The HbA1c and all-cause mortality relationship in patients with type 2 diabetes is J-shaped: a meta-analysis of observational studies

Association between diet quality and all-cause mortality in a large Dutch cohort

Food-based dietary guidelines are helpful for governments and health agencies to encourage healthy eating at the population level. In order to assess adherence to such guidelines, index scores have been developed, the version in the Netherlands being the Dutch Healthy Diet-index (2015) (DHD2015-index), which reflect adherence to the 2015 Dutch dietary guidelines. Because a higher diet quality, i.e. a higher adherence to the dietary guidelines, is associated with better health outcomes, a higher DHD2015-index score would also mean better outcomes on measures of health, such as all-cause mortality. The present study aimed to elucidate this by investigating the association between DHD2015-index score and mortality in the Dutch population using data from 97 999 participants in the Lifelines cohort study. For the analyses, Cox Proportional Hazards regression was used, whilst accounting for age, sex, physiological measurements, exercise, and biochemical and lifestyle variables. There was a strong negative association between DHD2015-index score and mortality. Hazard ratios for DHD2015-index scores below 60 were approximately 1.2x larger than the mean. Every 10 unit increase in DHD2015-index scores between 60 and 90 led to a 0.1 reduction in hazard ratio, and every 10 unit increase between 90 and the highest DHD2015-index scores led to a reduction in hazard ratios of 0.05. The hazard ratio for the lowest quartile of DHD2015-index scores was 1.14 (95% CI = 1.04-1.26), whereas that for the highest quartile was 0.88 (95% CI = 0.84-0.92). Our results show a clear inverse relationship between DHD2015-index score and all-cause mortality.

Associations of fasting plasma glucose with all-cause mortality and cardiovascular events in older Chinese diabetes patients: A population-based cohort study

AIMS/INTRODUCTION

Our aim was to investigate the optimal fasting glucose (FPG) range in Chinese older adults with type 2 diabetes, and to clarify whether the optimal range varies according to the control of risk factors.

MATERIALS AND METHODS

The baseline survey for the cohort study began in 2018, with follow up ending in 2022. Our study enrolled 59,030 older diabetes patients with no history of cardiovascular disease (CVD). Participants were divided into nine groups based on their baseline glycemic status. The association between FPG and the risk of adverse outcomes was mainly estimated by multivariate Cox proportional risk models and restricted spline analysis.

RESULTS

During the 4-year follow-up period, a total of 5,637 deaths and 4,904 CVD events occurred. The associations of FPG with mortality and CVD events showed J-shaped curves. Among all-cause deaths, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.50 (95% confidence interval [CI] 1.31-1.71) and 1.84 (95% CI 1.67-2.02). Among CVD, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.31 (95% CI 1.13-1.53) and 1.71 (95% CI 1.54-1.89), respectively. The optimal FPG ranges of all-cause mortality and CVD were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. For participants with at least two risk factors, the optimal FPG levels were higher than those with fewer risk factors.

CONCLUSIONS

In older Chinese diabetes patients, the FPG ranges related to the minimum death and CVD event rates were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. Patients with more cardiovascular risk factors had higher optimal blood glucose ranges than those with fewer risk factors.

Sex-specific associations between haemoglobin glycation index and the risk of cardiovascular and all-cause mortality in individuals with pre-diabetes and diabetes: A large prospective cohort study

AIM

The aim of this study was to investigate the relationship between the haemoglobin glycation index (HGI), and cardiovascular disease (CVD) and all-cause mortality in adults with pre-diabetes and diabetes.

METHODS

This study included 10 267 adults with pre-diabetes and diabetes from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. Sex-differentiated relationships between HGI and mortality were elucidated using multivariate Cox proportional hazards models, restricted cubic splines and a two-piecewise Cox proportional hazards model.

