Cardiovascular and metabolic risk profiles in young and old patients with type 2 diabetes

Trajectory of haemoglobin A1c and incidence of cardiovascular disease in patients with type 2 diabetes mellitus

AIM

To evaluate the association between changes in haemoglobin A1c (HbA1c) and the concurrent incidence of cardiovascular disease (CVD) in type 2 diabetes mellitus (T2DM) patients.

METHOD

We conducted a retrospective cohort study among T2DM patients with HbA1c measurement after T2DM diagnosis between August 2009 and September 2010. The patients were classified into six subgroups based on baseline HbA1c (<7%; 7%-7.9%; ≥8%) and age (<65; ≥65 years), and then clustered into classes by HbA1c trajectory and CVD incidence over the 12-year follow-up period using joint latent class mixture models. We explored the HbA1c trajectories and CVD incidences in each latent class. Multinomial logistic regression was used to compare the baseline characteristics among different latent classes.

RESULTS

A total of 128 843 T2DM patients were included with a median follow-up period of 11.7 years. Ten latent classes were identified in patients with baseline HbA1c ≥ 8% and age <65 years, while seven classes were identified in the other five groups. Among all the identified latent classes, patients with fluctuating HbA1c trajectories, characterized by alternating periods of increase and decrease, had higher CVD incidences. Male patients, and patients with higher baseline HbA1c and use of antidiabetic drugs were more likely to have a fluctuating HbA1c trajectory. More specifically, patients aged < 65 years with younger age or a smoking habit, and patients aged ≥ 65 years with a longer duration of T2DM were more likely to have a fluctuating HbA1c trajectory.

CONCLUSION

We found that T2DM patients with fluctuating HbA1c trajectories could have a higher CVD risk. Different trajectory-associated characteristics in age subgroups highlight the need for individualized management of T2DM patients.

Characteristics of Glycemic Control and Long-Term Complications in Patients with Young-Onset Type 2 Diabetes

BACKGRUOUND

The prevalence of young-onset diabetes (YOD) has been increasing worldwide. As the incidence of YOD increases, it is necessary to determine the characteristics of YOD and the factors that influence its development and associated complications.

METHODS

In this retrospective study, we recruited patients who were diagnosed with type 2 diabetes mellitus between June 2001 and December 2021 at a tertiary hospital. The study population was categorized according to age: YOD (age <40 years), middle-age-onset diabetes (MOD, 40≤ age <65 years), and late-onset diabetes (LOD, age ≥65 years). We examined trends in glycemic control by analyzing fasting glucose levels during the first year in each age group. A Cox proportional-hazards model was used to determine the relative risk of developing complications according to glycemic control trends.

RESULTS

The fasting glucose level at the time of diagnosis was highest in the YOD group (YOD 149±65 mg/dL; MOD 143±54 mg/dL; and LOD 140±55 mg/dL; p=0.009). In the YOD group, glucose levels decreased at 3 months, but increased by 12 months. YOD patients and those with poor glycemic control in the first year were at a higher risk of developing complications, whereas the risk in patients with LOD was not statistically significant.

CONCLUSION

YOD patients had higher glucose levels at diagnosis, and their glycemic control was poorly maintained. As poor glycemic control can influence the development of complications, especially in young patients, intensive treatment is necessary for patients with YOD.

Obesity and its associated factors among older adults: MyHEBAT (alasian alth and Well-eing ssessmen) study

Background

Despite being a preventable disease, the prevalence of obesity is rising progressively worldwide. However, the prevalence of obesity and its associated factors among older adults remains unclear in Malaysia. The aim of this study was to determine the prevalence of obesity and its associated factors among older adults who voluntarily attended the health screening programs, which were part of the Malaysian HEalth and Well-Being AssessmenT (My-HEBAT) Study.

Methods

Cross-sectional study was conducted among Malaysian adults, aged ≥60 years. A standardized self-administered questionnaire was used to gather information regarding socio-demographic status, personal, family and medical history. Anthropometric indices, blood pressure and physical examinations were conducted on site. Venous blood samples were collected for lipid profile and blood glucose analysis. Participants with BMI of ≥30 kg/m2 or < 30kg/m2 were classified as obese or non-obese respectively. Age was categorized into three subgroups: 60-69, 70-79, and ≥80 years old. The factors associated with obesity among older adults were then identified using multiple logistic regression.

Results

A total of 716 older adults aged ≥60 years (mean ± SD: 66.6 ± 6.0 years) were recruited. The prevalence of obesity among older adults was 15.8%, while higher prevalence was found among females (42.9%) compared to males (38.3%). The prevalence of obesity decreased with increasing age (48.5% in 60-69 years, 20.8% in 70-79 years, and 11.8% in ≥80 years).

Conclusion

The prevalence of obesity among Malaysian population is higher than that of worldwide prevalence. Current national health promotion and educational programs should focus on identifying factors associated with obesity, and promotion of healthy lifestyle with obesity should be improved and modified, particularly for older adults in Malaysia.

Prevalence of cardiovascular disease risk factors in Chinese patients with type 2 diabetes mellitus, 2013-2018

OBJECTIVE

Coronary heart disease (CHD) is the most common cause of death in patients with type 2 diabetes (T2DM). We aim to estimate the prevalence of CHD and cardiovascular risk factors in Chinese patients with T2DM.

METHODS

A total of 66,536 inpatients with diabetes treated from 2013 to 2018 were investigated, and demographic and clinical data were collected from 30,693 patients with T2DM. Age-standardized prevalence of CHD was calculated on the basis of data from the Chinese population census in 2010. Logistic regression analysis was used to analyze the risk factors.

RESULTS

The crude prevalence of CHD was estimated to be 23.5% and a standardized prevalence was 13.9% (16.0% in men and 11.9% in women). More than half of patients with CHD have four or more of the five traditional risk factors, much higher than the 38.96% of patients without CHD (p < .01). Multivariate regression analysis showed that diabetes duration, hypertension, smoking, underweight, overweight, obesity and hypoglycaemia were significantly associated with increased risk of CHD (all p < .05). The odds ratio of CHD in patients with three, four or five defined CHD risk factors (i.e. diabetes, hypertension, dyslipidaemia, overweight or obese, and smoking) were 2.35 (95% CI 1.81-3.04), 2.96 (95% CI 2.28-3.85) or 5.29 (95% CI 4.04-6.93), compared with diabetes patients without any other risk factors.

