Type 2 Diabetes: When Does It Start?

Association of single-point insulin sensitivity estimator index (SPISE) with future cardiovascular outcomes in patients with type 2 diabetes

AIMS

To investigate the association of single-point insulin sensitivity estimator (SPISE) index with future cardiovascular outcomes in patients with type 2 diabetes.

MATERIALS AND METHODS

SPISE index (= 600 × high-density lipoprotein cholesterol [mg/dL]0.185/triglycerides [mg/dL]0.2 × body mass index [kg/m2]1.338) was calculated in 10 190 participants. Cox proportional hazard regression models were applied to evaluate the association between SPISE index and future cardiovascular outcomes. Restricted cubic spline analyses and two-piecewise linear regression models were employed to explore the nonlinear association and to determine the threshold value. Subgroup and interaction analyses were conducted to test the robustness of the results.

RESULTS

After fully adjusting for well-established metabolic confounders, higher SPISE index was significantly associated with lower risk of future cardiovascular outcomes in patients with type 2 diabetes (major adverse cardiovascular event [MACE]): hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.98, p = 0.0026; overall mortality: HR 0.90, 95% CI 0.86-0.93, p < 0.0001; cardiovascular disease [CVD] mortality: HR 0.85, 95% CI 0.79-0.92, p < 0.0001; congestive heart failure (CHF): HR 0.72, 95% CI 0.67-0.78, p < 0.0001; major coronary events: HR 0.91, 95% CI 0.87-0.95, p < 0.0001. There was a nonlinear association between SPISE index and future cardiovascular outcomes (the threshold value was 5.68 for MACE, 5.71 for overall mortality, 4.64 for CVD mortality, 4.48 for CHF, and 6.09 for major coronary events, respectively).

CONCLUSIONS

Higher SPISE index was independently associated with lower risk of future cardiovascular outcomes in type 2 diabetes patients after full adjustment for well-established metabolic confounders.

The single point insulin sensitivity estimator (SPISE) index as a predictor of metabolic syndrome in Korean adults

PURPOSE

Recently, the single-point insulin sensitivity estimator (SPISE) has been developed as a simple surrogate of insulin resistance based on BMI, triglycerides (TG), and HDL-C. However, no studies have focused on the predictive power of the SPISE index for identifying metabolic syndrome (MetSyn) in Korean adults. Here, this study aimed to estimate the predictive power of the SPISE index for determining MetSyn and to compare its predictive power with other insulin sensitivity/resistance indices in South Korean adults.

METHODS

A total of 7837 participants from the 2019 and 2020 Korean National Health and Nutrition Examination Surveys were analyzed in the present study. MetSyn was defined by the AHA/NCEP criteria. In addition, HOMA-IR, inverse insulin, TG/HDL, TyG index (triglyceride-glucose index), and SPISE index were calculated based on the previous literature.

RESULTS

Predictive power of the SPISE index for determining MetSyn (ROC-AUC [95 % CI] = 0.90 [0.90-0.91], sensitivity = 83.4 %, specificity = 82.2 %, cut-off point = 6.14, p < .001) was higher than that of HOMA-IR (ROC-AUC: 0.81), inverse insulin (ROC-AUC: 0.76), TG/HDL-C (ROC-AUC: 0.87), and TyG index (ROC-AUC: 0.88), the P value for ROC-AUC comparison < .001.

CONCLUSION

SPISE index has demonstrated superior predictive value for diagnosing MetSyn regardless of sex and is strongly correlated with blood pressure compared with other surrogate indices of insulin resistance, attesting to its utility as a reliable indicator of insulin resistance and MetSyn in Korean adults.

Prognostic factors for the development and progression of proliferative diabetic retinopathy in people with diabetic retinopathy

