Body mass index and blood pressure in adult type 2 diabetic patients in Taiwan

Co-occurrence of hypertension and type 2 diabetes: prevalence and associated factors among Haramaya University employees in Eastern Ethiopia

Background

Both hypertension (HTN) and diabetes are public health concerns in low- and middle-income countries, particularly in sub-Saharan African countries. The co-occurrence of HTN and diabetes is associated with an increased risk of mortality, morbidity, and reduced productivity in the working force. In Ethiopia, there is limited evidence on the co-occurrence of HTN and type 2 diabetes (T2DM). Therefore, this study was conducted to assess the co-occurrence of HTN and T2DM and their associated factors among Haramaya University employees in Eastern Ethiopia.

Methods

A cross-sectional survey was conducted among 1,200 employees at Haramaya University using a simple random sampling technique from December 2018 to February 2019. Demographic and behavioral factors were collected on a semi-structured questionnaire, followed by measurement of anthropometry and blood pressure. Blood glucose and lipid profile measurements were performed by collecting 6 ml of venous blood samples after 8 h of overnight fasting. Data were entered into EpiData 3.1 version and analyzed using Stata 16 software. Bivariable and multivariable logistic regressions were applied to observe the association between independent variables with co-occurrence of HPN and T2DM using odds ratio, 95% confidence interval (CI), and p-values of ≤ 0.05 were considered statistically significant.

Results

The prevalence of HTN and T2DM was 27.3 and 7.4%, respectively. The co-occurrence of HTN and T2DM was 3.8%. The study found that being older (AOR = 3.97; 95 % CI: 1.80-8.74), khat chewing (AOR = 2.76; 95 % CI: 1.23-6.18), body mass index ≥ 25 kg/m² (AOR = 5.11; 95 % CI: 2.06-12.66), and sedentary behavior ≥8 h per day (AOR = 6.44; 95 % CI: 2.89-14.34) were statistically associated with co-occurrence of HTN and T2DM. On the other hand, consuming fruits and vegetables (AOR = 0.10; 95 % CI: 0.04-0.22) and a higher level of education (AOR = 0.39; 95% CI: 0.17-0.89) were negatively statistically associated with the co-occurrence of HTN and T2DM.

Conclusion

The co-occurrence of HTN and T2DM was prevalent among the study participants. This may create a substantial load on the healthcare system as an end result of increased demand for healthcare services. Therefore, rigorous efforts are needed to develop strategies for screening employees to tackle the alarming increase in HTN and T2DM in university employees.

Development and validation of a nomogram model for individualized prediction of hypertension risk in patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) with hypertension (DH) is the most common diabetic comorbidity. Patients with DH have significantly higher rates of cardiovascular disease morbidity and mortality. The objective of this study was to develop and validate a nomogram model for the prediction of an individual's risk of developing DH. A total of 706 T2DM patients who met the criteria were selected and divided into a training set (n = 521) and a validation set (n = 185) according to the discharge time of patients. By using multivariate logistic regression analysis and stepwise regression, the DH nomogram prediction model was created. Calibration curves were used to evaluate the model's accuracy, while decision curve analysis (DCA) and receiver operating characteristic (ROC) curves were used to evaluate the model's clinical applicability and discriminatory power. Age, body mass index (BMI), diabetic nephropathy (DN), and diabetic retinopathy (DR) were all independent risk factors for DH (P < 0.05). Based on independent risk factors identified by multivariate logistic regression, the nomogram model was created. The model produces accurate predictions. If the total nomogram score is greater than 120, there is a 90% or higher chance of developing DH. In the training and validation sets, the model's ROC curves are 0.762 (95% CI 0.720-0.803) and 0.700 (95% CI 0.623-0.777), respectively. The calibration curve demonstrates that there is good agreement between the model's predictions and the actual outcomes. The decision curve analysis findings demonstrated that the nomogram model was clinically helpful throughout a broad threshold probability range. The DH risk prediction nomogram model constructed in this study can help clinicians identify individuals at high risk for DH at an early stage, which is a guideline for personalized prevention and treatments.

Pioglitazone and Prostate Cancer Risk in Taiwanese Male Patients with Type 2 Diabetes: A Retrospective Cohort Study

PURPOSE

This study investigated prostate cancer risk associated with pioglitazone use.

MATERIALS AND METHODS

The Taiwan's National Health Insurance database was used to create a propensity score-matched cohort of male patients with type 2 diabetes mellitus newly diagnosed in 1999-2005 and aged ≥25 years at baseline. The matched cohort included 20437 ever users and 20437 never users of pioglitazone. The patients were followed up for the incidence of prostate cancer until December 31, 2011. Hazard ratios (HRs) were created from Cox regression weighted on propensity score.

RESULTS

Prostate cancer was diagnosed in 121 ever users of pioglitazone (incidence: 175.84 per 100,000 person-years) and 143 never users of pioglitazone (incidence: 216.66 per 100,000 person-years). When ever users were compared to never users of pioglitazone, the HR was 0.815 (95% confidence interval [CI], 0.639-1.039; p=0.0987). When ever users were categorized into tertiles of cumulative duration of pioglitazone therapy (<6.83, 6.83-20.23, and >20.23 months), the HRs were 1.044 (95% CI, 0.741-1.471), 0.975 (95% CI, 0.690-1.377) and 0.539 (95% CI, 0.374-0.778), respectively. For the tertiles of cumulative dose of <5,040, 5,040-15,330, and >15,330 mg, the HRs were 1.008 (95% CI, 0.710-1.429), 1.090 (95% CI, 0.785-1.515) and 0.484 (95% CI, 0.330-0.711), respectively. A significantly lower risk associated with pioglitazone use could only be seen in patients aged <65 years (HR, 0.578; 95% CI, 0.360-0.927) but not in patients aged ≥65 years.

CONCLUSIONS

A significantly lower risk of prostate cancer is observed after a cumulative duration of pioglitazone therapy for >20.23 months or a cumulative dose of >15,330 mg. The risk reduction is mainly observed in patients aged <65 years.

The Risk of Multiple Myeloma Is Reduced in Metformin Initiators: A Retrospective Cohort Study in Taiwanese Patients with Type 2 Diabetes Mellitus

BACKGROUND

Whether metformin might reduce the risk of multiple myeloma (MM) has not been extensively researched in humans.

