Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes

Warning Signs: Occult Diabetes and Dysglycemia in the Hand Surgery Patient Population

BACKGROUND

Diabetes mellitus often exists for many years prior to diagnosis, and very little is known about the role of the prediagnosis stage of metabolic impairment in contributing to hand and upper-extremity pathology. The goal of this study is to determine the prevalence of undiagnosed glucose dysregulation in patients presenting with the 2 most commonly treated conditions of the hand and wrist.

METHODS

A retrospective study was performed of hand surgery patients with no established diagnosis of prediabetes or diabetes referred for a 2-hour glucose tolerance test according to American Diabetes Association criteria. Patients were divided into 3 groups: peripheral neuropathies, trigger finger, and controls with various upper-extremity diagnoses. Rates of undiagnosed prediabetes and diabetes were compared between groups, including subgroup analysis of patients based on unilateral or bilateral presentation. Binary logistic regression analysis was also used to calculate odds ratios for multiple variables.

RESULTS

Patients with neuropathy had a significantly higher incidence of undiagnosed dysglycemia compared with the control group. Of those patients, 51.3% were prediabetic and 12.8% were diabetic. The control group had significantly lower rates. Within the bilateral neuropathy patients, 59.6% had prediabetes and 15.4% had diabetes, versus 34.6% with prediabetes and 7.7% with diabetes in the unilateral group.

CONCLUSIONS

Hand surgeons encounter a patient population with high rates of undiagnosed prediabetes and diabetes, with some presentations as much as 6 times higher than the general population. Certain patient presentations should prompt appropriate diagnostic testing and referral, especially those presenting with bilateral compression neuropathy and elevated body mass index.

Can the postload-fasting glucose gap be used to determine risk of developing diabetes in chinese adults: A prospective cohort study

OBJECTIVE

To evaluate the relationship between fasting plasma glucose (FPG) and 2-hour postload plasma glucose (2hPG) measured during an oral glucose tolerance test, and the risk of developing diabetes in Chinese adults.

METHODS

We followed 3,094 participants without diabetes, categorizing them based on their oral glucose tolerance test (OGTT) results into low post load (2hPG ≤ FPG) and high post load (2hPG > FPG) at baseline. We monitored the incidence of diabetes, incidence of prediabetes, disease progression from prediabetes to diabetes and disease reversal from prediabetes to normal glucose tolerance (NGT) over an average of 3.2 years of follow-up. After the Schoenfeld residual test, Cox's time-varying covariate (Cox-TVC) models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) to compare the different clinical events between low and high post load groups.

RESULTS

In the cohort study, of the 3,094 participants, 702 (22.7 %) had low post load (2hPG ≤ FPG, mean postload-fasting gap: -0.8 ± 0.7 mmol/L) and 2,392 (77.3 %) had high post load (2hPG > FPG, mean postload-fasting gap: 1.8 ± 1.2 mmol/L). Over 3.2 ± 0.2 years of follow-up, 282 (9.1 %) developed diabetes. In the low post load group, the incidence rates per 1,000 person-years were: diabetes was 7.9, prediabetes was 70.0, disease progression from prediabetes to diabetes was 23.4 and disease reversal to NGT was 327.2. For the high post load group, incidence rates for diabetes was 13.9, prediabetes was 124.3, disease progression was 59.5 and disease reversal was 238.6 per 1,000 person-years. Participants with high post load showed higher incidence rates of diabetes, prediabetes, and progression from prediabetes to diabetes compared to those with low post load. HRs were significantly higher for incident diabetes and prediabetes, and disease progression from prediabetes to diabetes, whereas disease reversal was lower.

CONCLUSION

The risk of developing prediabetes/diabetes after 3.2 years of follow-up was higher in the participants with high post load. It suggested that postload-fasting gap may be a simple tool to predict the risk of developing prediabetes, diabetes or reversal to NGT.

Prevalence and risk factors for diabetic retinopathy at diagnosis of type 2 diabetes: an observational study of 77 681 patients from the Swedish National Diabetes Registry

INTRODUCTION

To assess the prevalence of diabetic retinopathy (DR) in persons with newly diagnosed type 2 diabetes (T2D) to understand the potential need for intensified screening for early detection of T2D.

RESEARCH DESIGN AND METHODS

Individuals from the Swedish National Diabetes Registry with a retinal photo <2 years after diagnosis of T2D were included. The proportion of patients with retinopathy (simplex or worse) was assessed. Patient characteristics and risk factors at diagnosis were analyzed in relation to DR with logistic regression.

RESULTS

In total, 77 681 individuals with newly diagnosed T2D, mean age 62.6 years, 41.1% females were included. Of these, 13 329 (17.2%) had DR.DR was more common in older persons (adjusted OR 1.03 per 10-year increase, 95% CI 1.01 to 1.05) and men compared with women, OR 1.10 (1.05 to 1.14). Other variables associated with DR were OR (95% CI): lower education 1.08 (1.02 to 1.14); previous stroke 1.18 (1.07 to 1.30); chronic kidney disease 1.29 (1.07 to 1.56); treatment with acetylsalicylic acid 1.14 (1.07 to 1.21); ACE inhibitors 1.12 (1.05 to 1.19); and alpha blockers 1.41 (1.15 to 1.73). DR was more common in individuals born in Asia (OR 1.16, 95% CI 1.08 to 1.25) and European countries other than those born in Sweden (OR 1.11, 95% CI 1.05 to 1.18).

CONCLUSIONS

Intensified focus on screening of T2D may be needed in Sweden in clinical practice since nearly one-fifth of persons have retinopathy at diagnosis of T2D. The prevalence of DR was higher in men, birthplace outside of Sweden, and those with a history of stroke, kidney disease, and hypertension.

Carpal Tunnel Syndrome and Trigger Finger May Be an Early Symptom of Preclinic Type 2 Diabetes

Background

Type 2 diabetes (T2D) is a major risk factor for carpal tunnel syndrome (CTS) and trigger finger (TF), but less is known regarding the risk of developing T2D after being diagnosed with CTS or TF. CTS and TF could be early signs of preclinical T2D, and early detection of T2D is crucial to prevent complications and morbidity. Therefore, we investigate the association between CTS/TF and T2D in an adult population without previous T2D using big data registers in Sweden.

Methods

Data were collected by crosslinking five nationwide Swedish registers. Individuals aged 40-85 years on December 31, 2010, without prior overt diabetes, were included (n = 3,948,517) and followed up from baseline (ie, a diagnosis of CTS or TF) or January 1, 2011, for controls, until a diagnosis of T2D, prescription of oral antidiabetics or insulin, or end of follow-up four years after baseline. Multivariate Cox regression models were created to calculate hazard ratios for T2D.

Results

In total, 37,346 (0.95%) patients were diagnosed with CTS, whereof 1329 (3.46%) developed T2D. There were 17,432 (0.44%) patients who developed TF, whereof 639 (3.67%) developed T2D. Among the controls, 2.73% developed T2D. Compared with controls, there was an increased risk of developing T2D after being diagnosed with either CTS (HR 1.35; 95% confidence interval 1.28-1.43) or TF (HR 1.21; 95% confidence interval 1.12-1.31).

Conclusion

Compared with controls, a diagnosis of CTS or TF was associated with 35% and 21% higher risk for later T2D, respectively, which might indicate the existence of undetected T2D in this population.

Causal association between type 2 diabetes mellitus and acute suppurative otitis media: insights from a univariate and multivariate Mendelian randomization study

Background

Type 2 diabetes mellitus (T2DM) and hearing loss (HL) constitute significant public health challenges worldwide. Recently, the association between T2DM and HL has aroused attention. However, possible residual confounding factors and other biases inherent to observational study designs make this association undetermined. In this study, we performed univariate and multivariable Mendelian Randomization (MR) analysis to elucidate the causal association between T2DM and common hearing disorders that lead to HL.

Methods

Our study employed univariate and multivariable MR analyses, with the Inverse Variance Weighted method as the primary approach to assessing the potential causal association between T2DM and hearing disorders. We selected 164 and 9 genetic variants representing T2DM from the NHGRI-EBI and DIAGRAM consortium, respectively. Summary-level data for 10 hearing disorders were obtained from over 500,000 participants in the FinnGen consortium and MRC-IEU. Sensitivity analysis revealed no significant heterogeneity of instrumental variables or pleiotropy was detected.