CONCLUSIONS

The prevalence of CHD was rather high in Chinese T2DM inpatients, and the aggregation of CHD risk factors was severe. Thus, hierarchical CHD prevention strategies based on risk factors are necessary.

Relationship between onset age of type 2 diabetes mellitus and vascular complications based on Propensity score matching analysis

Aims/Introduction

To assess the relationship between type 2 diabetes mellitus onset age and vascular complications in China.

Materials and Methods

A retrospective review of 3,568 patients with type 2 diabetes mellitus using a propensity score‐matched (PSM) cohort analysis was carried out in two different age of onset groups (age 40 and 60 years). These groups were then subdivided into two groups, early‐onset diabetes (EOD40 and EOD60; the onset age before 40 and 60 years, respectively) and late‐onset diabetes (LOD40 and LOD60: the onset age after 40 and 60 years, respectively). Macrovascular and microvascular complications were analyzed before and after PSM.

Results

Patients categorized in both the early‐onset disease (EOD) groups had a higher risk of developing macro‐ and microvascular complications before PSM. After PSM, no differences existed between the EOD and late‐onset disease groups in the risk of macrovascular complications. Compared with the late‐onset disease group, the odds ratio of having a microvascular complication of diabetic retinopathy, chronic kidney disease and diabetic peripheral neuropathy in the 40‐year‐old EOD group increased to 2.906, 1.967 and 1.672 (P < 0.05), respectively. The odds ratio of diabetic retinopathy and diabetic peripheral neuropathy in the 60‐year‐old EOD group was 1.763 and 1.675 (P < 0.05), respectively.

Conclusions

The earlier the onset of type 2 diabetes mellitus, the higher risk of microvascular, but not necessarily macrovascular, complications. It is not too late to prevent diabetes at any age. Pre‐emptive microvascular treatment or preventative measures in EOD patients who do not yet show symptoms, might be beneficial.

Association Analysis Between Different Diabetic Family History and Gender with Diagnosed Age of Type 2 Diabetes Mellitus: A Cross-Sectional Study in Tianjin, China

Background

Type 2 diabetes mellitus (T2DM) was previously considered a common disease in middle-aged and older people, but the age of diagnosis of T2DM is advancing every year, and the trend toward a younger age is obvious. Early-onset T2DM is a clinical syndrome caused by genetic and environmental factors. This study aimed to investigate the association between diabetic family history and gender with the diagnosed age of T2DM.

Methods

The newly diagnosed T2DM patients admitted to the diabetes identification center of Tianjin 4th Central Hospital (TJ4thch) from October 2017 to June 2020 were registered. According to whether the diagnosis age is over 40 years old, patients were divided into 2 groups (early-onset T2DM group and late-onset T2DM group). In the study, the T2DM family history was divided into 5 types: (a) Father T2DM: father with T2DM, but not the mother; (b) Mother T2DM: mother with T2DM, but not the father; (c) Both parents with T2DM; (d) Another relative(s) (other than the parents) with a history of T2DM; and (e) Without a family history of T2DM. The diagnosed age with different genders and diabetic family history was compared. Multivariate logistic regression analysis was used to investigate the association factors of early-onset T2DM.

Results

A total of 3725 patients completed the survey. There were 589 patients (15.8%) with early-onset T2DM, and 2469 patients (66.3%) had a diabetic family history. The T2DM-diagnosed age in males was lower than in females (51.7 ± 11.2 vs 54.0 ± 10.2, P = .000). The result was also reflected in the different T2DM family histories (with Both parents T2DM, 46.7 ± 11.1 vs 48.5 ± 10.3, P = .271; with Father T2DM, 46.8 ± 10.8 vs 49.8 ± 11.3, P = .005; with Mother T2DM, 50.4 ± 10.6 vs 52.3 ± 10.2, P = .019; with Other T2DM family history, 54.0 ± 10.8 vs 55.7 ± 9.5, P = .008; with no T2DM family history, 53.0 ± 11.0 vs 55.9 ± 9.3, P = .000). The order of the T2DM-diagnosed age in the different groups was Both parents T2DM (47.5 ± 11.0) and Father T2DM (47.9 ± 11.1) family history < that with Mother T2DM family history (51.1 ± 10.5) < that with Other T2DM family history (54.7 ± 10.3) and no T2DM family history (54.1 ± 10.5). Logistic regression analysis indicated that gender (OR, 1.733; P = .000), Father T2DM history (OR, 2.738; P = .000), Mother T2DM history (OR, 1.536; P = .001), Both parents T2DM (OR, 2.866; P = .000) and body mass index (OR, 1.108, P = .000) were correlated with early-onset T2DM.

Conclusion

Patients with early-onset T2DM tend to have a more obvious T2DM family history in China. This survey shows that when a parent has a T2DM family history, especially the father with T2DM, male patients are diagnosed with T2DM earlier. We need more intensive screening for diabetes in children with a family history of diabetes, especially in male children.

Estimation of the prevalence of type 2 diabetes in combination with diabetic kidney disease and identification of the associated factors in patients attending primary hospitals in Anhui Province, China

Objective

To evaluate the prevalence of type 2 diabetes mellitus (T2DM) with chronic kidney disease (DM-CKD) and identify the associated factors in patients attending primary hospitals in Anhui Province, China.

Methods

A multi-stage sampling method was used to collect the demographic information, general clinical data, and details of the kidney disease of patients in 2019 through a questionnaire survey, physical examination, and laboratory examination.