BACKGROUND

Diabetic retinopathy (DR) is characterised by neurovascular degeneration as a result of chronic hyperglycaemia. Proliferative diabetic retinopathy (PDR) is the most serious complication of DR and can lead to total (central and peripheral) visual loss. PDR is characterised by the presence of abnormal new blood vessels, so-called "new vessels," at the optic disc (NVD) or elsewhere in the retina (NVE). PDR can progress to high-risk characteristics (HRC) PDR (HRC-PDR), which is defined by the presence of NVD more than one-fourth to one-third disc area in size plus vitreous haemorrhage or pre-retinal haemorrhage, or vitreous haemorrhage or pre-retinal haemorrhage obscuring more than one disc area. In severe cases, fibrovascular membranes grow over the retinal surface and tractional retinal detachment with sight loss can occur, despite treatment. Although most, if not all, individuals with diabetes will develop DR if they live long enough, only some progress to the sight-threatening PDR stage.  OBJECTIVES: To determine risk factors for the development of PDR and HRC-PDR in people with diabetes and DR.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5), Ovid MEDLINE, and Ovid Embase. The date of the search was 27 May 2022. Additionally, the search was supplemented by screening reference lists of eligible articles. There were no restrictions to language or year of publication.  SELECTION CRITERIA: We included prospective or retrospective cohort studies and case-control longitudinal studies evaluating prognostic factors for the development and progression of PDR, in people who have not had previous treatment for DR. The target population consisted of adults (≥18 years of age) of any gender, sexual orientation, ethnicity, socioeconomic status, and geographical location, with non-proliferative diabetic retinopathy (NPDR) or PDR with less than HRC-PDR, diagnosed as per standard clinical practice. Two review authors independently screened titles and abstracts, and full-text articles, to determine eligibility; discrepancies were resolved through discussion. We considered prognostic factors measured at baseline and any other time points during the study and in any clinical setting. Outcomes were evaluated at three and eight years (± two years) or lifelong.  DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included studies using a data extraction form that we developed and piloted prior to the data collection stage. We resolved any discrepancies through discussion. We used the Quality in Prognosis Studies (QUIPS) tool to assess risk of bias. We conducted meta-analyses in clinically relevant groups using a random-effects approach. We reported hazard ratios (HR), odds ratios (OR), and risk ratios (RR) separately for each available prognostic factor and outcome, stratified by different time points. Where possible, we meta-analysed adjusted prognostic factors. We evaluated the certainty of the evidence with an adapted version of the GRADE framework.   MAIN RESULTS: We screened 6391 records. From these, we identified 59 studies (87 articles) as eligible for inclusion. Thirty-five were prospective cohort studies, 22 were retrospective studies, 18 of which were cohort and six were based on data from electronic registers, and two were retrospective case-control studies. Twenty-three studies evaluated participants with type 1 diabetes (T1D), 19 with type 2 diabetes (T2D), and 17 included mixed populations (T1D and T2D). Studies on T1D included between 39 and 3250 participants at baseline, followed up for one to 45 years. Studies on T2D included between 100 and 71,817 participants at baseline, followed up for one to 20 years. The studies on mixed populations of T1D and T2D ranged from 76 to 32,553 participants at baseline, followed up for four to 25 years.  We found evidence indicating that higher glycated haemoglobin (haemoglobin A1c (HbA1c)) levels (adjusted OR ranged from 1.11 (95% confidence interval (CI) 0.93 to 1.32) to 2.10 (95% CI 1.64 to 2.69) and more advanced stages of retinopathy (adjusted OR ranged from 1.38 (95% CI 1.29 to 1.48) to 12.40 (95% CI 5.31 to 28.98) are independent risk factors for the development of PDR in people with T1D and T2D. We rated the evidence for these factors as of moderate certainty because of moderate to high risk of bias in the studies.  There was also some evidence suggesting several markers for renal disease (for example, nephropathy (adjusted OR ranged from 1.58 (95% CI not reported) to 2.68 (2.09 to 3.42), and creatinine (adjusted meta-analysis HR 1.61 (95% CI 0.77 to 3.36)), and, in people with T1D, age at diagnosis of diabetes (< 12 years of age) (standardised regression estimate 1.62, 95% CI 1.06 to 2.48), increased triglyceride levels (adjusted RR 1.55, 95% CI 1.06 to 1.95), and larger retinal venular diameters (RR 4.28, 95% CI 1.50 to 12.19) may increase the risk of progression to PDR. The certainty of evidence for these factors, however, was low to very low, due to risk of bias in the included studies, inconsistency (lack of studies preventing the grading of consistency or variable outcomes), and imprecision (wide CIs). There was no substantial and consistent evidence to support duration of diabetes, systolic or diastolic blood pressure, total cholesterol, low- (LDL) and high- (HDL) density lipoproteins, gender, ethnicity, body mass index (BMI), socioeconomic status, or tobacco and alcohol consumption as being associated with incidence of PDR. There was insufficient evidence to evaluate prognostic factors associated with progression of PDR to HRC-PDR.  AUTHORS' CONCLUSIONS: Increased HbA1c is likely to be associated with progression to PDR; therefore, maintaining adequate glucose control throughout life, irrespective of stage of DR severity, may help to prevent progression to PDR and risk of its sight-threatening complications. Renal impairment in people with T1D or T2D, as well as younger age at diagnosis of diabetes mellitus (DM), increased triglyceride levels, and increased retinal venular diameters in people with T1D may also be associated with increased risk of progression to PDR. Given that more advanced DR severity is associated with higher risk of progression to PDR, the earlier the disease is identified, and the above systemic risk factors are controlled, the greater the chance of reducing the risk of PDR and saving sight.

Single Point Insulin Sensitivity Estimator (SPISE) As a Prognostic Marker for Emerging Dysglycemia in Children with Overweight or Obesity

The single point insulin sensitivity estimator (SPISE) is a recently developed fasting index for insulin sensitivity based on triglycerides, high density lipoprotein cholesterol, and body mass index. SPISE has been validated in juveniles and adults; still, its role during childhood remains unclear. To evaluate the age- and sex-specific distribution of SPISE, its correlation with established fasting indexes and its application as a prognostic marker for future dysglycemia during childhood and adolescence were assessed. We performed linear modeling and correlation analyses on a cross-sectional cohort of 2107 children and adolescents (age 5 to 18.4 years) with overweight or obesity. Furthermore, survival analyses were conducted upon a longitudinal cohort of 591 children with overweight/obesity (1712 observations) with a maximum follow-up time of nearly 20 years, targeting prediabetes/dysglycemia as the end point. The SPISE index decreased significantly with age (−0.34 units per year, p < 0.001) among children and adolescents with overweight and obesity. Sex did not have an influence on SPISE. There was a modest correlation between SPISE and established fasting markers of insulin resistance (R = −0.49 for HOMA-IR, R = −0.55 for QUICKI-IR). SPISE is a better prognostic marker for future dysglycemia (hazard ratio (HR) 3.47, 95% confidence interval (CI) 1.60−7.51, p < 0.01) than HOMA-IR and QUICKI-IR (HR 2.44, 95% CI 1.24−4.81, p < 0.05). The SPISE index is a surrogate marker for insulin resistance predicting emerging dysglycemia in children with overweight or obesity, and could, therefore, be applied to pediatric cohorts that lack direct insulin assessment.

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.

Time to Diagnosis and Treatment of Diabetes Mellitus among Korean Adults with Hyperglycemia: Using a Community-Based Cohort Study

OBJECTIVES

To identify the time from hyperglycemia to diabetes mellitus (DM) diagnosis and treatment, the risk factors for diabetes development, and the prevalence of comorbidities/complications in patients > 40 years of age.

METHODS

This secondary data analysis study used data from the Korean Genome and Epidemiology Study. The participants comprised 186 patients who did not have diabetes at baseline, but developed hyperglycemia at the first follow-up. The average and median periods until DM diagnosis and treatment were calculated using Kaplan-Meier survival analysis.

RESULTS

Of the 186 participants, 57.0% were men and 35.5% were 40-49 years old. The average time to DM diagnosis and treatment was 10.87 years and 11.34 years, respectively. The risk factors for the duration of DM were current smoking, body mass index (BMI), fasting blood sugar (FBS), and postprandial 2-hour glucose (PP2). The risk factors for the duration of diabetes treatment were current smoking, hypertension, BMI, FBS, and PP2. The development of one or more comorbidities or diabetes complications was identified at the time of DM diagnosis (36.5%) and DM treatment (41.4%).

CONCLUSIONS

As diabetes complications occur at the time of DM, and early treatment can impact the development of diabetes complications or mortality, it is necessary to establish a referral program so that participants presenting with high blood sugar levels in the screening program can be diagnosed and treated in a timely manner.