Results

In univariate MR analysis, genetically predicted T2DM from both sources was associated with an increased risk of acute suppurative otitis media (ASOM) (In NHGRI-EBI: OR = 1.07, 95% CI: 1.02-1.13, P = 0.012; In DIAGRAM: OR = 1.14, 95% CI: 1.02-1.26, P = 0.016). Multivariable MR analysis, adjusting for genetically predicted sleep duration, alcohol consumption, body mass index, and smoking, either individually or collectively, maintained these associations. Sensitivity analyses confirmed the robustness of the results.

Conclusion

T2DM was associated with an increased risk of ASOM. Strict glycemic control is essential for the minimization of the effects of T2DM on ASOM.

Association of prediabetes with clinical outcomes in patients with chronic coronary syndrome: a post hoc analysis of the ISCHEMIA and ISCHEMIA-CKD trials

BACKGROUND

There is conflicting evidence whether prediabetes is associated with adverse clinical outcomes in patients with chronic coronary syndrome. We aimed to assess the effect of prediabetes in patients with chronic coronary syndrome on clinical outcomes.

METHODS

This is a secondary analysis of data from the ISCHEMIA and ISCHEMIA-CKD trials, including patients with chronic coronary syndrome determined by coronary computed tomography angiography or exercise-stress testing. Participants were assigned to the normoglycemia group (HbA1c < 5.7% [< 39 mmol/mol]), prediabetes group (HbA1c 5.7-6.4% [40-47 mmol/mol]), or diabetes group (HbA1c ≥ 6.5% [≥ 48 mmol/mol]). The primary end point of this study was all-cause mortality. Secondary endpoints included major adverse cardiovascular events and composites thereof.

RESULTS

Overall, the primary endpoint all-cause mortality occurred in 330 (8.4%) of 3910 patients over a median follow-up time of 3.1 years (IQR 2.1-4.1). The primary endpoint all-cause mortality occurred in 37 (5.2%) of 716 patients in the normoglycemia group, in 63 (6.9%) of 911 in the prediabetes group, and in 230 (10.1%) of 2283 in the diabetes group. In the covariate-adjusted Cox model analysis, the estimated adjusted HR (aHR) in the prediabetes group as compared with the normoglycemia group was 1.45 (95%CI, 0.95-2.20). The aHR in the diabetes group as compared with the normoglycemia group was 1.84 (95%CI, 1.29-2.65). Prediabetes, compared with normoglycemia, was associated with an increased risk of stroke (aHR, 3.44, 95%CI, 1.15-10.25). Subgroup analyses suggested an increased risk of all-cause death associated with prediabetes in males and patients under 65 years.

CONCLUSIONS

In patients with chronic coronary syndrome, diabetes but not prediabetes was associated with significantly increased risk of all-cause death within a median follow-up period of 3.1 years. Trial Registration NCT01471522, BioLINCC ID 13936.

Interruption of perivascular and perirenal adipose tissue thromboinflammation rescues prediabetic cardioautonomic and renovascular deterioration

The cardiovascular and renovascular complications of metabolic deterioration are associated with localized adipose tissue dysfunction. We have previously demonstrated that metabolic impairment delineated the heightened vulnerability of both the perivascular (PVAT) and perirenal adipose tissue (PRAT) depots to hypoxia and inflammation, predisposing to cardioautonomic, vascular and renal deterioration. Interventions either addressing underlying metabolic disturbances or halting adipose tissue dysfunction rescued the observed pathological and functional manifestations. Several lines of evidence implicate adipose tissue thromboinflammation, which entails the activation of the proinflammatory properties of the blood clotting cascade, in the pathogenesis of metabolic and cardiovascular diseases. Despite offering valuable tools to interrupt the thromboinflammatory cycle, there exists a significant knowledge gap regarding the potential pleiotropic effects of anticoagulant drugs on adipose inflammation and cardiovascular function. As such, a systemic investigation of the consequences of PVAT and PRAT thromboinflammation and its interruption in the context of metabolic disease has not been attempted. Here, using an established prediabetic rat model, we demonstrate that metabolic disturbances are associated with PVAT and PRAT thromboinflammation in addition to cardioautonomic, vascular and renal functional decline. Administration of rivaroxaban, a FXa inhibitor, reduced PVAT and PRAT thromboinflammation and ameliorated the cardioautonomic, vascular and renal deterioration associated with prediabetes. Our present work outlines the involvement of PVAT and PRAT thromboinflammation during early metabolic derangement and offers novel perspectives into targeting adipose tissue thrombo-inflammatory pathways for the management its complications in future translational efforts.

Incident Proteinuria differs by HIV Serostatus among Men with Pre-diabetes: The Multicenter AIDS Cohort Study

BACKGROUND

Pre-diabetes is associated with proteinuria, a risk factor for chronic kidney disease. While people living with HIV (PWH) have a higher risk of proteinuria than people without HIV (PWOH), it is unknown whether incident proteinuria differs by HIV serostatus among pre-diabetic persons.

METHODS

Urine protein-to-creatinine ratio (PCR) was measured at semi-annual visits among men in the Multicenter AIDS Cohort Study since April 2006. Men with pre-DM on or after April 2006 and no prevalent proteinuria or use of anti-diabetic medications were included. Pre-diabetes was defined as fasting glucose (FG) of 100-125 mg/dL confirmed within a year by a repeat FG or hemoglobin A1c 5.7-6.4%. Incident proteinuria was defined as PCR > 200 mg/g, confirmed within a year. We used Poisson regression models to determine whether incident proteinuria in participants with pre-diabetes differed by HIV serostatus and, among PWH, whether HIV-specific factors were related to incident proteinuria.

RESULTS

Between 2006 and 2019, among 1276 men with pre-diabetes, 128/613 PWH (21%) and 50/663 PWOH (8%) developed proteinuria over a median 10-year follow-up. After multivariable adjustment, the incidence of proteinuria in PWH with pre-diabetes was 3.3 times [95% CI: 2.3-4.8 times] greater than in PWOH (p < 0.01). Among PWH, current CD4 count <500 cells/mm3 (p < 0.01) and current use of protease inhibitors (p = 0.03) were associated with incident proteinuria, while lamivudine and integrase inhibitor use were associated with a lower risk.

CONCLUSION

Among men with pre-DM, the risk of incident proteinuria was 3 times higher in PWH. Strategies to preserve renal function are needed in this population.

The Effectiveness of Digital Health Lifestyle Interventions on People With Prediabetes: Protocol for a Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

There has been an increasing interest in the use of digital health lifestyle interventions for people with prediabetes, as these interventions may offer a scalable approach to preventing type 2 diabetes. Previous systematic reviews on digital health lifestyle interventions for people with prediabetes had limitations, such as a narrow focus on certain types of interventions, a lack of statistical pooling, and no broader subgroup analysis of intervention characteristics. The identified limitations observed in previous systematic reviews substantiate the necessity of conducting a comprehensive review to address these gaps within the field. This will enable a comprehensive understanding of the effectiveness of digital health lifestyle interventions for people with prediabetes.

OBJECTIVE

The objective of this systematic review, meta-analysis, and meta-regression is to systematically investigate the effectiveness of digital health lifestyle interventions on prediabetes-related outcomes in comparison with any comparator without a digital component among adults with prediabetes.

METHODS

This systematic review will include randomized controlled trials that investigate the effectiveness of digital health lifestyle interventions on adults (aged 18 years or older) with prediabetes and compare the digital interventions with nondigital interventions. The primary outcome will be change in body weight (kg). Secondary outcomes include, among others, change in glycemic status, markers of cardiometabolic health, feasibility outcomes, and incidence of type 2 diabetes. Embase, PubMed, CINAHL, and CENTRAL (Cochrane Central Register of Controlled Trials) will be systematically searched. The data items to be extracted include study characteristics, participant characteristics, intervention characteristics, and relevant outcomes. To estimate the overall effect size, a meta-analysis will be conducted using the mean difference. Additionally, if feasible, meta-regression on study, intervention, and participant characteristics will be performed. The Cochrane risk of bias tool will be applied to assess study quality, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach will be used to assess the certainty of evidence.