Results

A total of 1067 patients with T2DM were studied, of whom 345 had chronic kidney disease (CKD; 32.33%); 18.8%, 12.2%, 58.0%, 9.9% and 1.2% of the participants had stages 1 to 5 CKD. Fifty-point-three percent of the participants were female and they were 59 ± 11.3 years old. Multivariate regression analysis revealed that age, systolic blood pressure, the duration of diabetes, hyperlipidaemia, and smoking were associated with DM-CKD. The duration of diabetes was positively associated with body mass index, 2-hour postprandial glucose, fasting blood glucose concentration, glycosylated haemoglobin, total cholesterol concentration and triglyceride concentration.

Conclusions

The incidence of DM-CKD is relatively high in primary hospitals in Anhui Province. Appropriate preventive and therapeutic measures should be instituted according to the age, the duration of diabetes, sex, hypertension, smoking habits, and lipidaemia of patients.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

Background

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

Methods

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

Results

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

Conclusions

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01209-w.

Clinical and metabolic characteristics of the Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I) randomised clinical trial cohort

OBJECTIVES

Diabetes Intervention Accentuating Diet and Enhancing Metabolism-I (DIADEM-I) is the first randomised controlled trial (RCT) in the Middle East and North Africa (MENA) region testing the effectiveness of an intensive lifestyle intervention (ILI) for weight loss and diabetes remission. We report on the recruitment process and baseline characteristics of the DIADEM-I cohort based on origin (Middle East vs North Africa), and waist circumference.

DESIGN

DIADEM-I is an open-label randomised, controlled, parallel group RCT recruiting young individuals (18-50 years) with early type 2 diabetes (≤3 years since diagnosis) originating from MENA. Individuals from primary care were randomised to usual medical care or ILI (total dietary replacement phase using meal replacement products, followed by staged food reintroduction and physical activity support). The primary outcome is weight loss at 12 months. Other outcomes are glycaemic control and diabetes remission.

SETTING

Primary care, Qatar.

PARTICIPANTS

147 (73% men) randomised within DIADEM-I who were included in the final trial data analysis.

OUTCOME MEASURES

Recruitment metrics, and baseline clinical and metabolic characteristics.

RESULTS

Of 1498 people prescreened, 267 (18%) were invited for screening and 209 (78%) consented. 173 (83%) were eligible. 15 (7%) withdrew before randomisation and the remaining 158 were randomised. Mean age was 42.1 (SD 5.6) years and mean body mass index was: 36.3 (5.5) kg/m² (women) and 34.4 (5.4) kg/m² (men). Mean diabetes duration was 1.8 (1.0) years and mean glycosylated haemoglobin (HbA1c) was 7.0% (1.30) (52.5 mmol/mol (SD 14.3)). Participants originated from 13 countries. Those from North Africa reported greater physical activity and had lower family history of diabetes. 90% of subjects were taking diabetes medications and 31% antihypertensives. Those with greater waist circumference had significantly higher insulin resistance and lower quality of life.

CONCLUSION

Recruitment of participants originating from the MENA region into the RCT was successful, and study participation was readily accepted. While DIADEM-I participants originated from 13 countries, there were few baseline differences amongst participants from Middle East versus North Africa, supporting generalisability of RCT results.

TRIAL REGISTRATION NUMBER

ISRCTN20754766; NCT03225339.

Effect of intensive lifestyle intervention on bodyweight and glycaemia in early type 2 diabetes (DIADEM-I): an open-label, parallel-group, randomised controlled trial

BACKGROUND

Type 2 diabetes is affecting people at an increasingly younger age, particularly in the Middle East and in north Africa. We aimed to assess whether an intensive lifestyle intervention would lead to significant weight loss and improved glycaemia in young individuals with early diabetes.

METHODS

This open-label, parallel-group, randomised controlled trial (DIADEM-I), done in primary care and community settings in Qatar, compared the effects of an intensive lifestyle intervention with usual medical care on weight loss and glycaemic outcomes in individuals with type 2 diabetes, aged 18-50 years, with a short diabetes duration (≤3 years), had a BMI of 27·0 kg/m² or more, and who were from the Middle East and north Africa region. Participants were randomly allocated (1:1) either to the intensive lifestyle intervention group or the usual medical care control group by a computer-generated sequence and an online randomisation service. The intensive lifestyle intervention comprised a total diet replacement phase, in which participants were given formula low-energy diet meal replacement products followed by gradual food reintroduction combined with physical activity support, and a weight-loss maintenance phase, involving structured lifestyle support. Participants in the control group received usual diabetes care, which was based on clinical guidelines. The primary outcome was weight loss at 12 months after receiving the assigned intervention. Our analysis was based on the intention-to-treat principle. Key secondary outcomes included diabetes control and remission. The trial was registered with the ISRCTN registry, ISRCTN20754766, and ClinicalTrials.gov, NCT03225339.

FINDINGS

Between July 16, 2017, and Sept 30, 2018, we enrolled and randomly assigned 158 participants (n=79 in each group) to the study. 147 participants (70 in the intervention group and 77 in the control group) were included in the final intention-to-treat analysis population. Between baseline and 12 months, the mean bodyweight of participants in the intervention group reduced by 11·98 kg (95% CI 9·72 to 14·23) compared with 3·98 kg (2·78 to 5·18) in the control group (adjusted mean difference -6·08 kg [95% CI -8·37 to -3·79], p<0·0001). In the intervention group, 21% of participants achieved more than 15% weight loss between baseline and 12 months compared with 1% of participants in the control group (p<0·0001). Diabetes remission occurred in 61% of participants in the intervention group compared with 12% of those in the control group (odds ratio [OR] 12·03 [95% CI 5·17 to 28·03], p<0·0001). 33% of participants in the intervention group had normoglycaemia compared with 4% of participants in the control group (OR 12·07 [3·43 to 42·45], p<0·0001). Five serious adverse events were reported in four participants in the control group; four admissions to hospital because of unanticipated events (supraventricular tachycardia, abdominal pain, pneumonia, and epididymo-orchitis), and one admission to hospital for an anticipanted event (hyperglycaemia).

INTERPRETATION

Our findings show that the intensive lifestyle intervention led to significant weight loss at 12 months, and was associated with diabetes remission in over 60% of participants and normoglycaemia in over 30% of participants. The provision of this lifestyle intervention could allow a large proportion of young individuals with early diabetes to achieve improvements in key cardiometabolic outcomes, with potential long-term benefits for health and wellbeing.