METHODS

The study subjects were enrolled from the reimbursement database of Taiwan's National Health Insurance. A total of 739,553 patients who had a new diagnosis of type 2 diabetes mellitus during 1999-2009 were identified. They were categorized as metformin initiators (metformin (+)) and non-metformin initiators (metformin (-)) based on the prescriptions of antidiabetic drugs that included metformin and did not include metformin within the initial 12 months, respectively. MM incidence was calculated after the initial 12 months of treatment group assignment until 31 December 2011. Hazard ratios based on intention-to-treat (ITT) and per-protocol (PP) approaches were estimated by Cox regression weighted by propensity scores.

RESULTS

In the ITT analyses, the respective incidence rates for 497,248 metformin (+) and 242,305 metformin (-) were 9.97 and 14.33 per 100,000 person-years. The hazard ratio that compared metformin (+) to metformin (-) in the ITT analysis was 0.710 (95% confidence interval 0.593-0.850). In the PP analysis, the respective incidence rates were 5.14 and 13.98 per 100,000 person-years, and the hazard ratio was 0.355 (95% confidence interval, 0.270-0.466). The lower risk of MM among metformin (+) was supported by subgroup and sensitivity analyses.

CONCLUSIONS

Type 2 diabetes patients who are initiated with metformin treatment have a significantly lower risk of MM, especially when they adhere to metformin treatment.

Relationship between Depression with Physical Activity and Obesity in Older Diabetes Patients: Inflammation as a Mediator

Obesity and physical activity (PA) may affect inflammation and are also related to depression. This study aimed to explore the association between depression, obesity, and PA in older diabetes patients mediated by inflammation. We conducted a cross-sectional study with 197 elderly diabetes patients (≥65 y/o). Participants were interviewed to gather demographic and lifestyle data. Assessment of depression was based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. High-sensitivity C-reactive protein was used as a marker of inflammation. Participants with a body mass index (kg/m2) ≥ 27 were considered to be obese. Our data indicated that among all participants with (n = 57) and without (n = 140) depression, older diabetes patients with depression had a lower intake of energy and protein and a lower prevalence of smoking and alcohol consumption than those without depression (p < 0.05). We also found that inflammation may be a partial mediator in the relationship between obesity and depression, and a significant mediator between PA and depression. Additionally, a regression model of obesity and PA showed that PA was a significant predictor of inflammation. However, the association between obesity and inflammation was not significant. When obesity, PA, and inflammation were included in a regression model together, inflammation significantly predicted depression (OR = 4.18, p = 0.004). The association between obesity and depression was also significant (OR = 2.45, p = 0.038). However, the association between PA and depression was not significant, and the mediating effect of inflammation was significant according to the Sobel test (z = −2.01, p = 0.045). In conclusion, the beneficial effects of PA may lower levels of inflammation produced by obesity, thus reducing inflammatory effects that may be related to depression. Overall, inflammation may mediate the relationship between depression and PA in older diabetes patients.

Metformin’s effects on varicocele, erectile dysfunction, infertility and prostate-related diseases: A retrospective cohort study

Objectives: To investigate the risk of varicocele, erectile dysfunction (ED), infertility, prostatitis, benign prostate hyperplasia (BPH) and prostate cancer associated with metformin use.

Materials and methods: A total of 261,838 males, mean age 52.39 years (SD: 11.39), with a new-onset type 2 diabetes mellitus in 1999–2009 were identified from Taiwan’s National Health Insurance. Among them, 175,171 were metformin initiators [metformin (+)] and 86,667 were non-metformin initiators [metformin (−)] in the initial 12-month prescriptions of antidiabetic drugs. Follow-up started after the initial 12-month prescriptions. Outcomes were followed up until 31 December 2011. Intention-to-treat (ITT) and per-protocol (PP) hazard ratios comparing metformin (+) to metformin (−) were estimated by Cox regression incorporated with the inverse probability of treatment-weighting using propensity scores.

Results: The median follow-up time ranged 5.55–6.82 years in metformin (−) and 4.36–5.17 years in metformin (+) for different outcomes in ITT analyses. The respective median follow-up time in PP analyses ranged 2.20–2.61 years in metformin (−) and ranged 3.99–4.65 years in metformin (+). In the ITT analyses, for metformin (−), the incidence rates (per 100,000 person-years) of varicocele, ED, infertility, prostatitis, BPH and prostate cancer were 26.42, 455.89, 22.82, 590.23, 4226.19, and 141.69, respectively; and the respective incidence rates for metformin (+) were 25.65, 488.10, 32.60, 510.30, 3685.66, and 116.57. The hazard ratios (95% confidence intervals) comparing metformin (+) to metformin (−) in the ITT analyses were 0.960 (0.784–1.174) for varicocele, 1.077 (1.026–1.130) for ED, 1.368 (1.116–1.676) for infertility, 0.887 (0.849–0.927) for prostatitis, 0.883 (0.868–0.899) for BPH and 0.878 (0.802–0.961) for prostate cancer. The hazard ratios for the respective outcomes in the PP analyses were 0.845 (0.662–1.078), 1.350 (1.264–1.441), 1.396 (1.078–1.808), 0.800 (0.756–0.846), 0.875 (0.855–0.895), and 0.613 (0.548–0.686).

Conclusion: Metformin use in patients with type 2 diabetes mellitus is associated with a neutral effect on varicocele, a higher risk of sexual dysfunction (ED and infertility) and a reduced risk of prostate-related health (prostatitis, BPH and prostate cancer).

Prevalence of overweight/obesity and its associated factors among a sample of Moroccan type 2 diabetes patients

BACKGROUND

Obesity constitutes a major risk factor for the development of diabetes, and has been linked with poor glycaemic control among type 2 diabetic patients.

AIMS

This study examines the prevalence of overweight/obesity and associated factors in type 2 diabetic patients in the Beni-Mellal Khenifra region in Morocco.

METHODS

A questionnaire-based cross-sectional study was conducted in 2017 among 975 diabetes patients attending primary health centres. Demographic and clinical data were collected through face-to-face interviews. Anthropometric measurements, including body weight, height and waist circumference, were taken using standardized techniques and calibrated equipment.