RESULTS

The results are projected to yield an overall estimate of the effectiveness of digital health lifestyle interventions on adults with prediabetes and elucidate the characteristics that contribute to their effectiveness.

CONCLUSIONS

The insights gained from this study may help clarify the potential of digital health lifestyle interventions for people with prediabetes and guide the decision-making regarding future intervention components.

TRIAL REGISTRATION

PROSPERO CRD42023426919; http://tinyurl.com/d3enrw9j.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50340.

Diabetes and chronic kidney disease in Chinese adults: a population-based cohort study

INTRODUCTION

Cohort evidence of the association of diabetes mellitus (DM) with chronic kidney disease (CKD) is limited. Previous studies often describe patients with kidney disease and diabetes as diabetic kidney disease (DKD) or CKD, ignoring other subtypes. The present study aimed to assess the prospective association of diabetes status (no diabetes, pre-diabetes, screened diabetes, previously diagnosed controlled/uncontrolled diabetes with/without antidiabetic treatment) and random plasma glucose (RPG) with CKD risk (including CKD subtypes) among Chinese adults.

RESEARCH DESIGN AND METHODS

The present study included 472 545 participants from the China Kadoorie Biobank, using baseline information on diabetes and RPG. The incident CKD and its subtypes were collected through linkage with the national health insurance system during follow-up. Cox regression models were used to calculate the HR and 95% CI.

RESULTS

During 11.8 years of mean follow-up, 5417 adults developed CKD. Screened plus previously diagnosed diabetes was positively associated with CKD (HR=4.52, 95% CI 4.23 to 4.83), DKD (HR=33.85, 95% CI 29.56 to 38.76), and glomerulonephritis (HR=1.66, 95% CI 1.40 to 1.97). In those with previously diagnosed diabetes, participants with uncontrolled diabetes represented higher risks of CKD, DKD, and glomerulonephritis compared with those with controlled RPG. The risk of DKD was found to rise in participants with pre-diabetes and increased with the elevated RPG level, even in those without diabetes.

CONCLUSIONS

Among Chinese adults, diabetes was positively associated with CKD, DKD, and glomerulonephritis. Screen-detected and uncontrolled DM had a high risk of CKD, and pre-diabetes was associated with a greater risk of DKD, highlighting the significance of lifelong glycemic management.

Metformin prescription for U.S. veterans with prediabetes, 2010-2019

Affecting an estimated 88 million Americans, prediabetes increases the risk for developing type 2 diabetes mellitus (T2DM), and independently, cardiovascular disease, retinopathy, nephropathy, and neuropathy. Nevertheless, little is known about the use of metformin for diabetes prevention among patients in the Veterans Health Administration, the largest integrated healthcare system in the U.S. This is a retrospective observational cohort study of the proportion of Veterans with incident prediabetes who were prescribed metformin at the Veterans Health Administration from October 2010 to September 2019. Among 1,059,605 Veterans with incident prediabetes, 12,009 (1.1%) were prescribed metformin during an average 3.4 years of observation after diagnosis. Metformin prescribing was marginally higher (1.6%) among those with body mass index (BMI) ≥35 kg/m2, age <60 years, HbA1c≥6.0%, or those with a history of gestational diabetes, all subgroups at a higher risk for progression to T2DM. In a multivariable model, metformin was more likely to be prescribed for those with BMI ≥35 kg/m2 incidence rate ratio [IRR] 2.6 [95% confidence intervals (CI): 2.1-3.3], female sex IRR, 2.4 [95% CI: 1.8-3.3], HbA1c≥6% IRR, 1.93 [95% CI: 1.5-2.4], age <60 years IRR, 1.7 [95% CI: 1.3-2.3], hypertriglyceridemia IRR, 1.5 [95% CI: 1.2-1.9], hypertension IRR, 1.5 [95% CI: 1.1-2.1], Major Depressive Disorder IRR, 1.5 [95% CI: 1.1-2.0], or schizophrenia IRR, 2.1 [95% CI: 1.2-3.8]. Over 20% of Veterans with prediabetes attended a comprehensive structured lifestyle modification clinic or program. Among Veterans with prediabetes, metformin was prescribed to 1.1% overall, a proportion that marginally increased to 1.6% in the subset of individuals at highest risk for progression to T2DM.

2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Prevalence of pre-diabetes in adults aged 25 - 45 years in a Durban-based clinical setting, South Africa: A retrospective study

AIM

Due to pre-diabetes being underexplored, its prevalence was investigated in study participants aged 25-45 years in a Durban-based tertiary-level clinical setting in South Africa.

METHODS

The study was done using a retrospective study design. Fasting blood samples from consented patients with no previous diagnosis of diabetes and within the specified age range were collected from King Edward Hospital in Durban. The pre-diabetes diagnosis was confirmed in participants with fasting glucose concentrations between 5.6 and 6.9 mmol/L and glycated haemoglobin (HbA1c) levels between 5.7 % and 6.4 % using the American Diabetes Association (ADA) and World Health Organisation (WHO) diagnosis criteria. The study participants' characterisation was stratified according to the diagnosis criterion, age, gender and ethnicity.

RESULTS

An alarming 68 % average pre-diabetes prevalence across ADA and WHO criteria in the Durban, eThekwini district sample population. The highest prevalence was recorded using the IFG criterion (83%) and the lowest when using the HbA1c criterion (54 %). Between the White, Black and Indian ethnic groups, the Indian group were more predisposed to pre-diabetes onset, with a prevalence of 62.7 %.

CONCLUSION

If pre-diabetes management is unattended, an unprecedented increase in metabolic disorders such as Type 2 Diabetes Mellitus (T2DM) and all-cause mortality incidence can be expected. Therefore, the study reveals a window of opportunity to intensify preventative measures and mitigate the incidence of T2DM.

Carnosine Did Not Affect Vascular and Metabolic Outcomes in Patients with Prediabetes and Type 2 Diabetes: A 14-Week Randomized Controlled Trial

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality in patients with prediabetes and type 2 diabetes mellitus (T2DM). Carnosine has been suggested as a potential approach to reduce ASCVD risk factors. However, there is a paucity of human data. Hence, we performed a 14-week double-blind randomized placebo-controlled trial to determine whether carnosine compared with placebo improves vascular and metabolic outcomes in individuals with prediabetes and T2DM. In total, 49 patients with prediabetes and T2DM with good glycemic control were randomly assigned either to receive 2 g/day carnosine or matching placebo. We evaluated endothelial dysfunction, arterial stiffness, lipid parameters, blood pressure, heart rate, hepatic and renal outcomes before and after the intervention. Carnosine supplementation had no effect on heart rate, peripheral and central blood pressure, endothelial function (logarithm of reactive hyperemia (LnRHI)), arterial stiffness (carotid femoral pulse wave velocity (CF PWV)), lipid parameters, liver fibroscan indicators, liver transient elastography, liver function tests, and renal outcomes compared to placebo. In conclusion, carnosine supplementation did not improve cardiovascular and cardiometabolic risk factors in adults with prediabetes and T2DM with good glycemic control. Therefore, it is improbable that carnosine supplementation would be a viable approach to mitigating the ASCVD risk in these populations. The trial was registered at clinicaltrials.gov (NCT02917928).

Serum cystatin C for risk stratification of prediabetes and diabetes populations

BACKGROUND

The association between serum cystatin C level and vascular outcomes has not been fully elucidated in diabetes and is unclear in prediabetes. We aim to evaluate whether cystatin C level predicts future risk for mortality and vascular outcomes in prediabetes and diabetes.

METHODS

A total of 85,371 participants with prediabetes and diabetes, and available baseline cystatin C in the UK biobank were included with a 14-year follow-up. Cox hazards models were used to calculate the associations between cystatin C level, mortality (all-cause, cause-specfic mortality) and vascular outcomes (myocardial infarction [MI], stroke, end-stage renal disease [ESRD] and diabetic retinopathy [DR]). The 1136 diabetes subjects in Guangzhou Diabetic Eye Study (GDES) were included for examing the impact of cystatin C on in vivo retinal degeneration and microvascular changes by using SS-OCT and OCTA.