FUNDING

Qatar National Research Fund.

Clinical Features and Microvascular Complications Risk Factors of Early-onset Type 2 Diabetes Mellitus

The aim of this research was to study the clinical features and microvascular complications risk factors of early-onset type 2 diabetes mellitus (T2DM). We analyzed the clinical data from 1421 T2DM inpatients at Wuhan Union Hospital. Subjects were divided into early-onset T2DM group (diagnostic age <40 years) and late-onset T2DM group (diagnostic age >40 years). All subjects underwent a standardized assessment of microvascular complications. Data were compared with independent-samples t test or Chi-square test. Multiple logistic regression was used to determine the risk factors of microvascular complications. Patients with early-onset T2DM were more inclined to have a lower systolic blood pressure (SBP), a longer duration of diabetes and higher levels of body mass index (BMI), uric acid (UA), fasting plasma glucose (FPG), total cholesterol (TC)- triglyceride (TG) and glycosylated hemoglobin (HbA1c) than those with late-onset T2DM (P<0.05). The prevalence of diabetic retinopathy (DR) was significantly higher and that of diabetic peripheral neuropathy (DPN) was significantly lower in early-onset group than in late-onset group (P<0.05). For DN, UA was an independent risk factor in early-onset T2DM. SBP and TG were independent risk factors in late-onset T2DM. For DR, duration of diabetes and SBP were independent risk factors in early-onset T2DM. Duration of diabetes, SBP and HbA1c were independent risk factors in late-onset T2DM. This study demonstrated that the clinical characteristics of early-onset T2DM were metabolic disorders, including glucose metabolism, lipid metabolism and amino acid metabolism. Early-onset T2DM was more likely to be associated with DR. The potential pathogenesis of early and late-onset T2DM might be different. The management of metabolic risk factors especially HbA1c, SBP, TG and UA is advised to be performed in the early stage of diabetes.

Early-onset diabetes: an epidemic in China

Although type 2 diabetes is a disease often associated with aging, the global prevalence of early-onset diabetes has been increasing due to man's sedentary lifestyle, low-physical activity, obesity, and some nonmodifiable risk factors. Many studies have found that individuals with early-onset type 2 diabetes were at higher risk of developing vascular complications than those with late-onset diabetes. Individuals with early-onset diabetes are usually unwilling to visit hospital and have more confidence in their health, which results in poor glycemic control and the delayed detection of diabetes-related complications. Few studies have focused on the treatment and prevention of complications in specific population of individuals with early-onset type 2 diabetes. Therefore, focusing on this particular population is critical for the government and academic societies. Screening for T2DM is imminent for young adults with a family history of diabetes, obesity, markers of insulin resistance, or alcohol consumption. More data are definitely required to establish a reasonable risk model to screen for early-onset diabetes.

Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I): a randomised controlled trial to examine the impact of an intensive lifestyle intervention consisting of a low-energy diet and physical activity on body weight and metabolism in early type 2 diabetes mellitus: study protocol for a randomized controlled trial

Background

Type 2 diabetes mellitus (T2DM) and obesity are syndemic and will have a significant impact on affected individuals and healthcare services worldwide. Evidence shows that T2DM remission can be achieved with significant weight loss in those who are younger with early diabetes and requiring fewer medications for glycaemic control. DIADEM-I aims to examine the impact of an intensive lifestyle intervention (ILI) using a low-energy diet (LED) meal replacement approach combined with physical activity in younger individuals with early T2DM.

Methods

The planned study is an ongoing, non-blinded, pragmatic, randomised controlled, parallel-group trial examining the impact of an LED-based ILI on body weight and diabetes remission in younger (18–50 years) T2DM individuals with early diabetes (≤ 3-year duration). The ILI will be compared to usual medical care (UMC). The primary outcome will be weight loss at 12 months. Other key outcomes of interest include diabetes remission, glycaemic control, diabetes complications, cardiovascular health, physical activity, mental health, and quality of life. It is planned for the study to include 138 subjects for assessment of the primary outcome. Safety will be assessed throughout.

Discussion

If DIADEM-I demonstrates a clinically significant effect for younger individuals with early T2DM, it will inform clinical guidelines and services of the future for management of T2DM.

Trial registration

ISRCTN: ISRCTN20754766 (date assigned: 7 June 2017); ClinicalTrials.gov, ID: NCT03225339 Registered on 26 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2660-1) contains supplementary material, which is available to authorized users.

Impact of age at diagnosis and duration of type 2 diabetes on mortality in Australia 1997-2011

AIMS/HYPOTHESIS

Current evidence suggests that type 2 diabetes may have a greater impact on those with earlier diagnosis (longer duration of disease), but data are limited. We examined the effect of age at diagnosis of type 2 diabetes on the risk of all-cause and cause-specific mortality over 15 years.

METHODS

The data of 743,709 Australians with type 2 diabetes who were registered on the National Diabetes Services Scheme (NDSS) between 1997 and 2011 were examined. Mortality data were derived by linking the NDSS to the National Death Index. All-cause mortality and mortality due to cardiovascular disease (CVD), cancer and all other causes were identified. Poisson regression was used to model mortality rates by sex, current age, age at diagnosis, diabetes duration and calendar time.

RESULTS

The median age at registration on the NDSS was 60.2 years (interquartile range [IQR] 50.9-69.5) and the median follow-up was 7.2 years (IQR 3.4-11.3). The median age at diagnosis was 58.6 years (IQR 49.4-67.9). A total of 115,363 deaths occurred during 7.20 million person-years of follow-up. During the first 1.8 years after diabetes diagnosis, rates of all-cause and cancer mortality declined and CVD mortality was constant. All mortality rates increased exponentially with age. An earlier diagnosis of type 2 diabetes (longer duration of disease) was associated with a higher risk of all-cause mortality, primarily driven by CVD mortality. A 10 year earlier diagnosis (equivalent to 10 years' longer duration of diabetes) was associated with a 1.2-1.3 times increased risk of all-cause mortality and about 1.6 times increased risk of CVD mortality. The effects were similar in men and women. For mortality due to cancer (all cancers and colorectal and lung cancers), we found that earlier diagnosis of type 2 diabetes was associated with lower mortality compared with diagnosis at an older age.

