-transplant DM was associated with increased risks of NRM (hazard ratio (HR)1.46, 95% confidence interval (CI) 1.21-1.76, P<0.01) and infection-related NRM (HR 2.08, 95% CI 1.58-2.73, P<0.01). The presence of pre-transplant DM was associated with an increased risk of overall mortality in a multivariate analysis (HR 1.55, 95% CI 1.35-1.78, P<0.01). In conclusion, pre-transplant DM was a risk factor for NRM, particularly infection-related mortality, after allogeneic HSCT. To improve the clinical outcome in patients with DM, the benefits of strict infection control and appropriate glycemic control should be explored in future trials.

Diabetes mellitus and risk of prostate cancer in the European Prospective Investigation into Cancer and Nutrition

The current epidemiologic evidence suggests that men with type 2 diabetes mellitus may be at lower risk of developing prostate cancer, but little is known about its association with stage and grade of the disease. The association between self-reported diabetes mellitus at recruitment and risk of prostate cancer was examined in the European Prospective Investigation into Cancer and Nutrition (EPIC). Among 139,131 eligible men, 4,531 were diagnosed with prostate cancer over an average follow-up of 12 years. Multivariable hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards models stratified by EPIC-participating center and age at recruitment, and adjusted for education, smoking status, body mass index, waist circumference, and physical activity. In a subset of men without prostate cancer, the cross-sectional association between circulating concentrations of androgens and insulin-like growth factor proteins with diabetes status was also investigated using linear regression models. Compared to men with no diabetes, men with diabetes had a 26% lower risk of prostate cancer (HR, 0.74; 95% CI, 0.63-0.86). There was no evidence that the association differed by stage (p-heterogeneity, 0.19) or grade (p-heterogeneity, 0.48) of the disease, although the numbers were small in some disease subgroups. In a subset of 626 men with hormone measurements, circulating concentrations of androstenedione, total testosterone and insulin-like growth factor binding protein-three were lower in men with diabetes compared to men without diabetes. This large European study has confirmed an inverse association between self-reported diabetes mellitus and subsequent risk of prostate cancer.