RESULTS

The highest cystatin C quartile had increased risks of all-cause (hazard ratio [HR], 2.02; 95% confidence interval [CI] 1.86-2.19), cardiovascular (HR, 2.29; 95% CI 1.97-2.67), cancer (HR, 1.86; 95% CI 1.65-2.10) and other-cause mortality (HR, 2.24; 95% CI 1.90-2.64), MI (HR, 1.40; 95% CI 1.26-1.55), stroke (HR, 1.88; 95% CI, 1.57-2.26), ESRD (HR, 7.33; 95% CI, 5.02-10.71), DR (HR, 1.17; 95% CI 1.03-1.32) than those in the lowest quartile. Adding cystatin C to the conventional model improved C-statistic for all-cause (0.699-0.724), cardiovascular (0.762-0.789), cancer (0.661-0.674) and other-cause mortality (0.675-0.715), MI (0.748-0.750), stroke (0.712-0.718), and ESRD (0.808-0.827). The GDES analysis identified a strong association between increased cystatin C levels and diminished retinal neural layers, as well as microvascular rarefaction in both macular and optic disc regions (all P < 0.05).

CONCLUSIONS

Serum cystatin C refines the risk stratification for mortality and vascular outcomes among patients with prediabetes or diabetes.

A Lifestyle Communication Tool: Association of E-cigarette Use and Pre-diabetes

The aim of this study was to present a framework for clinicians to use when discussing electronic cigarette (e-cigarette) use and its association with pre-diabetes. A communication tool was designed using evidence-based strategies from the academic literature. A four-step framework is presented, which includes: step (1) helping patients to understand the association between e-cigarette use and pre-diabetes; step (2) the synergistic health impacts of e-cigarette use and pre-diabetes; step (3) management of diabetes-related lifestyle factors; and step (4) stages of change assessment related to e-cigarette reduction. This communication tool provides support for clinicians to discuss the risk of pre-diabetes associated with e-cigarette use. Moving forward, implementation and evaluation of this model are needed.

The prevalence and influencing factors of coexisting prediabetes and prehypertension among Bangladeshi adults

BACKGROUND

Early detection of diabetes and hypertension is helpful to prevent and/or delay the onset of these diseases through proper interventions. Therefore, it is a prerequisite to know the prevalence of prediabetes and prehypertension and the factors associated with these conditions but people from developing countries including Bangladesh often remain undiagnosed and unaware of these conditions. In this study we investigate the prevalence of prediabetes and prehypertension and their associated factors in Bangladesh using nationally representative data.

METHOD

We used nationally representative Bangladesh Demographic and Health Survey (BDHS) 2017-18 survey data, which included a total sample of 14,704 adults aged 18 years and more from whom blood pressure and fasting plasma glucose were collected. Chi-square test was used to examine the differences between sociodemographic and outcome variables. The univariate and multivariate logistic regression was performed to identify the factors associated with prediabetes and prehypertension.

RESULTS

Overall, the prevalence of prediabetes and prehypertension was 8.6% with 14% of the sampled population having from prediabetes and prehypertension separately. Among the prediabetic and prehypertensive participants, one-fourth of the participant were from the richest families and around one-third were overweight/obese, while more than fifty percent had normal Body Mass Index (BMI) and completed secondary and higher education. In the univariate analysis, the richest wealth status (UOR 3.3, 95% CI: 2.46 -4.35) and overweight/obesity (UOR 3.2, 95% CI: 2.62-3.85) are the highest predictors for prediabetes and prehypertension. After adjusting the other variables, overweight/obesity remains the largest predictor for prediabetes and prehypertension (AOR:2.5, 95% CI:2.05-3.05). Further, people aged 31 and above and from the richest family had around 2 times and 1.8 times higher risk of being prediabetic and prehypertensive compared to the younger age people (18-30 years) and the poorest family (respectively).

CONCLUSION

The coexistence of prediabetes and prehypertension is an early sign of a greater burden of noncommunicable diseases (NCDs) in the near future for Bangladesh. To reduce the higher burden of NCDs, our findings call for a multisectoral approach to identify the precondition of NCDs with particular attention to maintaining body weight.

MAFLD and Glomerular Hyperfiltration in Subjects with Prediabetes, Visceral Obesity and "Preserved" Kidney Function:A Cross-Sectional Study

AIMS

To investigate the prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) in prediabetes, visceral obesity, and preserved kidney function, and explore whether MAFLD is associated with hyperfiltration.

METHODS

We analyzed data from 6697 Spanish civil servants, aged 18-65 years, with fasting plasma glucose ≥100 and ≤125 mg/dL (prediabetes, ADA), waist circumference ≥94 cm in men and ≥80 cm in women (visceral obesity, IDF) and de-indexed estimated glomerular filtration rate (eGFR) ≥60 mL/min, collected during occupational health visits. The association between MAFLD and hyperfiltration (eGFR >age- and sex-specific 95^th percentile) was tested by multivariable logistic regression analyses.

RESULTS

Overall, 4213 patients (62.9%) had MAFLD, and 330 (4.9%) were hyperfiltering. MAFLD was more frequent in hyperfiltering than in non-hyperfiltering subjects (86.4% vs 61.7%, P<0.001). BMI, waist circumference, systolic, diastolic, mean arterial pressure, and prevalence of hypertension were higher in hyperfiltering than in non-hyperfiltering subjects (P<0.05). MAFLD was independently associated with hyperfiltration, even after adjusting for common confounders [OR (95% CI): 3.36 (2.33-4.84), P<0.001]. In stratified analyses MAFLD potentiated age-related eGFR decline vs. non-MAFLD (P<0.001).

CONCLUSIONS

More than half of subjects with prediabetes, visceral obesity and eGFR ≥60 ml/min presented MAFLD that was associated with hyperfiltration and potentiated the age-related eGFR decline.

Machine Learning for Predicting Micro- and Macrovascular Complications in Individuals With Prediabetes or Diabetes: Retrospective Cohort Study

BACKGROUND

Micro- and macrovascular complications are a major burden for individuals with diabetes and can already arise in a prediabetic state. To allocate effective treatments and to possibly prevent these complications, identification of those at risk is essential.

OBJECTIVE

This study aimed to build machine learning (ML) models that predict the risk of developing a micro- or macrovascular complication in individuals with prediabetes or diabetes.

METHODS

In this study, we used electronic health records from Israel that contain information about demographics, biomarkers, medications, and disease codes; span from 2003 to 2013; and were queried to identify individuals with prediabetes or diabetes in 2008. Subsequently, we aimed to predict which of these individuals developed a micro- or macrovascular complication within the next 5 years. We included 3 microvascular complications: retinopathy, nephropathy, and neuropathy. In addition, we considered 3 macrovascular complications: peripheral vascular disease (PVD), cerebrovascular disease (CeVD), and cardiovascular disease (CVD). Complications were identified via disease codes, and, for nephropathy, the estimated glomerular filtration rate and albuminuria were considered additionally. Inclusion criteria were complete information on age and sex and on disease codes (or measurements of estimated glomerular filtration rate and albuminuria for nephropathy) until 2013 to account for patient dropout. Exclusion criteria for predicting a complication were diagnosis of this specific complication before or in 2008. In total, 105 predictors from demographics, biomarkers, medications, and disease codes were used to build the ML models. We compared 2 ML models: logistic regression and gradient-boosted decision trees (GBDTs). To explain the predictions of the GBDTs, we calculated Shapley additive explanations values.

RESULTS

Overall, 13,904 and 4259 individuals with prediabetes and diabetes, respectively, were identified in our underlying data set. For individuals with prediabetes, the areas under the receiver operating characteristic curve for logistic regression and GBDTs were, respectively, 0.657 and 0.681 (retinopathy), 0.807 and 0.815 (nephropathy), 0.727 and 0.706 (neuropathy), 0.730 and 0.727 (PVD), 0.687 and 0.693 (CeVD), and 0.707 and 0.705 (CVD); for individuals with diabetes, the areas under the receiver operating characteristic curve were, respectively, 0.673 and 0.726 (retinopathy), 0.763 and 0.775 (nephropathy), 0.745 and 0.771 (neuropathy), 0.698 and 0.715 (PVD), 0.651 and 0.646 (CeVD), and 0.686 and 0.680 (CVD). Overall, the prediction performance is comparable for logistic regression and GBDTs. The Shapley additive explanations values showed that increased levels of blood glucose, glycated hemoglobin, and serum creatinine are risk factors for microvascular complications. Age and hypertension were associated with an elevated risk for macrovascular complications.