Single Point Insulin Sensitivity Estimator for predicting type 2 diabetes mellitus in obese adolescents

PURPOSE

The prevalence of adolescents with type 2 diabetes mellitus (T2DM) has rapidly increased in Korea over the past few decades with the increase in the number of obese adolescents. The single point insulin sensitivity estimator (SPISE) was recently introduced as a surrogate marker for insulin sensitivity to predict T2DM in adults. We aimed to determine risk factors for T2DM in obese adolescents, including SPISE.

METHODS

This retrospective study included 104 adolescents diagnosed with T2DM at Korea University Hospital between January 2010 and December 2020. We compared clinical and biochemical parameters and the SPISE of normoglycemic overweight and obese individuals with those of prediabetic and diabetic adolescents to determine risk factors for T2DM. Receiver operating characteristic analysis was performed with the Youden index to determine the cutoff point of SPISE.

RESULTS

Frequency of fatty liver and family history of T2DM were significantly higher and SPISE level was significantly lower in patients with T2DM than in normoglycemic overweight/obese and prediabetic adolescents (p<0.01). A family history of T2DM, fatty liver, and SPISE value below the cutoff point (4.49) were identified as significant risk factors for T2DM in multiple logistic regression analysis after controlling for age, sex, and body mass index standard deviation score (p<0.01).

CONCLUSION

Family history of T2DM, fatty liver, and low SPISE (<4.49) are risk factors that can independently affect the occurrence of T2DM in obese adolescents. Among these risk factors, SPISE is a promising marker for predicting adolescent T2DM; careful monitoring of these individuals is needed to prevent progression to T2DM.

Hepatic Steatosis and High-normal Fasting Glucose as Risk Factors for Incident Prediabetes

Context

The role of hepatic steatosis (HS) in the initial stages of developing type 2 diabetes remains unclear.

Objective

We aimed to clarify the impact of HS indexed by Fatty Liver Index (FLI) and high-normal fasting plasma glucose (FPG) as risk factors for incident prediabetes in a nonobese cohort.

Methods

Data from 1125 participants with ADA-defined normal glucose metabolism (median age 52 years; BMI 23.1 kg/m²) were used for retrospective analysis. In the entire population, correlation between normal FPG and FLI was evaluated by multiple regression adjusted for age and sex. Follow-up data from 599 participants in whom 75-g OGTT was repeated 3.7 years later showed that 169 developed prediabetes. This was analyzed by the multivariate Cox proportional hazards model.

Results

In the entire population, FLI was positively correlated with FPG (P < 0.01): mean FLI increased from 15.8 at FPG 4.2 mmol/L to 31.6 at FPG 5.5 mmol/L. Analysis of the 599 participants (2061 person-years) by Cox model, adjusted for sex, age, family history of diabetes, ISI_MATSUDA, and Stumvoll-1, clarified an increased risk of prediabetes with high-normal FPG and FLI. Risk was increased 2.2 times with FLI ≥ 16.5 vs FLI < 16.5, P < 0.001, and increased 2.1 times in participants with FPG ≥ 5.3 mmol/L, P < 0.001. Cutoff values (unadjusted) were obtained by ROC at the point of the largest Youden’s index using the entire range of the variables.

Conclusion

Even among nonobese individuals, HS indexed by FLI and a high-normal FPG (≥ 5.3 mmol/L) are risk factors for prediabetes, independently from insulin.

The Theory of Hyperlipidemic Memory of Type 1 Diabetes

A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.

Migraine, Brain Glucose Metabolism and the "Neuroenergetic" Hypothesis: A Scoping Review

Increasing evidence suggests that migraine may be the result of an impaired brain glucose metabolism. Several studies have reported brain mitochondrial dysfunction, impaired brain glucose metabolism and gray matter volume reduction in specific brain areas of migraineurs. Furthermore, peripheral insulin resistance, a condition demonstrated in several studies, may extend to the brain, leading to brain insulin resistance. This condition has been proven to downregulate insulin receptors, both in astrocytes and neurons, triggering a reduction in glucose uptake and glycogen synthesis, mainly during high metabolic demand. This scoping review examines the clinical, epidemiologic and pathophysiologic data supporting the hypothesis that abnormalities in brain glucose metabolism may generate a mismatch between the brain's energy reserve and metabolic expenditure, triggering migraine attacks. Moreover, alteration in glucose homeostasis could generate a chronic brain energy deficit promoting migraine chronification. Lastly, insulin resistance may link migraine with its comorbidities, like obesity, depression, cognitive impairment and cerebrovascular diseases. PERSPECTIVE: Although additional experimental studies are needed to support this novel "neuroenergetic" hypothesis, brain insulin resistance in migraineurs may unravel the pathophysiological mechanisms of the disease, explaining the migraine chronification and connecting migraine with comorbidities. Therefore, this hypothesis could elucidate novel potential approaches for migraine treatment.

Establishing a Reference Interval for an Estimate of Peripheral Insulin Resistance in a Group of Iraqi People

Background and aims: Insulin resistance (IR) is the cornerstone in pathophysiology of T2DM. Identifying people with IR can slow the progress to diabetes. Triglyceride and glucose index (TyG index) is a simple tool to assess IR without insulin measurement. This study aims at establishing the reference interval for TyG index in apparently healthy Iraqis. Material and method: This study involved (77) apparently healthy adults (41 men and 36 women) in Mosul, Iraq. Fasting Serum lipids, glucose and insulin were measured and BMI was calculated. The modified TyG index was calculated and compared to other surrogate measures of IR and its reference interval was calculated. Results: TyG index values were normally distributed and significantly correlated with HOMA-IR, Mc-Auley index, QUICKI, and triglycerides/ HDL-c index (r= 0.322, p= 0.004; r=-0.68, p<0001; r= -0.29, p=0.01; r=0.84, p<0.0001respectively). ANOVA and PostHoc Duncan’s analyses revealed significant differences in mean TyG between (lean people) and (overweight and obese subjects), (p=0.02). BMI- based TyG reference intervals were calculated as (4.11- 4.91) and (4.25- 5.05) respectively. This is the first study in Iraq to set a reference interval for TyG index. Values should be interpreted according to BMI.  