RESULTS

During the median follow-up time of 103.5 months, a total of 535 CVD deaths and 1918 all-cause deaths were recorded. After multivariate adjustment, in males with pre-diabetes and diabetes, there was a U-shaped relationship between HGI and CVD mortality and all-cause mortality, with threshold points of -0.68 and -0.63, respectively. Before the threshold point, HGI was negatively associated with CVD mortality [hazard ratio (HR) 0.60; 95% confidence interval (CI) 0.41, 0.89] and all-cause mortality (HR 0.56; 95% CI 0.43, 0.74), and after the threshold point, HGI was positively associated with CVD mortality (HR 1.46; 95% CI 1.23, 1.73) and all-cause mortality (HR 1.40; 95% CI 1.23, 1.59). In contrast, HGI had an L-shaped relationship with all-cause mortality and no significant association with CVD mortality in females. To the left of the threshold points, the risk of all-cause mortality decreased (HR 0.50; 95% CI 0.35, 0.71) progressively with increasing HGI.

CONCLUSIONS

In the cohort study, HGI in pre-diabetic and diabetic populations was found to have a U-shaped association with CVD mortality and all-cause mortality in males and an L-shaped association with all-cause mortality only in females. Further prospective and mechanistic studies are warranted.

Association Between Hemoglobin A1c and Development of Cardiovascular Disease in Canadian Men and Women Without Diabetes at Baseline: A Population-Based Study of 608 474 Adults

BACKGROUND

We examined the association between hemoglobin A1c (HbA1c) and the development of cardiovascular disease (CVD) in men and women, without diabetes or CVD at baseline.

METHODS AND RESULTS

This retrospective cohort study included adults aged 40 to <80 years in Alberta, Canada. Men and women were divided into categories based on a random HbA1c during a 3-year enrollment period. The primary outcome of CVD hospitalization and secondary outcome of combined CVD hospitalization/mortality were examined during a 5-year follow-up period until March 31, 2021. A total of 608 474 individuals (55.2% women) were included. Compared with HbA1c 5.0% to 5.4%, men with HbA1c of 5.5% to 5.9% had an increased risk of CVD hospitalization (adjusted hazard ratio [aHR], 1.12 [95% CI, 1.07-1.19]) whereas women did not (aHR, 1.01 [95% CI, 0.95-1.08]). Men and women with HbA1c of 6.0% to 6.4% had a 38% and 17% higher risk and men and women with HbA1c ≥6.5% had a 79% and 51% higher risk of CVD hospitalization, respectively. In addition, HbA1c of 6.0% to 6.4% and HbA1c ≥6.5% were associated with a higher risk (14% and 41%, respectively) of CVD hospitalization/death in men, but HbA1c ≥6.5% was associated with a 24% higher risk only among women.

CONCLUSIONS

In both men and women, HbA1c ≥6.0% was associated with an increased risk of CVD and mortality outcomes. The association between CVD and HbA1c levels of 5.5% to 5.9%, considered to be in the "normal" range, highlights the importance of optimizing cardiovascular risk profiles at all levels of glycemia, especially in men.

Physiological phenotypes have optimal values relevant to healthy aging: sweet spots deduced from the Canadian Longitudinal Study on Aging

Previous observations on a group of exceptionally healthy "Super-Seniors" showed a lower variance of multiple physiological measures relevant for health than did a less healthy group of the same age. The finding was interpreted as the healthier individuals having physiological measurement values closer to an optimal level, or "sweet spot." Here, we tested the generalizability of the sweet-spot hypothesis in a larger community sample, comparing differences in the variance between healthier and less healthy groups. We apply this method to the Canadian Longitudinal Study on Aging (CLSA) comprehensive cohort of 30,097 participants aged 45 to 85 years with deep phenotype data. Data from both sexes and four age ranges were analyzed. Five instruments were used to represent different aspects of health, physical, and cognitive functioning. We tested 231 phenotypic measures for lower variance in the most healthy vs. least healthy quartile of each sex and age group, as classified by the five instruments. Segmented regression was used to determine sex-specific optimal values. One hundred forty-two physiological measures (61%) showed lower variance in the healthiest than in the least healthy group, in at least one sex and age group. The difference in variance was most significant for hemoglobin A1c and was also significant for many body composition measurements, but not for bone mineral density. Ninety-four phenotypes showed a nonmonotonic relationship with health, consistent with the idea of a sweet spot; for these, we determined optimal values and 95% confidence intervals that were generally narrower than the ranges of current clinical reference intervals. These findings for sweet spot discovery validate the proposed approach for identifying traits important for healthy aging.