RESULTS

The prevalence of overweight was 40.4%, the general obesity was 28.8% and the abdominal obesity was 73.7%. Using multivariate analysis, we noted that the general obesity was associated with female sex (AOR= 3,004, 95% CI: 1.761-5.104, P<0.001), increased age (AOR=2.192, 95% CI: 1.116-4.307, P<0.023) and good glycaemic control (AOR=1.594, 95% CI: 1.056-2.407, P=0.027), whereas abdominal obesity was associated wih female sex (AOR=2.654, 95% CI: 1.507-4.671, P<0.001) and insulin treatment (AOR=2.927, 95% CI: 1.031-8.757, P=0.048).

CONCLUSION

Overweight, general obesity and abdominal obesity were high among participants, especially among women. Taken together, these findings urge the implementation of a roadmap for this diabetic subpopulation to have a new lifestyle.

Urine Uric Acid Excretion Levels are Positively Associated with Obesity and Abdominal Obesity in Type 2 Diabetes Patients without Chronic Kidney Disease

PURPOSE

We aimed to investigate whether urine uric acid excretion (UUAE) levels are associated with obesity and abdominal obesity in patients with type 2 diabetes (T2D).

METHODS

There were 2785 type 2 diabetic patients in this cross-sectional study. Obesity was defined as BMI ≥ 25 kg/m², and abdominal obesity was defined as waist circumference (WC) ≥90 cm for men and WC ≥ 80 cm for women based on World Health Organization (WHO) recommendations for Asians. Chronic kidney disease (CKD) was defined as the estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m² and/or urinary albumin excretion (UAE) ≥300 mg/24h. 24-h UUAE was determined enzymatically using a single 24-hour urine collection. All the subjects were stratified into quartiles based on UUAE levels. Both obesity and abdominal obesity were compared among the UUAE quartile groups, respectively. Furthermore, the associations of UUAE with obesity and abdominal obesity were analyzed in both CKD and non-CKD patients, respectively.

RESULTS

There was an obvious increased trend in both obesity prevalence (36.2%, 41.5%, 46.3%, and 63.4%, respectively, p < 0.001 for trend) and abdominal obesity prevalence (58.1%, 61.2%, 64.7%, and 75.8%, respectively, p < 0.001 for trend) in patients with T2D across the UUAE quartiles after controlling for age, sex and diabetes duration. Multiple logistic regression analyses revealed independent associations between UUAE quartiles and obesity (p < 0.001) and abdominal obesity (p < 0.001) in all patients. However, UUAE was significantly associated with obesity and abdominal obesity only in the T2D patients without CKD (p < 0.001 in model 1, model 2, model 3 and model 4, respectively).

CONCLUSION

Increased UUAE levels were significantly associated with the presence of obesity, especially abdominal obesity in T2D patients without CKD.

Metformin and Risk of Hypertension in Taiwanese Patients With Type 2 Diabetes Mellitus

Background

Whether metformin use may reduce hypertension risk has not been studied. This study investigated such possibility in patients with type 2 diabetes mellitus.

Methods and Results

Newly diagnosed patients with type 2 diabetes mellitus during 1999–2005 were enrolled from the reimbursement database of the Taiwan's National Health Insurance and followed to December 31, 2011. Hypertension was defined either by a diagnosis or by a diagnosis plus the use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers and/or calcium channel blockers. Analyses were conducted in a propensity score matched‐pair cohort of 4810 ever users and 4810 never users. Cox proportional hazards regression model was used to estimate the hazard ratios. Results showed that when hypertension was defined by a diagnosis, 2261 never users and 1908 ever users developed hypertension. The overall hazard ratio was 0.724 (0.681–0.769) and the hazard ratios for the first (<2.0 months), second (2.0–13.0 months) and third (>13.0 months) tertiles of cumulative duration were 0.820 (0.745–0.903), 0.692 (0.634–0.756), and 0.687 (0.630–0.749), respectively. When cumulative duration of metformin therapy was treated as a continuous variable, the hazard ratio was 0.991 (0.989–0.994) for every 1‐month increment of metformin use. When hypertension was defined by a diagnosis plus the use of antihypertensive drugs, the overall hazard ratio was 0.831 (0.771–0.895), the hazard ratios for the respective tertiles were 0.868 (0.769–0.980), 0.852 (0.767–0.946), and 0.787 (0.709–0.874), and the hazard ratio was 0.994 (0.991–0.997) for every 1‐month increment of metformin use.

Conclusions

A reduced risk of hypertension is observed in metformin users in a dose‐response pattern.

Twelve-year trends of increasing overweight and obesity in patients with diabetes: the Shiga Diabetes Clinical Survey

The prevalence of obesity is increasing globally in patients with diabetes. This study aimed to examine 12-year trends of increasing obesity in Japanese patients with diabetes, and their clinical features. The study used results of the Shiga Diabetes Clinical Survey, which recorded medical performance in diabetic patients in 2000, 2006 and 2012. Data were analyzed from 14,205, 14,407 and 21,449 adult patients in these three years, respectively. Overweight and obesity prevalence and the clinical features of diabetes patients were examined, stratified by body mass index (BMI) and age. The prevalence of overweight (BMI 25-30 kg/m²) and obesity (BMI ≥30 kg/m²) were 27.0% and 5.1% in 2000, 28.9% and 7.3% in 2006 and 30.9% and 10.0% in 2012. Glycemic control, blood pressure and serum lipid profile improved over 12 years in all BMI categories. However, glycemic and triglyceride control were insufficient in obese patients aged <65 years (hemoglobin A1c 7.5 ± 1.4%, triglyceride 197.7 ± 178.4 mg/dL in 2012). The percentage of patients who used antihypertensive and lipid-lowering drugs increased and patients with higher BMI had increased frequency of using these drugs, both in young and old age groups. Higher BMI was significantly and positively associated with albuminuria. In summary, overweight and obesity have increased in Japanese diabetic patients, particularly for younger generations. Findings suggest that obesity may lead to poorer glycemic control, blood pressure and lipid profiles. Overweight and obesity are important modifiable risk factors for diabetes, suggesting that more active weight-control interventions are warranted.