The single-point insulin sensitivity estimator (SPISE) index is a strong predictor of abnormal glucose metabolism in overweight/obese children: a long-term follow-up study

PURPOSE

To investigate the relationship between the single-point insulin sensitivity estimator (SPISE) index, an insulin sensitivity indicator validated in adolescents and adults, and metabolic profile in overweight/obese children, and to evaluate whether basal SPISE is predictive of impaired glucose regulation (IGR) development later in life.

METHODS

The SPISE index (= 600 × HDL^0.185/Triglycerides^0.2 × BMI^1.338) was calculated in 909 overweight/obese children undergoing metabolic evaluations at University of Cagliari, Italy, and in 99 normal-weight, age-, sex-comparable children, selected as a reference group, together with other insulin-derived indicators of insulin sensitivity/resistance. 200 overweight/obese children were followed-up for 6.5 [3.5-10] years, data were used for longitudinal retrospective investigations.

RESULTS

At baseline, 96/909 (11%) overweight/obese children had IGR; in this subgroup, SPISE was significantly lower than in normo-glycaemic youths (6.3 ± 1.7 vs. 7 ± 1.6, p < 0.001). The SPISE index correlated positively with the insulin sensitivity index (ISI) and the disposition index (DI), negatively with age, blood pressure, HOMA-IR, basal and 120 min blood glucose and insulin (all p values < 0.001). A correlation between SPISE, HOMA-IR and ISI was also reported in normal-weight children. At the 6.5-year follow-up, lower basal SPISE-but not ISI or HOMA-IR-was an independent predictor of IGR development (OR = 3.89(1.65-9.13), p = 0.002; AUROC: 0.82(0.72-0.92), p < 0.001).

CONCLUSION

In children, low SPISE index is significantly associated with metabolic abnormalities and predicts the development of IGR in life.

Function outperforms morphology in the assessment of muscular contribution to insulin sensitivity in premenopausal women

INTRODUCTION

Skeletal muscle contributes significantly to insulin sensitivity in humans. However, which non-invasive measurement best reflects this contribution remains unknown. Consequently, this paper compares morphologic and functional measurements.

RESEARCH METHODS AND DESIGN

We conducted a cross-sectional analysis of 144 premenopausal women enrolled in the "Prediction, Prevention, and Sub-classification of Type 2 Diabetes" (PPSDiab) cohort study. For the analysis, we quantified insulin sensitivity by oral glucose tolerance testing and, in a subgroup of 30 women, euglycemic clamp. To assess skeletal muscle, we measured volume by magnetic resonance imaging, intramyocellular lipid content by magnetic resonance spectroscopy, and physical fitness by cardiopulmonary exercise testing.

RESULTS

The mean age of the cohort was 35.7 ± 4.1 years and 94 participants (65%) had a history of gestational diabetes mellitus. Of the morphologic and functional muscle parameters, the maximum workload achieved during cardiopulmonary exercise testing associated most closely with insulin sensitivity (standardized beta = 0.39; p < .001). Peak oxygen uptake also demonstrated significant associations, whereas muscle volume and intramyocellular lipid content displayed none.

CONCLUSION

Functional measurements provided a better assessment of the muscular contribution to insulin sensitivity than morphologic measurements in premenopausal women. In particular, exercise testing rendered an easy and cost-effective method applicable in clinical settings and other human studies.

Single Point Insulin Sensitivity Estimator in Pediatric Non-Alcoholic Fatty Liver Disease

BACKGROUND

Attenuated insulin-sensitivity (IS) is a central feature of pediatric non-alcoholic fatty liver disease (NAFLD). We recently developed a new index, single point insulin sensitivity estimator (SPISE), based on triglycerides, high-density-lipoprotein and body-mass-index (BMI), and validated by euglycemic-hyperinsulinemic clamp-test (EHCT) in adolescents. This study aims to assess the performance of SPISE as an estimation of hepatic insulin (in-)sensitivity. Our results introduce SPISE as a novel and inexpensive index of hepatic insulin resistance, superior to established indices in children and adolescents with obesity.

MATERIALS AND METHODS

Ninety-nine pubertal subjects with obesity (13.5 ± 2.0 years, 59.6% males, overall mean BMI-SDS + 2.8 ± 0.6) were stratified by MRI (magnetic resonance imaging) into a NAFLD (>5% liver-fat-content; male n=41, female n=16) and non-NAFLD (≤5%; male n=18, female n=24) group. Obesity was defined according to WHO criteria (> 2 BMI-SDS). EHCT were used to determine IS in a subgroup (n=17). Receiver-operating-characteristic (ROC)-curve was performed for diagnostic ability of SPISE, HOMA-IR (homeostatic model assessment for insulin resistance), and HIRI (hepatic insulin resistance index), assuming null hypothesis of no difference in area-under-the-curve (AUC) at 0.5.

RESULTS

SPISE was lower in NAFLD (male: 4.8 ± 1.2, female: 4.5 ± 1.1) than in non-NAFLD group (male 6.0 ± 1.6, female 5.6 ± 1.5; P< 0.05 {95% confidence interval [CI]: male NAFLD 4.5, 5.2; male non-NAFLD 5.2, 6.8; female NAFLD 4.0, 5.1, female non-NAFLD 5.0, 6.2}). In males, ROC-AUC was 0.71 for SPISE (P=0.006, 95% CI: 0.54, 0.87), 0.68 for HOMA-IR (P=0.038, 95% CI: 0.48, 0.88), and 0.50 for HIRI (P=0.543, 95% CI: 0.27, 0.74). In females, ROC-AUC was 0.74 for SPISE (P=0.006), 0.59 for HOMA-IR (P=0.214), and 0.68 for HIRI (P=0.072). The optimal cutoff-level for SPISE between NAFLD and non-NAFLD patients was 5.18 overall (Youden-index: 0.35; sensitivity 0.68%, specificity 0.67%).

CONCLUSION

SPISE is significantly lower in juvenile patients with obesity-associated NAFLD. Our results suggest that SPISE indicates hepatic IR in pediatric NAFLD patients with sensitivity and specificity superior to established indices of hepatic IR.