CONCLUSIONS/INTERPRETATION

Our findings suggest that younger-onset type 2 diabetes increases mortality risk, and that this is mainly through earlier CVD mortality. Efforts to delay the onset of type 2 diabetes might, therefore, reduce mortality.

Early-onset type 2 diabetes: Age gradient in clinical and behavioural risk factors in 5115 persons with newly diagnosed type 2 diabetes-Results from the DD2 study

AIM

To examine the association between early onset of type 2 diabetes mellitus (DM) and clinical and behavioural risk factors for later complications of diabetes.

METHODS

We conducted a cross-sectional study of 5115 persons with incident type 2 DM enrolled during 2010-2015 in the Danish Centre for Strategic Research in Type 2 Diabetes-cohort. We compared risk factors at time of diagnosis among those diagnosed at ≤45 years (early onset) with diagnosis age 46 to 55, 56 to 65 (average onset = reference), 66 to 75, and >75 years (late onset). Prevalence ratios (PRs) were computed by using Poisson regression.

RESULTS

Poor glucose control, ie, HbA1c ≥ 75 mmol/mol (≥9.0%) in the early-, average-, and late-onset groups was observed in 12%, 7%, and 1%, respectively (PR 1.70 [95% confidence intervals (CI) 1.27, 2.28] and PR 0.17 [95% CI 0.06, 0.45]). A similar age gradient was observed for severe obesity (body mass index > 40 kg/m² : 19% vs. 8% vs. 2%; PR 2.41 [95% CI 1.83, 3.18] and 0.21 (95% CI 0.08, 0.57]), dyslipidemia (90% vs. 79% vs. 68%; PR 1.14 [95% CI 1.10, 1.19] and 0.86 [95% CI 0.79, 0.93]), and low-grade inflammation (C-reactive protein > 3.0 mg/L: 53% vs. 38% vs. 26%; PR 1.41 [95% CI 1.12, 1.78] and 0.68 [95% CI 0.42, 1.11]). Daily smoking was more frequent and meeting physical activity recommendations less likely in persons with early-onset type 2 DM.

CONCLUSIONS

We found a clear age gradient, with increasing prevalence of clinical and behavioural risk factors the younger the onset age of type 2 DM. Younger persons with early-onset type 2 DM need clinical awareness and support.

Type 2 diabetes in adolescents and young adults

The prevalence of type 2 diabetes in adolescents and young adults is dramatically increasing. Similar to older-onset type 2 diabetes, the major predisposing risk factors are obesity, family history, and sedentary lifestyle. Onset of diabetes at a younger age (defined here as up to age 40 years) is associated with longer disease exposure and increased risk for chronic complications. Young-onset type 2 diabetes also affects more individuals of working age, accentuating the adverse societal effects of the disease. Furthermore, evidence is accumulating that young-onset type 2 diabetes has a more aggressive disease phenotype, leading to premature development of complications, with adverse effects on quality of life and unfavourable effects on long-term outcomes, raising the possibility of a future public health catastrophe. In this Review, we describe the epidemiology and existing knowledge regarding pathophysiology, risk factors, complications, and management of type 2 diabetes in adolescents and young adults.

Gender Difference in the Association of Early- vs. Late-Onset Type 2 Diabetes with Non-Fatal Microvascular Disease in China: A Cross-sectional Study

BACKGROUND

This study aimed to test whether early-onset (defined as <40 years of age) type 2 diabetes mellitus (T2DM) imparted different risks of microvascular disease to Chinese men and women.

METHODS

222,537 Chinese patients with T2DM were recruited in 630 hospitals from 106 cities in 30 provinces of China in 2012 using a cross-sectional design. Logistic regression analysis was performed to obtain odds ratios (ORs) of male vs. female for diabetic retinopathy (DR) and diabetic nephropathy (DN). Additive interaction was used to test whether male gender and early-onset T2DM had interactive effects for DR and DN.

RESULTS

More men than women with T2DM had DN (4.5 vs. 3.0%, P < 0.0001), DR (5.3 vs. 5.1%, P < 0.0001), and microvascular disease (either DN or DR) (8.4 vs. 7.1%, P < 0.0001). After adjustment for age and levels of hospitals, the effect sizes of early-onset T2DM for microvascular disease were higher in men than in women, with a 2.67 [95% confidence intervals (CI): 2.51-2.85] fold risk in men and a 2.53 (95% CI: 2.35-2.72) fold risk in women. The risk effect sizes were greatly attenuated by further adjusting for diabetes durations and other traditional risk factors, with a 1.28 (95% CI: 1.19-1.37) fold risk in men and a 1.07 (95% CI: 0.99-1.16) fold risk in women. After adjustment for diabetes durations and other traditional risk factors, using women with late-onset T2DM as the reference, co-presence of early-onset and male gender significantly enhanced the ORs of either early-onset alone (1.10, 95% CI: 1.03-1.19) or male gender alone (0.96, 95% CI: 0.93-0.99) to 1.32 (95% CI: 1.24-1.41), with significant additive interaction. Kaplan-Meier analysis showed that in early-onset T2DM, DN developed 5 years earlier in men than in women.

CONCLUSION

Early-onset T2DM increased more risk of microvascular complications in Chinese men than in women, most of increased risks being attributable to longer diabetes durations.

Prevalence of low HDL cholesterol and its associations among Sri Lankan patients with diabetes mellitus on statin therapy

AIMS

We aimed to study the prevalence and associations of suboptimal high density lipoproteins level, a characteristic feature in diabetic dyslipidemia among patients under statin therapy.

MATERIALS AND METHODS

From a database of 2416 patients, data on age, gender, duration of diabetes, body mass index (BMI) and waist circumference (WC), low density lipoproteins (LDL), triglyceride, high density lipoproteins (HDL) were obtained. Prevalence of suboptimal HDL (<40mg/dL in males and <50mg/dL in females) and its association with gender, age, duration of diabetes, BMI and WC were studied.