Factors Associated with Cancer- and Non-Cancer-Related Deaths among Taiwanese Patients with Diabetes after 17 Years of Follow-Up

OBJECTIVE

A previous 12-year follow-up of a large diabetes cohort in Taiwan suggested a survival advantage in the patients with obesity. The present study further investigated additional determinants for cancer and non-cancer death in the cohort after a follow-up of 17 years.

METHODS

A cohort of 92546 diabetes patients recruited since 1995 was followed for vital status by matching the National Death Certificate Database until 2011. Cox regression estimated the hazard ratios for the following variables: age at baseline, sex, diabetes type, screen-detected diabetes (diabetes diagnosed accidentally through epidemiological screening programs or during visits to medical settings without a history of diabetes), diabetes duration, body mass index, insulin use, hypertension, smoking, and living region. Fasting glucose and history of dyslipidemia were available for additional adjustment in a subcohort of the patients (n = 14559).

RESULTS

A total of 40229 diabetes patients (43.5% of the cohort) died during follow-up and 10.9% died under the age of 60. Insulin use and smoking significantly predicted cancer and non-cancer death. The adjusted hazard ratio (95% confidence interval) associated with insulin use was 1.161 (1.052-1.281) for cancer death and 1.469 (1.413-1.526) for non-cancer death. Screen-detected diabetes and body mass index were consistently associated with a lower risk, but diabetes duration a higher risk, for non-cancer death, with adjusted hazard ratio of 0.683 (0.666-0.702), 0.955 (0.951-0.958) and 1.018 (1.017-1.020), respectively. Diabetes type had a null association disregarding the causes of death and living in rural areas was significantly associated with a higher mortality from non-cancer death. Hypertension, fasting glucose and dyslipidemia showed differential impacts on cancer and non-cancer death, and were significantly predictive for non-cancer death.

CONCLUSIONS

Screen-detected diabetes and a higher body mass index provide a survival advantage, especially for non-cancer death. However, insulin use is associated with a significantly higher risk of either cancer or non-cancer death.

Adiposity, hypertension and weight management behaviours in Ghanaian type 2 diabetes mellitus patients aged 20-70 years

OBJECTIVE

This study assessed the prevalence of general and abdominal obesity and hypertension as well the weight management behaviours of type 2 diabetes mellitus patients.

METHODS

It included 378 diabetes patients seeking care from two hospitals in Ghana. Standard methods and tools were used to assess participants' weight, height, waist circumference (WC), blood pressure (BP) and fasting plasma glucose (FPG). Weight management behaviours were measured using a questionnaire.

RESULTS

The prevalence of general obesity, abdominal obesity and hypertension was 20.1%, 46.6% and 67.7% respectively. Abdominal obesity was more likely in participants who: skipped breakfast, engaged in exercise to lose weight and were generally overweight/obese. General overweight and obesity was more likely in participants who: reported receipt of weight management counselling, engaged in exercise to lose weight, had a weight management plan/goal, and were abdominally obese. Hypertension was less likely in participants who had: no formal education, diabetes for ≥5 years and modified their dietary habits to lose weight but more likely in those who skipped breakfast.

CONCLUSION

Abdominal obesity, general overweight/obesity, and hypertension were frequent in this sample and were influenced by weight management behaviours.

The Cut-Off Point and Boundary Values of Waist-to-Height Ratio as an Indicator for Cardiovascular Risk Factors in Chinese Adults from the PURE Study

To explore a scientific boundary of WHtR to evaluate central obesity and CVD risk factors in a Chinese adult population. The data are from the Prospective Urban Rural Epidemiology (PURE) China study that was conducted from 2005-2007. The final study sample consisted of 43 841 participants (18 019 men and 25 822 women) aged 35-70 years. According to the group of CVD risk factors proposed by Joint National Committee 7 version and the clustering of risk factors, some diagnosis parameters, such as sensitivity, specificity and receiver operating characteristic (ROC) curve least distance were calculated for hypertension, diabetes, high serum triglyceride (TG), high serum low density lipoprotein cholesterol (LDL-C), low serum high density lipoprotein cholesterol (HDL-C) and clustering of risk factors (number≥2) to evaluate the efficacy at each value of the WHtR cut-off point. The upper boundary value for severity was fixed on the point where the specificity was above 90%. The lower boundary value, which indicated above underweight, was determined by the percentile distribution of WHtR, specifically the 5th percentile (P5) for both males and females population. Then, based on convenience and practical use, the optimal boundary values of WHtR for underweight and obvious central obesity were determined. For the whole study population, the optimal WHtR cut-off point for the CVD risk factor cluster was 0.50. The cut-off points for severe central obesity were 0.57 in the whole population. The upper boundary values of WHtR to detect the risk factor cluster with specificity above 90% were 0.55 and 0.58 for men and women, respectively. Additionally, the cut-off points of WHtR for each of four cardiovascular risk factors with specificity above 90% in males ranged from 0.55 to 0.56, whereas in females, it ranged from 0.57 to 0.58. The P5 of WHtR, which represents the lower boundary values of WHtR that indicates above underweight, was 0.40 in the whole population. WHtR 0.50 was an optimal cut-off point for evaluating CVD risks in Chinese adults of both genders. The optimal boundaries of WHtR were 0.40 and 0.57, indicating low body weight and severe risk for CVD, respectively, in Chinese adults.

Use of metformin and risk of kidney cancer in patients with type 2 diabetes

BACKGROUND

The anticancer effect of metformin has been reported in the literature but requires additional confirmation in epidemiologic studies. With respect to kidney cancer scarce data are available. This study investigates whether metformin use in patients with type 2 diabetes mellitus (T2DM) might affect kidney cancer risk.

METHODS

The reimbursement database of the National Health Insurance in Taiwan was used. T2DM patients aged ≥ 40 years and newly treated with either metformin (n=171,753, "ever users of metformin") or other antidiabetic drugs (n=75,499, "never users of metformin") within 1998-2002 were followed for at least 6 months for kidney cancer until 31 December 2009. The treatment effect was estimated by Cox regression using propensity score weighting by inverse probability of treatment weighting approach. Hazard ratios were estimated for ever versus never users, and for tertiles of cumulative duration of metformin therapy.