Diabetes: Concepts of β-Cell Organ Dysfunction and Failure Would Lead to Earlier Diagnoses and Prevention

As the world endures a viral pandemic superimposed on a diabetes pandemic, the latter incorporates most of the comorbidities associated with the former, thereby exacerbating risk of death in both. An essential approach to both pandemics is prevention and unrealized earlier treatment. Thus, in this Perspective relating to diabetes, we emphasize a paradigm of, first, reversible β-cell organ dysfunction and then irreversible β-cell organ failure, which directly indicate the potential for earlier prevention, also unrealized in current guidelines. Four pillars support this paradigm: epidemiology, pathophysiology, molecular pathology, and genetics. A substantial worldwide knowledge base defines each pillar and informs a more aggressive preventive approach to most forms of the disorder. This analysis seeks to clarify the temporal and therapeutic relationships between lost β-cell function and content, illuminating the potential for earlier diagnoses and, thus, prevention. We also propose that myriad pathways leading to most forms of diabetes converge at the endoplasmic reticulum, where stress can result in β-cell death and content loss. Finally, genetic and nongenetic origins common to major types of diabetes can inform earlier diagnosis and, potentially, prevention, with the aim of preserving β-cell mass.

The Troubling Link Between Non-alcoholic Fatty Liver Disease (NAFLD) and Extrahepatic Cancers (EHC)

Non-alcoholic fatty liver disease (NAFLD) is a fast-spreading epidemic across the globe and has serious implications far beyond that of a "benign" liver condition. It is usually an outcome of ectopic fat storage due to chronic positive energy balance leading to obesity and is associated with multiple health problems. While association with cardiovascular disease and hepatocellular cancer is well recognized, it is becoming clear the NAFLD carries with it an increased risk of cancers of extrahepatic tissues. Studies have reported a higher risk for cancers of the colon, breast, prostate, lung, and pancreas. Fatty liver is associated with increased mortality; there is an urgent need to understand that fatty liver is not always benign, and not always associated with obesity. It is, however, a reversible condition and early recognition and intervention can alter its natural history and associated complications.

Latent tuberculosis infection among patients with and without type-2 diabetes mellitus: results from a hospital case-control study in Atlanta

OBJECTIVE

The purpose of this study is to compare the prevalence of latent TB infection (LTBI) among patients with type-2 diabetes mellitus (T2DM) to healthy controls without T2DM. To achieve this objective, we conducted a case-control study in a large hospital in Atlanta from 2016 to 2019.

RESULTS

We enrolled 98 cases; 119 potential controls were screened, 84 of which had HbA1c  ≥  5.7% and one did not have QFT result, leaving 34 (28.6%) individuals enrolled as controls. LTBI prevalence was 9.2% among cases and 14.7% among controls (crude odds ratio 0.59, 95% CI 0.19-2.04). After adjusting for age and sex, the adjusted odds of LTBI among patients with T2DM was 0.45 (95% CI 0.13, 1.71) times the controls. We did not observe a statistically significant association between LTBI and T2DM. However, we reported a positive correlation between HbA1c level and nil count among individuals with LTBI (R²  =  0.55, p  <  0.01). In addition, we reported a high prevalence of LTBI among adults with T2DM and family members without T2DM.

Cardiovascular autonomic neuropathy in diabetes: Pathophysiology, clinical assessment and implications

Cardiovascular autonomic neuropathy (CAN) is a debilitating condition that mainly occurs in long-standing type 2 diabetes patients but can manifest earlier, even before diabetes is diagnosed. CAN is a microvascular complication that results from lesions of the sympathetic and parasympathetic nerve fibers, which innervate the heart and blood vessels and promote alterations in cardiovascular autonomic control. The entire mechanism is still not elucidated, but several aspects of the pathophysiology of CAN have already been described, such as the production of advanced glycation end products, reactive oxygen species, nuclear factor kappa B, and pro-inflammatory cytokines. This microvascular complication is an important risk factor for silent myocardial ischemia, chronic kidney disease, myocardial dysfunction, major cardiovascular events, cardiac arrhythmias, and sudden death. It has also been suggested that, compared to other traditional cardiovascular risk factors, CAN progression may have a greater impact on cardiovascular disease development. However, CAN might be subclinical for several years, and a late diagnosis increases the mortality risk. The duration of the transition period from the subclinical to clinical stage remains unknown, but the progression of CAN is associated with a poor prognosis. Several tests can be used for CAN diagnosis, such as heart rate variability (HRV), cardiovascular autonomic reflex tests, and myocardial scintigraphy. Currently, it has already been described that CAN could be detected even during the subclinical stage through a reduction in HRV, which is a non-invasive test with a lower operating cost. Therefore, considering that diabetes mellitus is a global epidemic and that diabetic neuropathy is the most common chronic complication of diabetes, the early identification and treatment of CAN could be a key point to mitigate the morbidity and mortality associated with this long-lasting condition.

Random forest approach for determining risk prediction and predictive factors of type 2 diabetes: large-scale health check-up data in Japan

Introduction

Early intervention in type 2 diabetes can prevent exacerbation of insulin resistance. More effective interventions can be implemented by early and precise prediction of the change in glycated haemoglobin A1c (HbA1c). Artificial intelligence (AI), which has been introduced into various medical fields, may be useful in predicting changes in HbA1c. However, the inability to explain the predictive factors has been a problem in the use of deep learning, the leading AI technology. Therefore, we applied a highly interpretable AI method, random forest (RF), to large-scale health check-up data and examined whether there was an advantage over a conventional prediction model.

Research design and methods

This study included a cumulative total of 42 908 subjects not receiving treatment for diabetes with an HbA1c <6.5%. The objective variable was the change in HbA1c in the next year. Each prediction model was created with 51 health-check items and part of their change values from the previous year. We used two analytical methods to compare the predictive powers: RF as a new model and multivariate logistic regression (MLR) as a conventional model. We also created models excluding the change values to determine whether it positively affected the predictions. In addition, variable importance was calculated in the RF analysis, and standard regression coefficients were calculated in the MLR analysis to identify the predictors.

Results

The RF model showed a higher predictive power for the change in HbA1c than MLR in all models. The RF model including change values showed the highest predictive power. In the RF prediction model, HbA1c, fasting blood glucose, body weight, alkaline phosphatase and platelet count were factors with high predictive power.

Conclusions

Correct use of the RF method may enable highly accurate risk prediction for the change in HbA1c and may allow the identification of new diabetes risk predictors.