RESULTS

The mean (SD) age of the sample (n=2416) was 53 (10) years and 64.2% of them (n=1550) were males. Prevalence of suboptimal HDL was 17.6%. Regression analysis revealed female gender, (OR 7.73, 95% CI 5.99-9.97) younger age (OR 0.98, 95% CI 0.97-0.99), higher BMI (OR1.05. 95% CI 1.00-1.2) and LDL level over 100mg/dL (OR 1.004, 95% CI 1.00-1.007) had significant associations with suboptimal HDL.

CONCLUSIONS

Every sixth diabetic patient on statins has suboptimal HDL level. Females, younger and obese diabetic individuals should be more focused on achieving optimal HDL cholesterol levels.

Distinct Predictors and Comorbidities in Early Onset Type 2 Diabetes Mellitus Among Asian Indians

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) is increasing worldwide, and the age of disease onset is falling. Although there is rising prevalence of early onset T2DM in India, little is known about their clinical characteristics and cardiovascular risks profiles. The aim of this study was to address this knowledge gap by comparing the characteristics of early onset T2DM and usual onset T2DM patients from our clinic population in India.

METHODS

We studied the clinical and biochemical parameters of 98 consecutive early onset T2DM patients of age <45 and <5 years of disease duration and compared those parameters with 86 consecutive usual onset T2DM patients of age >50 years and similar disease duration.

RESULTS

There was a strong component of family history of T2DM in early onset T2DM patients; however, no difference was observed in body mass index or waist circumference between the groups. When compared with usual onset group, the early onset T2DM patients were more hypertriglycedemic, with higher total cholesterol, higher total cholesterol/high-density lipoprotein (HDL) ratio, higher low-density lipoprotein levels, and lower HDL cholesterol. Early onset T2DM patients showed significantly worse glycemic control and rapid decline in insulin secretion compared with usual onset T2DM patients.

CONCLUSIONS

Our results demonstrate that early onset T2DM in Asian Indians appears to be a disease phenotype with adverse risk factors having poor glycemic control and longer disease duration demanding strategies for novel clinical management.

The characteristics of newly diagnosed adult early-onset diabetes: a population-based cross-sectional study

To investigate the characteristics of newly diagnosed early-onset diabetes in the Chinese population, 2801 newly diagnosed diabetes participants without known diabetes or pre-diabetes in a national cross-sectional survey were analysed. Participants were divided into quartiles (22-43, 44-52, 53-61 and >61 years) according to age of diabetes onset and the first group were defined as early-onset diabetes group. Early-onset diabetes group had lower systolic blood pressure (SBP), total cholesterol, low density lipoprotein cholesterol, 2-hour post prandial blood glucose and urine albumin creatinine ratio. There was no difference in body mass index, Homeostasis model assessment (HOMA) of beta cell function and diabetes family history between early-onset diabetes participants and any other age groups. HOMA of insulin resistance (IR) scores and disposition index 30 minutes after glucose load (DI₃₀) were increased in early-onset diabetes participants. The beta cell function declination was more deteriorated in early-onset diabetes participants. Male gender, triglycerides, HOMA-IR and DI₃₀ were positively associated with an earlier age at diagnosis. In conclusion, patients diagnosed with diabetes at a younger age are characterized by a similar cardiovascular risk profile with increased insulin resistance and more severe beta cell failure than patients diagnosed at a later age.

Significant retinopathy in young-onset type 2 vs. type 1 diabetes: a clinical observation

OBJECTIVE

Little is known about the burden of severe retinal disease between young-onset type 2 (T2D) and type 1 diabetes (T1D). This study assessed the prevalence of significant retinopathy in young-onset T2D vs. T1D and its predictive factors.

METHODS

This was a cross-sectional study. Subjects with T1D and T2D diagnosed below age 40 were identified from diabetes eye screening register. Preproliferative, proliferative, maculopathy changes and/or previous laser photocoagulation treatment were considered to have significant retinopathy (SigDR).

RESULTS

A total of 1306 subjects were identified, of whom 842 and 464 had T1D and T2D, respectively. The mean age of diagnosis was significantly lower in T1D subjects (T1D vs. T2D; 20.1 ± 10.3 vs. 32.1 ± 6.0 years, p < 0.0005). Although the T2D cohort had shorter diabetes duration (T1D vs. T2D; 20.8 ± 13.0 vs. 13.7 ± 9.0 years, p < 0.0005), the overall prevalence of SigDR was similar to T1D (T1D vs. T2D; 21.6 vs. 20.9%, p = NS). After adjusting for diabetes duration, the T2D cohort experienced significantly higher prevalence of this complication than T1D after 10 years duration. The age threshold beyond which the T2D cohort began to experience greater burden of SigDR was approximately 50 years. The prevalence of any retinopathy after 15 years duration was 75-80% for both young-onset cohort. Risk factors for SigDR (older age, diabetes duration, systolic BP, HbA1c and creatinine) were similar in both young-onset diabetes cohort with poor glycaemic control being the strongest variable. Lower age of T2D diagnosis was not a predictive factor.

CONCLUSIONS

Irrespective of diabetes type, subjects with young-onset diabetes possessed high lifetime risk for retinopathy. However, young-onset T2D cohort was more susceptible to severe retinal disease with substantial burden of this complication by the fifth decade of life.

Clinical Characteristics of Young Type 2 Diabetes Patients with Atherosclerosis

Objective

The prevalence of type 2 diabetes is increasing rapidly in the young population. The clinical characteristics and risk factors for young type 2 diabetes patients with atherosclerosis are not fully explicated. The aim of the present study was to investigate various clinical and biochemical characteristics of young type 2 diabetic patients with atherosclerosis.