RESULTS

During follow-up, 917 ever users and 824 never users developed kidney cancer, with respective incidence of 80.09 and 190.30 per 100,000 person-years. The hazard ratio (95% confidence intervals) for ever versus never users is 0.279 (0.254-0.307); and is 0.598 (0.535-0.668), 0.279 (0.243-0.321) and 0.104 (0.088-0.124), respectively, for the first, second, and third tertile of cumulative duration of <14.5, 14.5-45.8 and >45.8 months. In subgroup analyses, the lower risk of kidney cancer associated with metformin use is consistently observed in both sexes, and in patients with or without concomitant use of other antidiabetic drugs.

CONCLUSION

Metformin use is associated with a decreased risk of kidney cancer in patients with T2DM.

Prolonged use of human insulin increases breast cancer risk in Taiwanese women with type 2 diabetes

Background

Human insulin is commonly used to treat hyperglycemia in patients with diabetes, but its potential link with female breast cancer is under debate. This study investigated whether human insulin use might be associated with breast cancer risk in Taiwanese women with type 2 diabetes.

Methods

The reimbursement databases of all Taiwanese diabetic patients from 1996 to 2009 were retrieved from the National Health Insurance. An entry date was set at 1 January 2004 and a total of 482,033 women with type 2 diabetes were followed up for breast cancer incidence until the end of 2009. Incidences for ever-users, never-users and subgroups of human insulin exposure (using tertile cutoffs of time since starting insulin, cumulative dose and cumulative duration of insulin) were calculated and the adjusted hazard ratios were estimated by Cox regression. The potential risk modification by concomitant treatment with metformin, statin and angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) was also evaluated.

Results

There were 59,798 ever-users and 422,235 never-users of human insulin, with respective numbers of incident breast cancer of 559 (0.93 %) and 4,711 (1.12 %), and respective incidence of 207.9 and 215.1 per 100,000 person-years. The overall adjusted hazard ratio (95 % confidence interval) did not show a significant association with insulin [1.033 (0.936-1.139)]. However, patients in the third tertiles of dose–response parameters might show a significantly higher risk of breast cancer while compared to never-users: 1.185 (1.026-1.368), 1.260 (1.096-1.450) and 1.257 (1.094-1.446) for ≥67 months for time since starting insulin, ≥39,000 units for cumulative dose of insulin, and ≥21.8 months for cumulative duration of insulin, respectively. Additional analyses suggested that the breast cancer risk associated with human insulin use might be beneficially modified by concomitant use of metformin, statin and ACEI/ARB.

Conclusions

This study discloses a significantly higher risk of breast cancer associated with prolonged use of human insulin. The increased risk of breast cancer associated with human insulin use may be modified by medications such as metformin, statin and ACEI/ARB.

Achievement of Target Blood Pressure Levels among Japanese Workers with Hypertension and Healthy Lifestyle Characteristics Associated with Therapeutic Failure

BACKGROUND

Few studies have examined Japanese with regard to the achievement rates for target blood pressure levels, or the relationship between these rates and healthy lifestyle characteristics in patients with hypertension as defined by the newly established hypertension management guidelines (JSH2014). The aim of this study was to elucidate achievement rates and examine healthy lifestyle characteristics associated with achievement status among Japanese.

METHODS

This cross-sectional study, conducted in January-December 2012, examined blood pressure control and healthy lifestyle characteristics in 8,001 Japanese workers with hypertension (mean age, 57.0 years; 78.8% were men) who participated in a workplace health checkup. Data were collected from workplace medical checkup records and participants' self-administered questionnaires. We divided into 5 groups [G1; young, middle-aged, and early-phase elderly patients (65-74 years old) without diabetes mellitus or chronic kidney disease (CKD) (<140/90 mmHg), G2; late-phase elderly patients (≥75 years old) without diabetes mellitus or CKD (<150/90 mmHg), G3; diabetic patients (<130/80 mmHg), G4; patients with CKD (<130/80 mmHg), and G5; patients with cerebrovascular and/or coronary artery diseases (<140/90 mmHg)] according to JSH2014. And then, achievement rates were calculated in each group. Multivariate analysis identified healthy lifestyle characteristics associated with "therapeutic failure" of target blood pressure.

RESULTS

Target blood pressures were achieved by 60.2% of young, middle-aged, and early-phase elderly patients (G1), 71.4% of late-phase elderly patients (G2), 30.5% of diabetic patients (G3), 33.4% of those with chronic kidney disease (G4), and 66.0% of those with cerebrovascular and/or coronary artery diseases (G5). A body mass index of 18.5-24.9 and non-daily alcohol consumption were protective factors, and adequate sleep was found to contribute to therapeutic success.

DISCUSSION

We found low achievement rates for treatment goals among patients with chronic kidney disease and diabetes mellitus. Maintaining an ideal body weight and adequate alcohol consumption may help with blood pressure control. Lifestyle modification may be necessary for better management of hypertension.

Metformin and endometrial cancer risk in Chinese women with type 2 diabetes mellitus in Taiwan

OBJECTIVE

To evaluate metformin effects on endometrial cancer risk in Chinese female patients with type 2 diabetes mellitus (T2DM) in Taiwan.

METHODS

This is a retrospective cohort analysis using the National Health Insurance database of Taiwan. Female patients with newly diagnosed T2DM and without endometrial cancer in 1998-2002 were followed to end of 2009 (n=478,921). Among them, 285,916 were never-users and 193,005 were ever-users of metformin. A time-dependent approach was used to calculate endometrial cancer incidence and estimate hazard ratios by Cox regression for ever-users, never-users, and subgroups of metformin exposure (tertiles of cumulative duration and cumulative dose). Sensitivity analyses were conducted in various subgroups.

RESULTS

During follow-up, 728 metformin ever-users and 2157 never-users developed endometrial cancer, representing an incidence of 60.00 and 121.69 per 100,000 person-years, respectively. The overall hazard ratio (95% confidence intervals) for ever- versus never-users after adjustment for propensity score (PS) was 0.675 (0.614-0.742). The PS-adjusted hazard ratios for the first, second, and third tertiles of cumulative duration of metformin therapy were 1.089 (0.966-1.228), 0.707 (0.616-0.812) and 0.313 (0.262-0.374), respectively (P-trend<0.0001); and 1.062 (0.942-1.197), 0.620 (0.538-0.715) and 0.376 (0.317-0.447), respectively (P-trend<0.0001), for cumulative dose of metformin. The dose-response relationship was demonstrated in various models and an overall reduced risk was consistently supported by sensitivity analyses.