Risk of Metabolic Syndrome in Kidney Stone Formers: A Comparative Cohort Study with a Median Follow-Up of 19 Years

Background: Kidney stone formers (SF) are more likely to develop diabetes mellitus (DM), but there is no study examining risk of metabolic syndrome (MetS) in this population. We aimed to describe the risk of MetS in SF compared to non-SF. Methods and Materials: SF referred to a tertiary referral metabolic centre in Southern England from 1990 to 2007, comparator patients were age, sex, and period (first stone) matched with 3:1 ratio from the same primary care database. SF with no documentation or previous MetS were excluded. Ethical approval was obtained and MetS was defined using the modified Association of American Clinical Endocrinologists (AACE) criteria. Analysis with cox proportional hazard regression. Results: In total, 828 SF were included after 1000 records were screened for inclusion, with 2484 age and sex matched non-SF comparators. Median follow-up was 19 years (interquartile range—IQR: 15–22) for both stone formers and stone-free comparators. SF were at significantly increased risk of developing MetS (hazard ratio—HR: 1.77; 95% confidence interval—CI: 1.55–2.03, p < 0.001). This effect was robust to adjustment for pre-existing components (HR: 1.91; 95% CI: 1.66–2.19, p < 0.001). Conclusions: Kidney stone formers are at increased risk of developing metabolic syndrome. Given the pathophysiological mechanism, the stone is likely a ‘symptom’ of an underlying metabolic abnormality, whether covert or overt. This has implications the risk of further stone events and cardiovascular disease.

Association between Coronary Artery Spasm and the risk of incident Diabetes: A Nationwide population-based Cohort Study

Background: Non-diabetic coronary artery spasm (CAS) without obstructive coronary artery disease increases insulin resistance. We investigated the risk of incident type 2 diabetes (diabetes) associated with CAS. Methods: Patient records were retrospectively collected from the Taiwan National Health Insurance Research Database during the period 2000-2012. The matched cohorts consisted of 12,413 patients with CAS and 94,721 patients in the control group. Results: During the entire follow-up, the incidence of newly-diagnosed diabetes was 22.2 events per 1000 person-years in the CAS group and 13.9 events per 1000 person-years in the control group. The increased risk of CAS-related incident diabetes was observed regardless of sex and length of follow-up. The median time to incident diabetes was 2.9 and 3.5 years in the CAS and the control group (P <0.001), respectively, regardless of sex. Although age did not affect the risk of CAS-related incident diabetes, the risk was less apparent in the subgroups of male, dyslipidemia, chronic obstructive pulmonary disease, stroke, gout and medicated hypertension. However, CAS patients aged <50 years compared with patients ≥50 years had a greater risk of incident diabetes in females but not in males. Older CAS patients developed diabetes in a shorter length of time than younger patients. Conclusion: CAS is a risk factor for incident diabetes regardless of sex. However, females aged <50 years have a more apparent risk for CAS-related diabetes than old females, which is not observed in males. The median time of 2.9 years to incident diabetes warrants close follow-up.

Mechanisms and early patterns of dyslipidemia in pediatric type 1 and type 2 diabetes

Objectives The is no consensus on the early patterns of lipid-based cardiovascular disease (CVD) risk in youth with either type 1 diabetes (T1D) or type 2 diabetes (T2D). The aim was todetermine the differences in CVD risk, using lipid profiles, in children and adolescents with either T1D or T2D at the time of their first lipid assessment, after stratifying the T1D cohort into remitters and non-remitters based on their honeymoon history. Methods A cross-sectional study of 249 subjects consisting of 73 controls, 53 T2D subjects, and 123 T1D subjects stratified into remitters (n=44), and non-remitters (n=79). Partial clinical remission (PCR) was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results After adjusting for age, sex, BMI, race, and pubertal status, T2D patients had significantly higher LDL-C compared to the controls (p=0.022), the remitters (p=0.029), but not the non-remitters (103.1 ± 5.9 mg/dL vs. 91.4 ± 4.2 mg/dL, p=0.49). Similarly, T2D patients had significantly higher non-HDL-C compared to the controls (p=0.006), the remitters (p=0.0002), but not the non-remitters (137.6 ± 7.1 mg/dL vs. 111.71 ± 5.0 mg/dL, p=0.053). Total cholesterol was also significantly higher in T2D patients compared to the controls (p=0.0005), the remitters (p=0.006) but not the non-remitters (183.5 ± 6.6 mg/dL vs. 166.2 ± 4.8 mg/dL, p=0.27). Conclusions Lack of the honeymoon phase in children and adolescents with T1D confers early and significantly increased lipid-based cardiovascular risk to these patients that is similar to the elevated cardiovascular risk seen in T2D.

Development of glomerular hyperfiltration, a multiphasic phenomenon

The trajectory of glomerular filtration rate (GFR) in relation to glomerular hyperfiltration (GHF) has been unknown. It was evaluated retrospectively in 23,982 GHF-free health examinees who were followed for 2-10 yr (mean: 5.1 yr). GFR was estimated by the serum creatinine concentration, and GHF was defined as age- and sex-specific estimated GFR (eGFR) ≥ 95% of the Japanese general population. The temporal profile of eGFR was plotted in a GHF-centered way, which was fitted to a random coefficient linear mixed model. Of the 23,982 subjects, 797 and 23,185 subjects developed or did not develop GHF, respectively, so that they were termed as the GHF₍₊₎ and GHF_(-) groups. At baseline, median eGFR was significantly elevated in the GHF₍₊₎ group compared with in the GHF_(-) group: 94.1 versus 77.3 mL/min/1.73 m² (P < 0.001). Elevation of basal eGFR lasted for a mean (SD) of 3.3 (1.9) yr in the GHF₍₊₎ group; mean eGFR then rose to the GHF range, which was 108.5 mL/min/1.73 m². The eGFR decline after the peak was steeper in the GHF₍₊₎ group than in the GHF_(-) group: -0.984 versus -0.497 mL/min/1.73 m²/yr (P < 0.001). Baseline eGFR, but no other variable, well predicted incident GHF, with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval: 0.86-0.88). In conclusion, GHF occurs as a chronic, multiphasic phenomenon: initially with a sustained GFR elevation for years, followed by a GFR surge to the GHF range, which was accompanied by accelerated GFR declining.

Effects of Vitamin D Supplementation on Prevention of Type 2 Diabetes in Patients With Prediabetes: A Systematic Review and Meta-analysis

BACKGROUND

While observational studies have shown an association between vitamin D insufficiency and diabetes, it is unclear whether intervention with vitamin D supplements can lower the risk of type 2 diabetes mellitus (T2DM).