CONCLUSIONS

Our ML models allow for an identification of individuals with prediabetes or diabetes who are at increased risk of developing micro- or macrovascular complications. The prediction performance varied across complications and target populations but was in an acceptable range for most prediction tasks.

Associations Among Biomarkers of Inflammation, Tubular Injury and Lipid Metabolism With Gestational Diabetes Mellitus Status, Microalbuminuria and Retinopathy in the Microalbuminuria and Retinopathy in Gestational Diabetes Study

OBJECTIVES

Pregnancy may be complicated by gestational diabetes mellitus (GDM) and/or microvascular complications like albuminuria, retinopathy and pre-eclampsia. In this study we aimed to identify whether mechanistic pathways associated with microvascular complications are active in pregnant women with GDM or microvascular disease.

METHODS

Urinary albumin excretion and biomarkers of inflammation, lipoprotein metabolism and tubular injury were quantified in 355 pregnant women with and without GDM. Participants underwent fundus photography graded for retinopathy. Adjusted associations between individual biomarkers and each outcome variable of interest, including GDM status, albuminuria and retinopathy, were performed using logistic regression.

RESULTS

After adjusting for age, systolic blood pressure, body mass index and ethnicity, significant associations between GDM status and apolipoprotein A1, interleukin (IL)-6, IL-8, soluble tumour necrosis factor receptor-I and -II (sTNFR-I and -II), vascular endothelial growth factor and von Willebrand factor were observed. Increased high-sensitivity C-reactive protein (hsCRP) and sTNFR-II were associated with higher levels of albuminuria. hsCRP and previous GDM were associated with retinopathy.

CONCLUSION

Mechanistic pathways associated with microvascular complications appear to be active in pregnant women with GDM or microvascular disease.

Patient Perspectives on a Targeted Text Messaging Campaign to Encourage Screening for Diabetes: Qualitative Study

BACKGROUND

A sizeable proportion of prediabetes and diabetes cases among adults in the United States remain undiagnosed. Patient-facing clinical decision support (CDS) tools that leverage electronic health records (EHRs) have the potential to increase diabetes screening. Given the widespread mobile phone ownership across diverse groups, text messages present a viable mode for delivering alerts directly to patients. The use of unsolicited text messages to offer hemoglobin A_1c (HbA_1c) screening has not yet been studied. It is imperative to gauge perceptions of "cold texts" to ensure that information and language are optimized to promote engagement with text messages that affect follow-through with health behaviors.

OBJECTIVE

This study aims to gauge the perceptions of and receptiveness to text messages to inform content that would facilitate engagement with text messages intended to initiate a mobile health (mHealth) intervention for targeted screening. Messages were designed to invite those not already diagnosed with diabetes to make a decision to take part in HbA_1c screening and walk them through the steps required to perform the behavior based solely on an automated text exchange.

METHODS

In total, 6 focus groups were conducted at Wake Forest Baptist Health (WFBH) between September 2019 and February 2020. The participants were adult patients without diabetes who had completed an in-person visit at the Family and Community Medicine Clinic within the previous year. We displayed a series of text messages and asked the participants to react to the message content and suggest improvements. Content was deductively coded with respect to the Health Belief Model (HBM) and inductively coded to identify other emergent themes that could potentially impact engagement with text messages.

RESULTS

Participants (N=36) were generally receptive to the idea of receiving a text-based alert for HbA_1c screening. Plain language, personalization, and content, which highlighted perceived benefits over perceived susceptibility and perceived severity, were important to participants' understanding of and receptiveness to messages. The patient-physician relationship emerged as a recurring theme in which patients either had a desire or held an assumption that their provider would be working behind the scenes throughout each step of the process. Participants needed further clarification to understand the steps involved in following through with HbA_1c screening and receiving results.

CONCLUSIONS

Our findings suggest that patients may be receptive to text messages that alert them to a risk of having an elevated HbA_1c in direct-to-patient alerts that use cold texting. Using plain and positive language, integrating elements of personalization, and defining new processes clearly were identified by participants as modifiable content elements that could act as facilitators that would help overcome barriers to engagement with these messages. A patient's relationship with their provider and the financial costs associated with texts and screening may affect receptiveness and engagement in this process.

Addressing the Continuum of Dysglycaemia and Vascular Complications in Prediabetes and Type 2 Diabetes: Need for Early and Intensive Treatment

The onset of type 2 diabetes increases the risk of vascular complications and death. We know now that that this risk begins long before the diabetes diagnosis. Prediabetes and type 2 diabetes are not separate entities in practice and exist within a continuum of dysglycaemia and vascular risk that increases in severity over time. This excess risk requires early intervention with lifestyle therapy supported with pharmacologic antidiabetic therapy, intensified promptly where necessary throughout the duration of the diabetes continuum. Metformin is an evidence-based treatment for preventing prediabetes and improves cardiovascular outcomes in people with type 2 diabetes from diagnosis onwards. Newer agents (SGLT2 inhibitors and GLP-1 agonists) are appropriate for people presenting with type 2 diabetes and significant cardiovascular comorbidity. Additional therapies should be used without delay to achieve patients' individualised HbA1c goals and to minimise cardiovascular risk.

2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Metformin is associated with reduced COVID-19 severity in patients with prediabetes

AIMS

Studies suggest that metformin is associated with reduced COVID-19 severity in individuals with diabetes compared to other antihyperglycemics. We assessed if metformin is associated with reduced incidence of severe COVID-19 for patients with prediabetes or polycystic ovary syndrome (PCOS), common diseases that increase the risk of severe COVID-19.

METHODS

This observational, retrospective study utilized EHR data from 52 hospitals for COVID-19 patients with PCOS or prediabetes treated with metformin or levothyroxine/ondansetron (controls). After balancing via inverse probability score weighting, associations with COVID-19 severity were assessed by logistic regression.

RESULTS

In the prediabetes cohort, when compared to levothyroxine, metformin was associated with a significantly lower incidence of COVID-19 with "mild-ED" or worse (OR [95% CI]: 0.636, [0.455-0.888]) and "moderate" or worse severity (0.493 [0.339-0.718]). Compared to ondansetron, metformin was associated with lower incidence of "mild-ED" or worse severity (0.039 [0.026-0.057]), "moderate" or worse (0.045 [0.03-0.069]), "severe" or worse (0.183 [0.077-0.431]), and "mortality/hospice" (0.223 [0.071-0.694]). For PCOS, metformin showed no significant differences in severity compared to levothyroxine, but was associated with a significantly lower incidence of "mild-ED" or worse (0.101 [0.061-0.166]), and "moderate" or worse (0.094 [0.049-0.18]) COVID-19 outcome compared to ondansetron.

CONCLUSIONS

Metformin use is associated with less severe COVID-19 in patients with prediabetes or PCOS.

The clinical implications of pre-liver transplant diabetes on post-liver transplant outcomes in patients with NASH: analysis of the UNOS database

BACKGROUND AND AIMS

The presence of perioperative diabetes may lead to increased mortality risks following liver transplant (LT) in patients with non-alcoholic steatohepatitis (NASH). This risk factor was evaluated using a UNOS-STAR national database.

METHODS

The UNOS-STAR liver transplant registry 2005-2019 was used to select patients with NASH (including cryptogenic liver disease). The following populations were excluded: those younger than 18 years old and those with living donors/dual transplants. Selected patients were stratified into those with and without pre-LT diabetes and compared to the individual mortality endpoints using iterative Cox analyses.

RESULTS

6324 recipients with and 8251 without diabetes were selected. The median follow-up time was 3.07 years. Those with diabetes were older (58.50 vs. 54.50 years, p < 0.001), were more likely to be Hispanic or Asian, and had higher BMI than the non-diabetics (31.10 vs. 29.70 kg/m² p < 0.001); however, there was no difference in gender (female 41.9 vs. 43.1% p = 0.170). Compared to non-diabetics, recipients with diabetes had a higher rate of all-cause mortality (61.68 vs. 47.80 per 1000 person-years). In multivariate iterations, pre-LT diabetes was associated with all-cause mortality (aHR 1.19 95% CI 1.11-1.27) as well as deaths due to cardiac (p = 0.014 aHR 1.24 95% CI 1.04-1.46) and renal causes (p = 0.039 aHR 1.38 95% CI 1.02-1.87).