CONCLUSIONS

The use of metformin in women with T2DM was associated with an overall significantly lower risk of endometrial cancer with dose-response relationship.

Use of Insulin and Mortality from Breast Cancer among Taiwanese Women with Diabetes

Background. To evaluate whether insulin use was predictive for mortality from breast cancer in Taiwanese women with diabetes mellitus. Methods. A total of 48,880 diabetic women were followed up to determine the mortality from breast cancer during 1995-2006. Cox models were used, considering the following independent variables: age, sex, diabetes type, diabetes duration, body mass index, smoking, insulin use, and area of residence. Insulin use was also considered for its duration of use at cutoffs of 3 years and 5 years. Results. Age was a significant predictor in all analyses. The multivariable-adjusted hazard ratio (95% confidence interval, P value) for insulin use without considering the duration of use was not statistically significant (1.339 [0.782-2.293, P = 0.2878]). Compared with nonusers, insulin users showed the following adjusted hazard ratios for insulin use <3 years, ≥3 years, <5 years, and ≥5 years: 0.567 (0.179-1.791, P = 0.3333), 2.006 (1.102-3.653, P = 0.0228), 1.045 (0.505-2.162, P = 0.9048), and 1.899 (0.934-3.860, P = 0.0763). Conclusions. Insulin use (mainly human insulin) for ≥3 years may be associated with a higher risk of breast cancer mortality.

Determinants of new-onset diabetes in older adults—Results of a national cohort study

BACKGROUND & AIMS

Diabetes mellitus is prevalent in many countries around the world, but the potential causal factors are not clearly known. We attempted to determine the risk factors for new-onset diabetes in ≥53-year old Taiwanese.

METHODS

We analyzed the 1999 and 2003 datasets of the Taiwan Longitudinal Survey on Aging (TLSA). We performed logistic regression analyses to determine the cross-sectional and longitudinal (1999-2003) associations of the sociodemographic, lifestyle, and health-related variables with diabetes and new-onset diabetes, respectively. We excluded those who were diabetic at baseline in the longitudinal analysis.

RESULTS

Results of the cross-sectional analysis showed that higher weight, past betel-quid chewing, IADL dependency, hypertension, heart disease, chronic kidney disease and depressive symptoms were positively associated with diabetes while alcohol drinking was negatively associated with diabetes. Longitudinal analysis showed that excessive weight, physical inactivity, depressive symptoms, and hypertension were associated with increased likelihood of new-onset diabetes while higher physical activity was associated with reduced likelihood of new-onset diabetes. Cigarette-smoking and moderate alcohol drinking showed no clear impacts on new-onset diabetes in older Taiwanese.

CONCLUSIONS

Results show that excessive weight, physical inactivity, hypertension and depressive symptoms are the major risk factors for new-onset diabetes for both Eastern and Western populations, whereas smoking and alcohol drinking have varying impacts among these populations. Better understanding of these relationships should be helpful for planning effective health promotion strategies for reducing the risk of new-onset diabetes in older adults.

Diabetes and gastric cancer: The potential links

This article reviews the epidemiological evidence linking diabetes and gastric cancer and discusses some of the potential mechanisms, confounders and biases in the evaluation of such an association. Findings from four meta-analyses published from 2011 to 2013 suggest a positive link, which may be more remarkable in females and in the Asian populations. Putative mechanisms may involve shared risk factors, hyperglycemia, Helicobacter pylori (H. pylori) infection, high salt intake, medications and comorbidities. Diabetes may increase the risk of gastric cancer through shared risk factors including obesity, insulin resistance, hyperinsulinemia and smoking. Hyperglycemia, even before the clinical diagnosis of diabetes, may predict gastric cancer in some epidemiological studies, which is supported by in vitro, and in vivo studies. Patients with diabetes may also have a higher risk of gastric cancer through the higher infection rate, lower eradication rate and higher reinfection rate of H. pylori. High salt intake can act synergistically with H. pylori infection in the induction of gastric cancer. Whether a higher risk of gastric cancer in patients with diabetes may be ascribed to a higher intake of salt due to the loss of taste sensation awaits further investigation. The use of medications such as insulin, metformin, sulfonylureas, aspirin, statins and antibiotics may also influence the risk of gastric cancer, but most of them have not been extensively studied. Comorbidities may affect the development of gastric cancer through the use of medications and changes in lifestyle, dietary intake, and the metabolism of drugs. Finally, a potential detection bias related to gastrointestinal symptoms more commonly seen in patients with diabetes and with multiple comorbidities should be pointed out. Taking into account the inconsistent findings and the potential confounders and detection bias in previous epidemiological studies, it is expected that there are still more to be explored for the clarification of the association between diabetes and gastric cancer.

Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review

BACKGROUND

Hypertension and obesity are known to contribute, directly or indirectly, to the development of long-term complications of type 2 diabetes mellitus (T2DM). Knowing the prevalence of these comorbidities is important for determining the size of the population that may benefit from strategies that reduce blood pressure and weight while controlling blood glucose.

METHODS

In this systematic literature review, electronic searches of PubMed, Embase, and the Cochrane Library were conducted to identify observational studies of hypertension and/or obesity prevalence in patients with T2DM throughout the world. The searches were limited to studies reported in English from January 1, 2001 to February 16, 2012.

RESULTS

From a total of 2,688 studies, 92 observational studies provided prevalence rates for hypertension and/or obesity specifically in adults with T2DM. Fifteen studies of specific subtypes of hypertension or subpopulations with T2DM were subsequently excluded, leaving 78 studies (in 77 articles) for inclusion in this article. Of these, 61studies reported hypertension prevalence, 44 reported obesity prevalence, and 12 reported the prevalence of hypertension with obesity. Most studies had a low risk of bias regarding diagnosis of T2DM (70/78), hypertension (59/69), or obesity (45/47). The continental regions with the most observational studies of hypertension or obesity prevalence were Europe (n = 30) and Asia (n = 26). Hypertension rates typically were high in all regions; most studies presented rates above 50%, and many presented rates above 75%. Obesity rates exceeded 30% in 38 of 44 studies and 50% in 14 of 44 studies, especially those assessing central obesity (based on waist circumference). Among obese adults, hypertension rates were at or above 70% in Asia and above 80% in Europe; rates were lower in North and South America but still above 30%.