PURPOSE

To assess whether vitamin D supplementation reduces the risk of T2DM in people with prediabetes.

DATA SOURCES

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 5 July 2019.

STUDY SELECTION

We included randomized controlled trials assessing vitamin D supplementation versus placebo in relation to new-onset T2DM in people with prediabetes.

DATA EXTRACTION

We screened studies and extracted data from published trials independently.

DATA SYNTHESIS

We identified eight eligible trials with a total of 4,896 subjects. Vitamin D supplementation significantly reduced the risk of T2DM (risk ratio [RR] 0.89 [95% CI 0.80-0.99]; I ² = 0%). Benefit was found in nonobese subjects (RR 0.73 [95% CI 0.57-0.92]) but not in obese subjects (RR 0.95 [95% CI 0.84-1.08]) (P _interaction = 0.048). The reversion of prediabetes to normoglycemia occurred in 116 of 548 (21.2%) participants in the vitamin D group and 75 of 532 (14.1%) in the control group. Vitamin D supplementation increased reversion rate of prediabetes to normoglycemia (RR 1.48 [95% CI 1.14-1.92]; I ² = 0%.) LIMITATIONS: Definitions of prediabetes and new-onset diabetes in eligible studies were different, and long-term data on outcomes of T2DM prevention were lacking.

CONCLUSIONS

In persons with prediabetes, vitamin D supplementation reduces the risk of T2DM and increases the reversion rate of prediabetes to normoglycemia. The benefit of the prevention of T2DM could be limited to nonobese subjects. Individual participant data meta-analyses are needed to confirm these findings.

SPISE and other fasting indexes of insulin resistance: risks of coronary heart disease or type 2 diabetes. Comparative cross-sectional and longitudinal aspects

Background: Fasting insulin resistance indexes are used extensively nowadays. We intended to analyze a new recently presented fasting index, SPISE (sensitivity formula: 600 × HDL-cholesterol^0.185/triglycerides^0.2/BMI^1.338), in comparison with three previously known fasting indexes, regarding correlation with the insulin clamp index, and for the predictive effects of future long-term risks of coronary heart disease (CHD) or manifest type 2 diabetes.Methods: A total of 1049 71-year-old male subjects from the Swedish ULSAM study, median follow-up 8 years, were included. All subjects performed the euglycemic insulin clamp, and analyses of four fasting insulin resistance indexes: SPISE-IR (= 10/SPISE), QUICKI-IR, Log HOMA-IR, and Revised QUICKI-IR.Results: Spearman correlation coefficients with the insulin clamp were 0.60-0.62 for all indexes. Area under curve at ROC analysis was 0.80 for SPISE-IR, and 0.84 for QUICKI-IR, Log HOMA-IR, and Rev QUICKI-IR. Adjusted hazard ratios per 1 SD index increase for long-term risk CHD were similar in all patients: 1.20-1.24 (p = 0.02-0.03). However, comparing the highest quartile (recommended to define insulin resistance) with the lower quartiles, SPISE-IR was the strongest and the only statistically significant insulin resistance index: HR 1.53 (p = 0.02). Adjusted odds ratios per 1 SD index increase for long-term risk of type 2 diabetes were fairly similar (p < 0.001) in all patients: 1.62 for SPISE-IR, 1.97 for QUICKI-IR and Log HOMA-IR, and 2.04 for Rev QUICKI-IR, and also when comparing the highest versus the lower quartiles: 2.8-3.1 (p < 0.001).Conclusion: SPISE, easily applicable, performed equally well as other fasting insulin indexes previously recommended for clinical use, regarding correlation with the insulin clamp, and as predictor for future long-term risks of CHD or type 2 diabetes.

Childhood obesity in New Zealand

BACKGROUND

Paediatric obesity has reached epidemic proportions globally, resulting in significant adverse effects on health and wellbeing. Early life events, including those that happen before, during, and after pregnancy can predispose children to later obesity. The purpose of this review is to examine the magnitude of obesity among New Zealand children and adolescents, and to determine their underlying risk factors and associated comorbidities.

DATA SOURCES

PubMed, Web of Science, and Google Scholar searches were performed using the key terms "obesity", "overweight", "children", "adolescents", and "New Zealand".

RESULTS

Obesity is a major public health concern in New Zealand, with more than 33% of children and adolescents aged 2-14 years being overweight or obese. Obesity disproportionately affects Māori (New Zealand's indigenous population) and Pacific children and adolescents, as well as those of lower socioeconomic status. New Zealand's obesity epidemic is associated with numerous health issues, including cardiometabolic, gastrointestinal, and psychological problems, which also disproportionately affect Māori and Pacific children and adolescents. Notably, a number of factors may be useful to identify those at increased risk (such as demographic and anthropometric characteristics) and inform possible interventions.

CONCLUSIONS

The prevalence of overweight and obese children and adolescents in New Zealand is markedly high, with a greater impact on particular ethnicities and those of lower socioeconomic status. Alleviating the current burden of pediatric obesity should be a key priority for New Zealand, for the benefit of both current and subsequent generations. Future strategies should focus on obesity prevention, particularly starting at a young age and targeting those at greatest risk.

Insulin Sensitivity Is Associated with Lipoprotein Lipase (LPL) and Catenin Delta 2 (CTNND2) DNA Methylation in Peripheral White Blood Cells in Non-Diabetic Young Women

Hyperglycaemia and type 2 diabetes (T2D) are associated with impaired insulin secretion and/or insulin action. Since few studies have addressed the relation between DNA methylation patterns with elaborated surrogates of insulin secretion/sensitivity based on the intravenous glucose tolerance test (IVGTT), the aim of this study was to evaluate the association between DNA methylation and an insulin sensitivity index based on IVGTT (calculated insulin sensitivity index (CSi)) in peripheral white blood cells from 57 non-diabetic female volunteers. The CSi and acute insulin response (AIR) indexes, as well as the disposition index (DI = CSi × AIR), were estimated from abbreviated IVGTT in 49 apparently healthy Chilean women. Methylation levels were assessed using the Illumina Infinium Human Methylation 450k BeadChip. After a statistical probe filtering, the two top CpGs whose methylation was associated with CSi were cg04615668 and cg07263235, located in the catenin delta 2 (CTNND2) and lipoprotein lipase (LPL) genes, respectively. Both CpGs conjointly predicted insulin sensitivity status with an area under the curve of 0.90. Additionally, cg04615668 correlated with homeostasis model assessment insulin-sensitivity (HOMA-S) and AIR, whereas cg07263235 was associated with plasma creatinine and DI. These results add further insights into the epigenetic regulation of insulin sensitivity and associated complications, pointing the CTNND2 and LPL genes as potential underlying epigenetic biomarkers for future risk of insulin-related diseases.