CONCLUSION

The presence of pre-LT diabetes is associated with all-cause mortality and deaths due to cardiac and renal causes following LT. The findings warrant an early preoperative screening procedure to ensure that patients with diabetes have their metabolic risk factors optimized prior to LT.

Prevalence and correlates of pre-diabetes in adults of mixed ethnicities in the South African population: A systematic review and meta-analysis

INTRODUCTION

Pre-diabetes is a metabolic condition characterised by moderate glycaemic dysregulation and is a frontline risk factor for multiple metabolic complications such as type 2 diabetes mellitus. To the best of our knowledge, this will be the first systematic review and meta-analysis focusing on generating a comprehensive pooling of studies reporting on pre-diabetes prevalence in South Africa. Therefore, the review's purpose will be to screen and select reports that can be used to synthesise and provide the best estimate prevalence of pre-diabetes and its associated correlates in the South African population.

METHODS AND ANALYSIS

To determine the prevalence and correlates of pre-diabetes in South Africa, we searched PubMed, Web of Science, Google scholar and African Journal online for published or unpublished studies reporting the prevalence of pre-diabetes in South Africa starting from the year 2000 to 2020. Studies were assessed for eligibility by checking if they met the inclusion criteria.

RESULTS & CONCLUSION

The total number of studies deemed eligible is 13 and from these studies, an overall prevalence of pre-diabetes was reported to be 15,56% in the South African population. Hypertension, obesity and sedentary lifestyle were the common correlates recorded for the population of interest. Therefore, the review highlights the disturbingly high prevalence of pre-diabetes in South Africa and necessitates further investigations into the possible genetics, biochemical and hormonal changes in pre-diabetes.

ETHICS AND DISSEMINATION

The review will not require ethics clearance because non-identifiable data will be used. The review outcomes will give insight into the current burden that pre-diabetes has in South Africa.

PROSPERO REGISTRATION NUMBER

CRD42020182430.

Vascular complications in prediabetes and type 2 diabetes: a continuous process arising from a common pathology

The term, "prediabetes", describes a state of hyperglycaemia that is intermediate between true normoglycaemia and the diagnostic cut-offs for indices of glycaemia that are used to diagnose type 2 diabetes. The presence of prediabetes markedly increases the risk of developing type 2 diabetes. Numerous randomized, controlled evaluations of various agents have demonstrated significant prevention or delay of the onset of type 2 diabetes in subjects with prediabetes. Intensive lifestyle interventions and metformin have been studied most widely, with the lifestyle intervention being more effective in the majority of subjects. The application of therapeutic interventions at the time of prediabetes to preserve long-term outcomes has been controversial, however, due to a lack of evidence relating to the pathogenic effects of prediabetes and the effectiveness of interventions to produce a long-term clinical benefit. Recent studies have confirmed that prediabetes, however defined, is associated with a significantly increased risk of macrovascular and microvascular complications essentially identical to those of diabetes, and also with subclinical derangements of the function of microvasculature and neurons that likely signify increased risk of compilations in future. Normoglycaemia, prediabetes and type 2 diabetes appear to be part of a continuum of increased risk of adverse outcomes. Long-term (25-30 years) post-trial follow up of two major diabetes prevention trials have shown that short-term interventions to prevent diabetes lead to long-term reductions in the risk of complications. These findings support the concept of therapeutic intervention to preserve long-term health in people with prediabetes before type 2 diabetes becomes established.

Metformin is Associated with Reduced COVID-19 Severity in Patients with Prediabetes

Background

With the continuing COVID-19 pandemic, identifying medications that improve COVID-19 outcomes is crucial. Studies suggest that use of metformin, an oral antihyperglycemic, is associated with reduced COVID-19 severity in individuals with diabetes compared to other antihyperglycemic medications. Some patients without diabetes, including those with polycystic ovary syndrome (PCOS) and prediabetes, are prescribed metformin for off-label use, which provides an opportunity to further investigate the effect of metformin on COVID-19.

Participants

In this observational, retrospective analysis, we leveraged the harmonized electronic health record data from 53 hospitals to construct cohorts of COVID-19 positive, metformin users without diabetes and propensity-weighted control users of levothyroxine (a medication for hypothyroidism that is not known to affect COVID-19 outcome) who had either PCOS (n = 282) or prediabetes (n = 3136). The primary outcome of interest was COVID-19 severity, which was classified as: mild, mild ED (emergency department), moderate, severe, or mortality/hospice.

Results

In the prediabetes cohort, metformin use was associated with a lower rate of COVID-19 with severity of mild ED or worse (OR: 0.630, 95% CI 0.450 - 0.882, p < 0.05) and a lower rate of COVID-19 with severity of moderate or worse (OR: 0.490, 95% CI 0.336 - 0.715, p < 0.001). In patients with PCOS, we found no significant association between metformin use and COVID-19 severity, although the number of patients was relatively small.

Conclusions

Metformin was associated with less severe COVID-19 in patients with prediabetes, as seen in previous studies of patients with diabetes. This is an important finding, since prediabetes affects between 19 and 38% of the US population, and COVID-19 is an ongoing public health emergency. Further observational and prospective studies will clarify the relationship between metformin and COVID-19 severity in patients with prediabetes, and whether metformin usage may reduce COVID-19 severity.

The effects of omega-3 fatty acids in type 2 diabetes: A systematic review and meta-analysis

BACKGROUND

The effect of omega-3 polyunsaturated fatty acids (n-3 PUFAs), such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on cardiovascular risk modification in type 2 diabetes and related complications remain unclear. We aim to assess the published effects of n-3 PUFA interventions on lipid risk factors in type 2 diabetes.

METHODS

We searched the literature on Pubmed, Embase, CENTRAL, and Web of Science databases in order to perform a pooled analysis of randomized clinical trials (RCTs) assessing n-3 PUFA interventions in type 2 diabetes. The primary outcomes analyzed were the effect of n -3 PUFAs on metabolic biomarkers in type 2 diabetes.

RESULTS

46 RCTs involving 4991 patients with type 2 diabetes were identified for further analysis. Analysis of results showed that n-3 PUFAs interventions significantly improved total cholesterol (TC, WMD = -0.22; 95% CI: -0.32∼ -0.11), triglyceride (TG,WMD = -0.36; 95% CI: -0.48∼-0.25), high-density lipoprotein cholesterol (HDL-C,WMD = 0.05; 95% CI: 0.02∼ 0.08), hemoglobin A1c (HbA1c, WMD = -0.19; 95% CI: -0.31∼-0.06) and C-reactive protein (CRP,WMD = -0.40; 95% CI: -0.74∼-0.07) levels compared to controls (p < 0.05). There was no significant effect on renal function, fasting blood sugar (FBS), insulin resistance (HOMA-IR), low-density lipoprotein cholesterol (LDL-C), adiponectin and leptin (p > 0.05).

CONCLUSIONS

The results of this systematic review suggest that n-3 PUFAs can improve cardiovascular risk factors in type 2 diabetes.

Association of prediabetes with death and diabetic complications in older adults: the pros and cons of active screening for prediabetes

BACKGROUND

active screening can improve health outcomes for people with prediabetes. However, its efficacy in older adults remains uncertain.

OBJECTIVE

the study aimed to analyse the progression from prediabetes to diabetes in older adults, including associated complications and mortality rates, to determine the benefits of active screening.

DESIGN

retrospective cohort study.

SETTING

Korean National Health Insurance Service claims database.

SUBJECTS

a total of 36,946 adults aged ≥65 years who underwent national health examinations from 2006 to 2008.

METHODS

follow-up was until 31 December 2015. Cox's proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for death and diabetic complications.