CONCLUSION

Around the world, hypertension and obesity, separately or together, are common comorbidities in adults with T2DM.

Type 2 diabetes, smoking, insulin use, and mortality from hepatocellular carcinoma: a 12-year follow-up of a national cohort in Taiwan

BACKGROUND

The effect of smoking and insulin use in the association between diabetes and hepatocellular carcinoma (HCC) is not known.

MATERIALS AND METHODS

Age-standardized HCC mortality trends during 1995-2006 in the general population were calculated. A total of 88,694 type 2 diabetic patients aged ≥25 years recruited in 1995-1998 were followed till 2006. Age- and sex-specific mortality rates and the mortality rate ratios (vs. the average mortality rates in the general population) were calculated. Risk factors were evaluated by Cox regression.

RESULTS

The age-standardized mortality trend slightly increased significantly in women but was steady in men. For diabetic patients aged ≥25 years, 830 men and 515 women died of HCC during 1995-2006. Mortality rate ratios (95 % confidence interval) were larger with the decreasing age: 7.36 (6.52, 8.31), 2.48 (2.22, 2.78), 1.79 (1.59, 2.02), and 1.87 (1.51, 2.32) for age 25-54, 55-64, 65-74, and ≥75 years for men, respectively, 10.12 (7.73, 13.25), 4.08 (3.57, 4.67), 2.45 (2.15, 2.78), and 1.71 (1.34, 2.19) for women. Age, male sex, lower BMI, smoking, and insulin use were associated with HCC mortality, but diabetes duration was not. Smoking and insulin use carried a significantly higher risk of 22-29 % and 37-58 %, respectively, without interaction. A dose-responsive pattern between the duration of insulin use and HCC mortality was noted, with a relative risk of 1.5-1.7 in those who used insulin for ≥10 years.

CONCLUSIONS

Diabetic patients have a higher risk of HCC mortality, which is more remarkable in the younger age. Smoking and insulin are potentially modifiable risk factors.

Several lipid-related gene polymorphisms interact with overweight/obesity to modulate blood pressure levels

Little is known about the interactions of single nucleotide polymorphisms (SNPs) and overweight/obesity on blood pressure levels. The present study was undertaken to detect 10 lipid-related gene SNPs and their interactions with overweight/obesity on blood pressure levels. Genotyping of ATP-binding cassette transporter A1 (ABCA-1) V825I, acyl-CoA:cholesterol acyltransferase-1 (ACAT-1) rs1044925, low density lipoprotein receptor (LDL-R) AvaII hepatic lipase gene (LIPC) −250G > A, endothelial lipase gene (LIPG) 584C > T, methylenetetrahydrofolate reductase (MTHFR) 677C > T, the E3 ubiquitin ligase myosin regulatory light chain-interacting protein (MYLIP) rs3757354, proprotein convertase subtilisin-like kexin type 9 (PCSK9) E670G, peroxisome proliferator-activated receptor delta (PPARD) +294T > C, and Scavenger receptor class B type 1 (SCARB1) rs5888 was performed in 978 normal weight and 751 overweight/obese subjects. The interactions were detected by factorial regression analysis. The genotypes of ACAT-1 AC, LIPC GA and AA, and SCARB1 TT; LDL-R A-A- and LIPC GA; and SCARB1 TT were interacted with overweight/obesity to increase systolic, diastolic blood pressure (SBP, DBP) and pulse pressure (PP) levels; respectively. The genotypes of ACAT-1 CC; ACAT-1 AA and CC were interacted with overweight/obesity to decrease SBP, PP levels (p < 0.01–0.001); respectively. The differences in blood pressure levels between normal weight and overweight/obese subjects might partly result from different interactions of several SNPs and overweight/obesity.

Obesity paradox: differential effects on cancer and noncancer mortality in patients with type 2 diabetes mellitus

OBJECTIVE

To investigate associations between body mass index (BMI) and cause-specific mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

Prospective follow-up of a nationally representative cohort of 89,056 Taiwanese patients with T2DM recruited since 1995. Vital status was matched with the National Death Certificate Database until the end of 2006. Self-reported body weight and height were used to calculate BMI, which was treated either as a continuous or categorical variable (underweight, <18.5; normal, 18.5-22.9; overweight, 23.0-24.9; obesity I, 25.0-29.9; and obesity II, ≥30.0 kg/m(2)). Causes of death were classified as all-cause, cancer, diabetes complications (macrovascular and microvascular), and other. Cox regression was used to estimate the hazard ratios.

RESULTS

A total of 26,951 patients (30.3% of the cohort) died during follow-up (cancer 5.4%, diabetes complications 17.4%, and other causes 7.5%). As a continuous variable, BMI was inversely associated with mortality from all-cause, cancer, diabetes complications, and other causes, with respective adjusted hazard ratios (95% confidence intervals) of 0.942 (0.939-0.946), 0.966 (0.958-0.975), 0.935 (0.930-0.939), and 0.942 (0.935-0.949). Compared to normal weight, underweight was significantly predictive for any of causes of death, while overweight, obesity I, and obesity II were all significantly associated with mortality in an inverse pattern. After excluding patients with a follow-up duration <2 years, most BMI categories were not significantly predictive of mortality from cancer, suggesting a potential bias of cancer-induced weight loss.

CONCLUSIONS

The obesity paradox, mainly observed in noncancer mortality, exists in patients with T2DM, suggesting a survival advantage in obese diabetic patients.

Hypertension is the most important component of metabolic syndrome in the association with ischemic heart disease in Taiwanese type 2 diabetic patients

BACKGROUND

To evaluate the association between components of metabolic syndrome (MS) and ischemic heart disease (IHD) in Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS AND RESULTS

A total of 1,296 (604 men and 692 women) subjects with T2DM aged 62.5+/-11.7 (14-87) years were studied. MS was defined using the World Health Organization modified criteria and included more than 2 of hypertension, obesity, dyslipidemia and microalbuminuria. IHD was diagnosed through history or ischemic electrocardiogram according to the Minnesota codes. Results showed that MS was present in 76.2% and IHD in 36.3% of the patients, respectively. MS increased with age for both sexes, but there was no difference between men and women in the age groups of <45, 45-54 and 55-64 years. However, the prevalence of MS was significantly higher in women (87.7% vs 78.0%) in the age group>or=65 years. IHD prevalence was significantly higher in patients with MS, hypertension, dyslipidemia and obesity (p<0.01), and was higher with borderline significance for microalbuminuria (0.05<p<0.1). The respective age-adjusted odds ratios were 3.61 (2.57-5.08), 7.10 (5.38-9.38), 1.70 (1.32-2.18), 1.75 (1.33-2.28), and 1.11 (0.88-1.41).