Design and Methods

This was a cross-sectional study. The study involved 2199 hospitalized patients with type 2 diabetes. The young patients were classified into the atherosclerotic group or the non-atherosclerotic group, and we also enrolled an older group with peripheral atherosclerosis disease and an age of at least 45 years. Comparisons were made between the different groups to investigate the cardiovascular and metabolic risk profiles of young type 2 diabetes patients with atherosclerosis. We also used logistic regression models to assess the atherosclerosis risk factors for young patients.

Results

Compared to older type 2 diabetes patients with atherosclerosis, young patients with atherosclerosis had more deleterious profiles of weight and hyperlipidemia. Only age and diabetes duration were found to be significant independent risk factors for atherosclerosis in young patients. The ratio of the presence of atherosclerosis in the lower extremity arteries alone was significantly higher in young patients than older patients (26.4% vs. 14.0%, P = 0.000).

Conclusion

Young type 2 diabetes patients with atherosclerosis have more adverse cardiovascular risk profiles and inadequate control of these risk factors. Lower extremity examination is of high importance in young patients.

Risk of non-fatal cardiovascular diseases in early-onset versus late-onset type 2 diabetes in China: a cross-sectional study

BACKGROUND

The age of onset of type 2 diabetes is decreasing. Because non-Chinese patients with early-onset type 2 diabetes (defined here as diagnosis at <40 years) have increased risk of vascular complications, we investigated effects of early-onset versus late-onset type 2 diabetes on risk of non-fatal cardiovascular diseases in China.

METHODS

We did a cross-sectional survey using data from the China National HbA1c Surveillance System (CNHSS), including 222,773 Chinese patients with type 2 diabetes in 630 hospitals from 106 cities in 30 provinces of China in 2012. We documented demographic information and clinical profiles. Non-fatal cardiovascular disease was defined as non-fatal coronary heart disease or non-fatal stroke. Prevalence of non-fatal cardiovascular diseases was standardised to the Chinese population in 2011. We did logistic regression analysis to obtain odds ratios (ORs) for the risk of cardiovascular disease in patients with early-onset versus late-onset type 2 diabetes. Because the CNHSS did not contain patients on diet or lifestyle treatment alone, and did not capture information on smoking or lipid or antihypertensive treatment, we validated our findings in another dataset from a cross-sectional, multicentre observational study (the 3B study) of outpatients with type 2 diabetes to confirm that exclusion of patients with diet treatment only and non-adjustment for lipid-lowering and antihypertensive drugs did not introduce major biases in the main analysis.

FINDINGS

Of 222,773 patients recruited from April 1, 2012, to June 30, 2012, 24,316 (11%) had non-fatal cardiovascular disease. Patients with early-onset diabetes had a higher age-adjusted prevalence of non-fatal cardiovascular disease than did patients with late-onset diabetes (11·1% vs 4·9%; p<0·0001). After adjustment for age and sex, patients with early-onset type 2 diabetes had higher risk of non-fatal cardiovascular disease than did those with late-onset type 2 diabetes (OR 1·91, 95% CI 1·81-2·02). Adjustment for duration of diabetes greatly attenuated the effect size for risk of non-fatal cardiovascular disease (1·13, 1·06-1·20). Results of the validation study showed that exclusion of patients with diet only and non-adjustment for lipid-lowering and antihypertensive drugs resulted in marginal changes in ORs for risk of non-fatal cardiovascular disease in patients with early-onset versus late-onset type 2 diabetes. Early-onset type 2 diabetes remained associated with increased risk of cardiovascular disease, attributable to longer duration of diabetes.

INTERPRETATION

Chinese patients with early-onset type 2 diabetes are at increased risk of non-fatal cardiovascular disease, mostly attributable to longer duration of diabetes.

FUNDING

Novo Nordisk China (for the China National HbA1c Surveillance System [CNHSS]) and Merck Sharp & Dohme China (for the 3B study).

Prevalence of microvascular diseases among tertiary care Chinese with early versus late onset of type 2 diabetes

AIMS

This study aimed to investigate the impact of early-onset diabetes on the risk of microvascular diseases in Chinese with type 2 diabetes mellitus (T2DM).

METHODS

A cross sectional survey of 29,442 patients with T2DM in 77 tertiary hospitals in China was conducted in 2011. Early-onset diabetes was defined as diagnosis of diabetes before 40years of age. Microvascular complications and risk factors were documented. Prevalence of microvascular disease was standardized to the Chinese population in 2010. Logistic regression analysis was performed to obtain odds ratios (OR) for early versus late onset of T2DM.

RESULTS

A total of 1,303 (4.4%) patients had nephropathy, 2,137 (7.3%) had retinopathy and 3,012 (10.2%) had either of them. Early-onset diabetes greatly increased the prevalence of microvascular diseases compared with late-onset diabetes (nephropathy: 5.1% vs. 1.5%; retinopathy: 7.1% vs. 2.7%; either: 9.7% vs. 3.6%), especially among patients from 45 to 59years of age. After adjusting for age and sex, patients with early-onset T2DM were at 1.69-fold (95% CI 1.46-1.95) higher risk of microvascular diseases than those with late-onset T2DM. However, this was not significant after adjusting for traditional risk factors and disease duration (p=0.162).

CONCLUSION

Chinese patients with early-onset T2DM are at a marked increased risk of microvascular diseases.

Complication characteristics between young-onset type 2 versus type 1 diabetes in a UK population

BACKGROUND

In the UK, the care of young people with diabetes has focused predominantly on type 1 diabetes (T1D). However, young-onset T2D has become increasingly prevalent. At present, it is unclear which type of diabetes represents the more adverse phenotype to develop complications. This study aims to determine the complication burden and its predictive factors in young-onset T2D compared with T1D.

METHODS

A cross-sectional study using a hospital diabetes register to identify patients with young-onset T2D and T1D. Young-onset T2D was defined as age of diagnosis below 40 years. The T1D cohort with a similar age of diagnosis was used as a comparator. Data from the last clinic visit was used for analysis. Clinical characteristics and diabetes complications were evaluated at diabetes durations <10, 10-20, and >20 years. Predictive factors for diabetes complications (age, sex, glycated hemoglobin, creatinine, diabetes duration, hypertension, dyslipidemia, and body mass index >25) were determined by logistic regression analysis.