RESULTS

over a median follow-up of 8.2 years, 19.3% of older adults with prediabetes progressed to diabetes. Compared with normoglycaemic adults, the multivariable-adjusted HRs (95% CI) for major adverse cardiovascular events were 1.01 (0.95-1.07), 1.08 (0.95-1.23), 1.14 (1.05-1.23) and 1.50 (1.35-1.68) in adults with prediabetes, newly diagnosed diabetes, diabetes not on insulin and diabetes on insulin, respectively. The corresponding HRs (95% CI) for diabetic retinopathy risk were 1.28 (1.15-1.43), 3.16 (2.71-3.69), 6.58 (6.02-7.19) and 9.17 (8.21-10.24). Diabetic nephropathy risk also significantly increased.

CONCLUSIONS

progression from prediabetes to diabetes is an important concern among older adults. Prediabetes is associated with the risk of microvascular complications, but not cardiovascular complications and mortality. Therefore, active regular screening for prediabetes is necessary to prevent microvascular complications.

Prediabetes and risk of mortality, diabetes-related complications and comorbidities: umbrella review of meta-analyses of prospective studies

AIMS/HYPOTHESIS

The term prediabetes is used for individuals who have impaired glucose metabolism whose glucose or HbA_1c levels are not yet high enough to be diagnosed as diabetes. Prediabetes may already be associated with an increased risk of chronic 'diabetes-related' complications. This umbrella review aimed to provide a systematic overview of the available evidence from meta-analyses of prospective observational studies on the associations between prediabetes and incident diabetes-related complications in adults and to evaluate their strength and certainty.

METHODS

For this umbrella review, systematic reviews with meta-analyses reporting summary risk estimates for the associations between prediabetes (based on fasting or 2 h postload glucose or on HbA_1c) and incidence of diabetes-related complications, comorbidities and mortality risk were included. PubMed, Web of Science, the Cochrane Library and Epistemonikos were searched up to 17 June 2021. Summary risk estimates were recalculated using a random effects model. The certainty of evidence was evaluated by applying the GRADE tool. This study is registered with PROSPERO, CRD42020153227.

RESULTS

Ninety-five meta-analyses from 16 publications were identified. In the general population, prediabetes was associated with a 6-101% increased risk for all-cause mortality and the incidence of cardiovascular outcomes, CHD, stroke, heart failure, atrial fibrillation and chronic kidney disease, as well as total cancer, total liver cancer, hepatocellular carcinoma, breast cancer and all-cause dementia with moderate certainty of evidence. No associations between prediabetes and incident depressive symptoms and cognitive impairment were observed (with low or very low certainty of evidence). The association with all-cause mortality was stronger for prediabetes defined by impaired glucose tolerance than for prediabetes defined by HbA_1c.

CONCLUSIONS/INTERPRETATION

Prediabetes was positively associated with risk of all-cause mortality and the incidence of cardiovascular outcomes, CHD, stroke, chronic kidney disease, cancer and dementia. Further high-quality studies, particularly on HbA_1c-defined prediabetes and other relevant health outcomes (e. g. neuropathy) are required to support the evidence.

Prevalence of microvascular and macrovascular complications of diabetes in newly diagnosed type 2 diabetes in low-and-middle-income countries: A systematic review and meta-analysis

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings.

DR1 Activation Inhibits the Proliferation of Vascular Smooth Muscle Cells through Increasing Endogenous H2S in Diabetes

Tissue ischemia and hypoxia caused by the abnormal proliferation of smooth muscle cells (SMCs) in the diabetic state is an important pathological basis for diabetic microangiopathy. Studies in recent years have shown that the chronic complications of diabetes are related to the decrease of endogenous hydrogen sulfide (H₂S) in diabetic patients, and it has been proven that H₂S can inhibit the proliferation of vascular SMCs (VSMCs). Our study showed that the endogenous H₂S content and the expression of cystathionine gamma-lyase (CSE), which is the key enzyme of H₂S production, were decreased in arterial SMCs of diabetic mice. The expression of PCNA and Cyclin D1 was increased, and the expression of p21 was decreased in the diabetic state. After administration of dopamine 1-like receptors (DR1) agonist SKF38393 and exogenous H₂S donor NaHS, the expression of CSE was increased and the change in proliferation-related proteins caused by diabetes was reversed. It was further verified by cell experiments that SKF38393 activated calmodulin (CaM) by increasing the intracellular calcium ([Ca²⁺]_i) concentration, which activated the CSE/H₂S pathway, enhancing the H₂S content in vivo. We also found that SKF38393 and NaHS inhibited insulin-like growth factor-1 (IGF-1)/IGF-1R and heparin-binding EGF-like growth factor (HB-EGF)/EGFR, as well as their downstream PI3K/Akt, JAK2/STAT3 and ERK1/2 pathways. Taken together, our results suggest that DR1 activation up-regulates the CSE/H₂S system by increasing Ca²⁺-CaM binding, which inhibits the IGF-1/IGF-1R and HB-EGF/EGFR pathways, thereby decreasing their downstream PI3K/Akt, JAK2/STAT3 and ERK1/2 pathways to achieve the effect of inhibiting HG-induced VSMCs proliferation.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission

AIMS/HYPOTHESIS

Weight reduction is fundamental for type 2 diabetes management and remission, but uncertainty exists over which diet type is best to achieve and maintain weight loss. We evaluated dietary approaches for weight loss, and remission, in people with type 2 diabetes to inform practice and clinical guidelines.

METHODS

First, we conducted a systematic review of published meta-analyses of RCTs of weight-loss diets. We searched MEDLINE (Ovid), PubMed, Web of Science and Cochrane Database of Systematic Reviews, up to 7 May 2021. We synthesised weight loss findings stratified by diet types and assessed meta-analyses quality with A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2. We assessed certainty of pooled results of each meta-analysis using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (PROSPERO CRD42020169258). Second, we conducted a systematic review of any intervention studies reporting type 2 diabetes remission with weight-loss diets, in MEDLINE (via PubMed), Embase and Cochrane Central Register of Controlled Trials, up to 10 May 2021. Findings were synthesised by diet type and study quality (Cochrane Risk of Bias tool 2.0 and Risk Of Bias In Non-randomised Studies - of Interventions [ROBINS-I]), with GRADE applied (PROSPERO CRD42020208878).

RESULTS

We identified 19 meta-analyses of weight-loss diets, involving 2-23 primary trials (n = 100-1587), published 2013-2021. Twelve were 'critically low' or 'low' AMSTAR 2 quality, with seven 'high' quality. Greatest weight loss was reported with very low energy diets, 1.7-2.1 MJ/day (400-500 kcal) for 8-12 weeks (high-quality meta-analysis, GRADE low), achieving 6.6 kg (95% CI -9.5, -3.7) greater weight loss than low-energy diets (4.2-6.3 MJ/day [1000-1500 kcal]). Formula meal replacements (high quality, GRADE moderate) achieved 2.4 kg (95% CI -3.3, -1.4) greater weight loss over 12-52 weeks. Low-carbohydrate diets were no better for weight loss than higher-carbohydrate/low-fat diets (high quality, GRADE high). High-protein, Mediterranean, high-monounsaturated-fatty-acid, vegetarian and low-glycaemic-index diets all achieved minimal (0.3-2 kg) or no difference from control diets (low to critically low quality, GRADE very low/moderate). For type 2 diabetes remission, of 373 records, 16 met inclusion criteria. Remissions at 1 year were reported for a median 54% of participants in RCTs including initial low-energy total diet replacement (low-risk-of-bias study, GRADE high), and 11% and 15% for meal replacements and Mediterranean diets, respectively (some concerns for risk of bias in studies, GRADE moderate/low). For ketogenic/very low-carbohydrate and very low-energy food-based diets, the evidence for remission (20% and 22%, respectively) has serious and critical risk of bias, and GRADE certainty is very low.

CONCLUSIONS/INTERPRETATION

Published meta-analyses of hypocaloric diets for weight management in people with type 2 diabetes do not support any particular macronutrient profile or style over others. Very low energy diets and formula meal replacement appear the most effective approaches, generally providing less energy than self-administered food-based diets. Programmes including a hypocaloric formula 'total diet replacement' induction phase were most effective for type 2 diabetes remission. Most of the evidence is restricted to 1 year or less. Well-conducted research is needed to assess longer-term impacts on weight, glycaemic control, clinical outcomes and diabetes complications.