CONCLUSIONS

The prevalence of MS in subjects with T2DM is high and increases with age. The impact of different risk factors on IHD is diverse, with hypertension being the most important.

Role of exercise in the prevention of obesity and hemodynamic abnormalities in adolescents

BACKGROUND

Poor physical activity plays a key role in the development of obesity. Little is known, however, about how much or the level of intensity of exercise that is needed to prevent obesity and hemodynamic abnormalities in adolescents.

METHODS AND RESULTS

Height, bodyweight, resting heart rate (HR), and systolic and diastolic blood pressure was measured in 17,523 male and 16,906 female high school students. Self-reported exercise intensity was related to percentage of overweight (POW), diastolic blood pressure, and resting HR in boys, and to bodyweight and resting HR in girls. Self-reported exercise amount was associated with POW, diastolic blood pressure, and resting HR in both boys and girls. Also, high intensity or adequate amount of exercise was associated with a lower prevalence of obesity and resting tachycardia in both sexes, and slightly associated with the prevalence of systolic high blood pressure in boys.

CONCLUSION

Both intensity and amount of exercise are associated with the prevalence of obesity and hemodynamic abnormalities in adolescents.

Comparison of hypertension and its risk factors between the Guangxi Bai Ku Yao and Han populations

OBJECTIVE

Little is known about the prevalence of hypertension in Bai Ku Yao, an isolated subgroup of the Yao minority in China. The aim of this study was to compare the difference in the prevalence of hypertension and its risk factors between the Guangxi Bai Ku Yao and Han populations.

METHODS

A cross-sectional study of hypertension in 1170 subjects of Bai Ku Yao and 1173 participants of Han Chinese aged 15-89 was conducted by a stratified randomized cluster sampling. Information on diet and lifestyle was collected with standardized questionnaires. Blood pressure, serum lipids and several anthropometric parameters were obtained in all subjects.

RESULTS

Systolic, diastolic and pulse pressure levels and hypertension prevalence (10.85% vs 16.45%, p<0.001) were lower in Bai Ku Yao than in Han. Hypertension was positively correlated with male, age, physical activity, body mass index, waist circumference, total energy, total fat and sodium intakes, and negatively associated with education level and total dietary fibre intake in both ethnic groups (p<0.05-0.001). Hypertension was also positively associated with alcohol consumption in Han. The rates of awareness, treatment and control were lower in Bai Ku Yao than in Han (p<0.05 for all).

CONCLUSIONS

The difference in the hypertension prevalence between the two ethnic groups might result from different diet, lifestyle, physical activity level, sodium intake and genetic factors.

Waist-to-height ratio and coronary artery disease in Taiwanese type 2 diabetic patients

Waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHeiR), and BMI are indicators for obesity. This study examined the usefulness of these indicators for coronary artery disease (CAD) in Taiwanese type 2 diabetic patients. A total of 1,345 (646 men and 699 women) patients aged 63.3 +/- 11.5 years were studied. CAD was defined by history or Minnesota-coded electrocardiogram. The relative importance was evaluated by the magnitude of adjusted odds ratio per 1-s.d. increment, the decrease in -2 log likelihood after adding the index to the logistic model, the c-index, and the Akaiki's information criterion (AIC). Results showed that the four indices were highly intercorrelated and except BMI for men, all indices differed significantly between patients with and without CAD in either sex. In logistic regressions, the respective adjusted odds ratios for WC, WHR, WHeiR, and BMI for every 1-s.d. increment were 1.209 (1.010-1.448), 1.109 (0.935-1.316), 1.231 (1.027-1.474), and 1.207 (0.997-1.461) for men; and were 1.176 (0.995-1.390), 1.105 (0.923-1.322), 1.280 (1.079-1.518), and 1.277 (1.083-1.507) for women. Only WHeiR was significant for both sexes and it also showed the greatest decrease in -2 log likelihood, the largest magnitude of odds ratio, and the smallest AIC while compared with the other indices in either sex. It is concluded that WHeiR has the superiority of independent association with CAD and the highest magnitude of association than WC, WHR, and BMI in both sexes. The usefulness of WHeiR should not be neglected in clinical practice.

Obesity and intermediate clinical outcomes in diabetes: evidence of a differential relationship across ethnic groups

AIM

To examine associations between obesity, ethnicity and intermediate clinical outcomes in diabetes.

METHODS

Population-based, cross-sectional study using electronic primary care medical records of 7300 people with diabetes from White, Black and south Asian ethnic groups.

RESULTS

The pattern of obesity differed within ethnic groups, with rates significantly higher in younger when compared to older Black (women, 63% vs. 44%, P = 0.002; men, 37% vs. 20%, P = 0.005) and south Asian (women, 47% vs. 27%, P = 0.01; men, 21% vs. 13%, P = 0.05) people. Obese people with diabetes were significantly less likely to achieve an established target for blood pressure control (adjusted odds ratio 0.50, 95% confidence interval 0.42, 0.59). Differences in mean systolic blood pressure in obese and normal weight persons were significant in the White group but not in the Black groups or south Asian groups (6.9 mmHg, 1.9 mmHg and 2.7 mmHg, respectively). Differences in mean diastolic blood pressure between obese and normal weight persons were 4.8 mmHg, 3.6 mmHg and 3.4 mmHg in the White, Black and south Asian groups. Mean HbA(1c) and achievement of an established treatment target did not differ significantly with obesity in any ethnic group.

CONCLUSIONS

Obesity is more prevalent amongst younger people than older people with diabetes in ethnic minority groups. The relationship between obesity and blood pressure control in diabetes differs markedly across ethnic groups. Major efforts must be implemented, especially in young people, to reduce levels of obesity in diabetes and improve long-term outcomes.