RESULTS

Data were collected on 1287 patients, of which 760 and 527 had T1D and T2D, respectively. In all diabetes durations, the T2D cohort had an older age of onset (p<0.0005) with a higher prevalence of obesity, hypertension, and dyslipidemia (all p<0.0005) while glycemic control was similar in both groups. Cardiovascular disease (p<0.005) and neuropathy (p<0.05) were more prevalent in the young-onset T2D cohort in all diabetes durations. There was no difference in retinopathy. Cardiovascular disease was predominantly due to ischemic heart disease. Stroke and peripheral vascular disease became significantly higher in T2D after 20 years duration. After controlling for traditional risk factors, young-onset T2D was an independent predictor for cardiovascular disease (p<0.005) and neuropathy (p<0.05) but not for retinopathy.

CONCLUSIONS

Young-onset T2D is a more aggressive phenotype than T1D to develop diabetes complications, particularly for ischemic heart disease and neuropathy.

Early onset type 2 diabetes: risk factors, clinical impact and management

Early onset type 2 diabetes mellitus (T2DM) is increasingly prevalent with a significant impact on the individual, healthcare service delivery and planning. The individuals are likely to be obese, lead a sedentary lifestyle, have a strong family history of T2DM, be of black and minority ethnic (BME) origin and come from a less affluent socioeconomic group. They have a heightened risk of developing microvascular and macrovascular complications, often at an earlier stage and with greater frequency than seen in type 1 diabetes. As such, early and aggressive risk factor management is warranted. Early onset T2DM is complex and impacts on service delivery with a need for multidisciplinary care of complications and comorbidities', in addition to adequate educational and psychological support. This review on the impact of early onset T2DM provides the latest insights into this emerging epidemic.

Age and glycemic control among low-income Latinos

Younger adult patients with diabetes often have poorer glycemic control (HbA1c) than older patients. It is not known if this relationship holds true in the Latino population. Objective was to explore the relationship between age and HbA1c in a Mexican American population and what plausible factors might mediate this relationship. We analyzed data from 387 patients with diabetes self-identified as Mexican American recruited as a part of a cross-sectional study of safety net patients in two cities. Patients completed questionnaires and their last HbA1c was extracted from the medical record. We conducted multivariate regression analyses and Baron and Kenny tests of mediation. Participants were young with mean age of 53 ± 12 years. Younger age was associated with a higher HbA1c and having a higher fat diet. High fat diet partially mediated the relationship between age and HbA1c (p < 0.001 to p < 0.01). Age's indirect effect on HbA1c through diet was significant (Sobel = -2.44, p = 0.01). Younger Mexican American patients had higher HbA1c compared to older patients. Having a diet high in fat partially explained this relationship. Future epidemiological studies are needed to understand the multifaceted relationship between age and glycemic control.

General and gender characteristics of type 2 diabetes mellitus among the younger and older age groups

OBJECTIVES

To study the characteristics of cardiovascular risk factors in regard to age (before and after 60) and gender. Many reports refer to the higher prevalence of cardiovascular risk factors among the younger type 2 diabetics in comparison with the older population.

METHODS

The study included 462 randomly recruited type 2 diabetic subjects (above and below 60 years) attending Al-Zahrawi Private Hospital in Mosul City-Iraq, during the period from June to August 2011. They were analyzed in regard to age, duration of diabetes, smoking, socioeconomic status, anthropometric indices, blood pressure, fasting plasma glucose, glycated hemoglobin A1c and serum lipids. Data were analyzed using chi-square and unpaired Z test.

RESULTS

Duration of diabetes, diastolic blood pressure, glycated hemoglobin A1c, fasting plasma glucose, serum lipids, number of hypercholesterolemic patients, number of patients having unfavorable total cholesterol/HDL ratio (≥5) and positive family history of coronary heart disease were all significantly higher in the younger diabetics. In addition, younger diabetic females were distinguished by a larger number of hypertensive patients, higher level of systolic blood pressure, higher means of body mass index, total cholesterol and LDL, and larger number of patients having low HDL-C (<1 mmol/L). The younger diabetic males were distinct by a larger number of smokers, number of smoked cigarettes/day, and longer duration of smoking. All parameters ranged between p<0.05 and p<0.005.

CONCLUSION

Cardiovascular risk factors were significantly higher among younger type 2 diabetics (<60 years), particularly females.

Validation of diabetic retinopathy and maculopathy diagnoses recorded in a U.K. primary care database

OBJECTIVE

To describe the validity of recorded diabetic retinopathy (DR) and diabetic maculopathy (DMP) diagnoses, including edema (DMO) in The Health Improvement Network (THIN) database.

RESEARCH DESIGN AND METHODS

In two independent computer searches, we detected 20,838 patients with diabetes aged 1-84 years with a first DR computer Read entry in 2000-2008 and 4,064 with a first DMP entry. A two-step strategy was used to validate both outcomes as follows: 1) review of patient profiles including free-text comments from primary care practitioners (PCPs) (containing referral information and test results) of a random sample of 500 DR and all DMP computer-detected patients. We classified them in probable, possible, and noncase according to the diagnosis plausibility based on the manual review of the computerized information; and 2) review of questionnaires sent by PCPs and medical records in a random sample (N = 200 for each outcome including 36 diabetic macular edema [DMO]). Gold standard was PCPs' confirmation.

RESULTS

After profiles review, we categorized 418 as probable/possible DR. In addition, 3,676 DMP were categorized as probable/possible (including 711 DMO). After review of information sent by PCPs, confirmation rates were 87.3 and 87.2%, respectively (90.3% for DMO). When we applied them to the whole sample of computer-detected patients, the weighted confirmation rate was 78.0% for DR and 78.8% for DMP (86.2% for DMO).

CONCLUSIONS

Read codes for DR, DM, and DMO are moderately accurate in identifying incident case subjects of these ophthalmologic complications. The validity improved when incorporating PCPs' text comments to the patient's profile. THIN database proved to be a valuable resource to study ophthalmological diabetes complications.