Interface of Multiple Sclerosis, Depression, Vascular Disease, and Mortality: A Population-Based Matched Cohort Study

Background and Objectives

To assess whether the association among depression, vascular disease, and mortality differs in people with multiple sclerosis (MS) compared with age-, sex-, and general practice–matched controls.

Methods

We conducted a population-based retrospective matched cohort study between January 1, 1987, and September 30, 2018, that included people with MS and matched controls without MS from England, stratified by depression status. We used time-varying Cox proportional hazard regression models to test the association among MS, depression, and time to incident vascular disease and mortality. Analyses were also stratified by sex.

Results

We identified 12,251 people with MS and 72,572 matched controls. At baseline, 21% of people with MS and 9% of controls had depression. Compared with matched controls without depression, people with MS had an increased risk of incident vascular disease regardless of whether they had comorbid depression. The 10-year hazard of all-cause mortality was 1.75-fold greater in controls with depression (95% confidence interval [CI] 1.59–1.91), 3.88-fold greater in people with MS without depression (95% CI 3.66–4.10), and 5.43-fold greater in people with MS and depression (95% CI 4.88–5.96). Overall, the interaction between MS status and depression was synergistic, with 14% of the observed effect attributable to the interaction. Sex-stratified analyses confirmed differences in hazard ratios.

Discussion

Depression is associated with increased risks of incident vascular disease and mortality in people with MS, and the effects of depression and MS on all-cause mortality are synergistic. Further studies should evaluate whether effectively treating depression is associated with a reduced risk of vascular disease and mortality.

Factors Behind the Higher COVID-19 Risk in Diabetes: A Critical Review

Diabetes mellitus (DM) and coronavirus disease 2019 (COVID-19) are public health issues worldwide, and their comorbidities trigger the progress to severe disease and even death in such patients. Globally, DM has affected an estimated 9.3% adults, and as of April 18, 2021, the World Health Organization (WHO) has confirmed 141,727,940 COVID-19 confirmed cases. The virus is spread via droplets, aerosols, and direct touch with others. Numerous predictive factors have been linked to COVID-19 severity, including impaired immune response and increased inflammatory response, among others. Angiotensin receptor blockers and angiotensin converting enzyme 2 have also been identified as playing a boosting role in both susceptibility and severity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Specifically, in DM patients, both their control and management during this pandemic is herculean as the restriction periods have markedly hampered the maintenance of means to control glycemia, hypertension, and neuroendocrine and kidney diseases. In addition, as a result of the underlyin cardio-metabolic and immunological disorders, DM patients are at a higher risk of developing the severe form of COVID-19 despite other comorbidities, such as hypertension, also potentially boosting the development of higher COVID-19 severity. However, even in non-DM patients, SARS-CoV-2 may also cause transient hyperglycemia through induction of insulin resistance and/or pancreatic β-cell injury. Therefore, a strict glucose monitoring of DM patients with COVID-19 is mandatory to prevent life-threatening complications.

A Cardiovascular Risk Score for Use in Occupational Medicine

Cardiovascular disease is one of the most frequent causes of long-term sickness absence from work. The study aims to develop and validate a score to assess the 10-year risk of unsuitability for work accounting for the cardiovascular risk. The score can be considered as a prevention tool that would improve the cardiovascular risk assessment during health surveillance visits under the assumption that a high cardiovascular risk might also translate into high risk of unsuitability for work. A total of 11,079 Italian workers were examined, as part of their scheduled occupational health surveillance. Cox proportional hazards regression models were employed to derive risk equations for assessing the 10-year risk of a diagnosis of unsuitability for work. Two scores were developed: the CROMA score (Cardiovascular Risk in Occupational Medicine) included age, sex, smoking status, blood pressure (systolic and diastolic), body mass index, height, diagnosis of hypertension, diabetes, ischemic heart disease, mental disorders and prescription of antidiabetic and antihypertensive medications. The CROMB score was the same as CROMA score except for the inclusion of only variables statistically significant at the 0.05 level. For both scores, the expected risk of unsuitability for work was higher for workers in the highest risk class, as compared with the lowest. Moreover results showed a positive association between most of cardiovascular risk factors and the risk of unsuitability for work. The CROMA score demonstrated better calibration than the CROMB score (11.624 (p-value: 0.235)). Moreover, the CROMA score, in comparison with existing CVD risk scores, showed the best goodness of fit and discrimination.

Different Curve Shapes of Fasting Glucose and Various Obesity-Related Indices by Diabetes and Sex

Fasting plasma glucose (FPG) and obesity-related indices are prognostic factors for adverse outcomes in both subjects with and without diabetes. A few studies have investigated sex differences in obesity indices related to the risk of diabetes, however no studies have compared the relationship between FPG and obesity-related indices by diabetes and sex. Therefore, in this study, we compared the curve shapes of FPG and various obesity-related indices by diabetes, and further explored sex differences in these associations. Data were derived from the Taiwan Biobank database, which included 5000 registered individuals. We used an adjusted generalized linear regression model and calculated the difference of least square means (Lsmean; standard error, SE) for males and females with and without diabetes. Associations between obesity-related indices and fasting glucose level by diabetes and sex groups were estimated, and the ORTHOREG procedure was used to construct B-splines. The post-fitting for linear models procedure was used to determine the range at which the trends separated significantly. The diabetes/sex/FPG interaction term was significant for all obesity-related indices, including body mass index, waist circumference, hip circumference, waist-to-hip ratio, waist-to-height ratio, lipid accumulation product, body roundness index, conicity index, body adiposity index and abdominal volume index. B-spline comparisons between males and females did not reach significance. However, FPG affected the trend towards obesity-related indices. As the fasting glucose level increased, the values of obesity-related indices varied more obviously in the participants without diabetes than in those with diabetes mellitus. The current study revealed that there was a different relationship between FPG and obesity-related indices by diabetes and sex. FPG affected the trend towards obesity-related indices more obviously in participants without diabetes than in those with diabetes. Further studies with a longitudinal design would provide a better understanding of the underlying mechanisms for the relationships.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Approach to the cardiometabolic continuum. Narrative description

Atherosclerotic cardiovascular disease (ACVD) is the major adverse outcome in the evolution of several metabolic conditions. For around several decades, the cardiovascular continuum has been used as a fantastic tool to explain the evolution of ACVD from the onset of risk factor, to clinical outcomes, and to death. Nowadays, metabolic diseases such as obesity, prediabetes, and type2 diabetes have been increasing enough to become serious public health problems and notorious contributors to the morbidity and mortality rates due to ACVD, including arterial hypertension. Other conditions seem to increase the list, such as: physical inactivity with its metabolic cluster, sarcopenia, and non-alcoholic fatty liver disease (NAFLD). Moreover, obesity in childhood has been growing at an exponential rate so the excess of adiposity in children and adolescents will translate into an excess of cardiometabolic risk in adults. Several longitudinal studies confirm the strong association of paediatric obesity with the persistence of adult obesity, as well as the future development of cardiometabolic conditions, such as prediabetes, diabetes, obesity, increased risk of arterial hypertension, and ACVD. Therefore, it is time to conceptualise the cardiometabolic continuum as a tool of an early, wider and preventive intervention in order to reduce the morbidity and mortality due to ACVD.

The contribution of diabetic micro-angiopathy to adverse outcomes in COVID-19

Increasing evidence points to endothelial cell dysfunction as a key pathophysiological factor in severe coronavirus disease-19 (COVID-19), manifested by platelet aggregation, microthrombi and altered vasomotor tone. This may be driven by direct endothelial cell entry by the virus, or indirectly by activated inflammatory cascade. Major risk groups identified for adverse outcomes in COVID-19 are diabetes, and those from the Black, Asian and ethnic minority (BAME) populations. Hyperglycaemia (expressed as glycated haemoglobin or mean hospital glucose) correlates with worse outcomes in COVID-19. It is not known whether hyperglycaemia is causative or is a surrogate marker - persistent hyperglycaemia is well known as an aetiological agent in microangiopathy. In this article, we propose that pre-existing endothelial dysfunction of microangiopathy, more commonly evident in diabetes and BAME groups, makes an individual vulnerable to the subsequent 'endothelitis' of COVID-19 infection.