Prediabetes defined by the International Expert Committee as a risk for development of glomerular hyperfiltration

AIMS

To clarify if prediabetes defined by the International Expert Committee (Prediabetes_IEC) and/or the American Diabetes Society (Prediabetes_ADA) is a risk for incident glomerular hyperfiltration (GH).

METHODS

24,524 health examinees without diabetes, chronic kidney disease (CKD), GH and antihypertensive treatment at baseline, and repeated examinations at least twice during a mean of 5.3 years were retrospectively analysed. Diabetes was defined as fasting plasma glucose (FPG) ≥ 7.0 mmol/L and/or HbA_1c ≥ 47 mmol/mol, CKD by estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² and/or dipstick-positive proteinuria, and GH by upper 95th eGFR in the Japanese adults. Prediabetes_IEC was diagnosed by "HbA_1c 42-46 mmol/mol and/or FPG 6.1-6.9 mmol/L", Prediabetes_ADA by "HbA_1c 39-46 mmol/mol and/or FPG 5.6-6.9 mmol/L", Prediabetes_ADA-IEC for the condition met the ADA but not the IEC prediabetes definition, and the ADA-normal glucose regulation (NGR_ADA) by both HbA_1c and FPG lower than Prediabetes_ADA. Risk of Prediabetes_IEC and Prediabetes_ADA for incident GH was examined by multivariate Cox proportional hazards model with seven covariates and probability of incident GH was calculated on the basis of it.

RESULTS

Prediabetes_IEC was a significant risk for incident GH [adjusted HR 1.91, 95% CI 1.32-2.71] but Prediabetes_ADA was not [adjusted HR 1.22, 95% CI 0.93-1.61]. The mean (SD) probability of incident GH was 2.3 (4.5)%, 1.0 (2.3)% and 1.0 (2.4)% for Prediabetes_IEC, Prediabetes_ADA-IEC and NGR_ADA, respectively: the former was significantly larger than the latter two which were not significantly different from each other.

CONCLUSIONS

Prediabetes_IEC was an independent risk for incident GH.

Elevated haemoglobin A1c but not fasting plasma glucose conveys risk of chronic kidney disease in non-diabetic individuals

AIMS

To compare impact of elevated HbA1c and fasting plasma glucose (FPG) on incident chronic kidney disease (CKD) in a non-diabetic cohort.

METHODS

Data from diabetes- and CKD-free 25,109 health examinees were retrospectively analysed with a mean observation period of 5.3 years. Prediabetes was diagnosed by the ADA and WHO criteria, and CKD by estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² and/or dipstick proteinuria. Cox proportional hazards model was applied with sex, age, insulin sensitivity, systolic blood pressure, eGFR and serum alanine aminotransferase level as covariates.

RESULTS

For incident CKD (n = 2483), high HbA1c but not FPG was an independent risk: adjusted hazard ratio (AHR, 95%CI) for HbA1c 1% and FPG 1 mmol/L, 1.91 (1.70-2.16) and 0.85 (0.60-1.20), respectively. Prediabetes by the ADA and WHO criteria were both risk for CKD with AHR (95%CI), 1.21 (1.12-1.32) and 1.31 (1.16-1.48), respectively. Prediabetes diagnosed by 'elevated HbA1c irrespective of FPG', either by the ADA and the WHO definition, was a risk with AHR (95%CI), 1.48 (1.36-1.61) and 1.51 (1.31-1.74), respectively. In contrast, prediabetes diagnosed by 'raised FPG irrespective of HbA1c' was not a CKD risk.

CONCLUSIONS

Elevated HbA1c, but not FPG, identified CKD risk in non-diabetic individuals.

Reappraisal of attenuated insulin sensitivity in the evolution of non-alcoholic fatty liver disease

BACKGROUND/OBJECTIVES

It has been unknown if attenuated insulin sensitivity (Si) in non-alcoholic fatty liver disease (NAFLD) is a cause or a result. We examined the impact of attenuated Si on NAFLD evolution.

SUBJECTS/METHODS

We observed 4856 NAFLD- and diabetes-free participants for a mean 2.9 years. Si was indexed by single point insulin sensitivity estimator (SPISE = [600 × HDL-c^0.185]/[TG^0.2 × BMI^1.338]), correlating with 1/HOMA-IR in an independent cohort (n = 1537, Spearman rho = 0.519, P < 0.01). Fatty liver (FL) was diagnosed by ultrasonography and diabetes by fasting plasma glucose (FPG) ≥ 7 mmol/L and/or glycohemoglobin A1c ≥ 6.5%. Multinominal comparison was performed with incident FL (FL_w/oDM, n = 486), diabetes (DM_w/oFL, n = 171), and FL plus diabetes (FL/diabetes, n = 58) as targets; none of the above (n = 4,138) was the control. SPISE was taken as a predictor with adjustment for covariates. Trajectory of SPISE during the 5 years before development of each condition was also assessed.

RESULTS

With SPISE tertile 3 (>10.06) as the reference, tertile 1 (<8.07) was related to incident FL_w/oDM and FL/diabetes with OR (95% CI) 3.47 (2.60-4.63) and 1.78 (1.10-2.87), respectively, and tertile 2 (8.07-10.06) related to FL_w/oDM with OR (95% CI) 1.38 (1.03-1.85). Low SPISE was not significantly related to incident diabetes. At -5 years, SPISE was 12% (P < 0.05) and 13% (P < 0.01) lower in those developed FL_w/oDM and FL/diabetes, respectively, than the control. At year 0, SPISE in the two groups was 18% and 21% lower than the control, respectively (P < 0.01).

CONCLUSIONS

Attenuation of Si indexed by SPISE was a risk factor for NAFLD.