Hemoglobin A1c Serum Level Predicts 5-year Mortality in Patients with Cognitive Impairment

Background

Subjective cognitive decline (SCD) and mild cognitive impairment (MCI) may occur as preclinical stages of Alzheimer's disease (AD), ultimately leading to dementia. Glycated hemoglobin A1c (HbA1c) is a diagnostic marker for diabetes mellitus and indicates mortality risk.

Objectives

This university-based, exploratory retrospective study examined the impact of HbA1c serum level on 5-year mortality among individuals with cognitive impairment.

Methods

Included were 1076 subjects aged at least 50 years who visited the Memory Outpatient Clinic of the Medical University of Vienna due to memory problems. Participants were diagnosed with SCD, MCI, or AD subsequent to neurological examination, standard laboratory blood tests, and neuropsychological testing. Survival was compared between diagnostic subgroups and with respect to HbA1c categories using log-rank tests based on Kaplan-Meier functions. The Neuropsychological Test Battery Vienna (NTBV) was dimensionally reduced, and a principal component analysis (PCA) was performed to further analyze results. Corresponding factor scores, HbA1c values, and baseline characteristics were included in Cox proportional hazards models to assess 5-year mortality risk.

Results

During the observation period, 323 patients (30%) died at a mean age comparable between diagnostic subgroups (SCD 84.2 ± 10.1, MCI 81.2 ± 8.3, AD 82.2 ± 7.4 years). Individuals with normal serum HbA1c levels had significant advantages in survival within the MCI (12.9 ± .3 vs. 10.0 ± .8 years) and the AD subgroups (8.2 ± .4 vs. 5.5 ± .6 years), and metric HbA1c predicted 5-year mortality (HR 1.24).

Conclusion

This study demonstrates an association between abnormal HbA1c serum levels and increased mortality.

Impact of Glucagon-Like Peptide 1 Receptor Agonists in Patients with Hemoglobin A1c of 9% or Greater

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 agonists) are effective hemoglobin A1c (HbA1c) and weight-lowering agents. The treatment effect is unknown in patients with HbA1c of 9% or greater. Objective: The purpose of this study was to evaluate glycemic control and weight loss after adding a GLP-1 agonist in patients with a baseline HbA1c of 9% (75 mmol/mol) or greater. Methods: A single-health system retrospective chart review screened adults with type 2 diabetes mellitus with a baseline hemoglobin A1c of 9% (75 mmol/mol) or greater and were prescribed a GLP-1 agonist for eligibility. The primary outcome assessed was the change in HbA1c from baseline to the first HbA1c check. Secondary outcomes included change in weight (kg) from baseline to the first HbA1c check. Results: Three hundred sixty-two patients were screened of which 151 (41.7%) were included in the final analysis. The mean change in HbA1c from baseline to first HbA1c check for all participants was -2.1% (95% CI: -2.3% to -1.8%; P < .001; -23 mmol/mol [95% CI: -25 to -20 mmol/mol]). The mean change in weight from baseline to first HbA1c check was -2.0 kg (95% CI: -2.6 kg to -1.4 kg; P < .001). Conclusion: In patients with type 2 diabetes mellitus with a baseline HbA1c ≥ 9%, GLP-1 agonist initiation resulted in a significant reduction of both HbA1c and weight compared to baseline. Large, prospective, multisite studies are needed to confirm findings of this retrospective study.

Type 2 diabetes remission trajectories and variation in risk of diabetes complications: A population-based cohort study

Biochemical remission of type 2 diabetes is achievable through dietary changes, physical activity and subsequent weight loss. We aim to identify distinct diabetes remission trajectories in a large population-based cohort over seven-years follow-up and to examine associations between remission trajectories and diabetes complications. Group-based trajectory modelling examined longitudinal patterns of HbA1c level (adjusting for remission status) over time. Multivariable Cox models quantified the association between each remission trajectory and microvascular complications, macrovascular complications, cardiovascular (CVD) events and all-cause mortality. Four groups were assigned. Group 1 (8,112 [13.5%]; achieving HbA1c <48 mmol/mol (6.5%) followed by increasing HbA1c levels); Group 2 (6,369 [10.6%]; decreasing HbA1c levels >48 mmol/mol (6.5%)); Group 3 (36,557 [60.6%]; stable high HbA1c levels); Group 4 (9,249 [15.3%]; stable low HbA1c levels (<48mmol/mol or <6.5%)). Compared to Group 3, Groups 1 and 4 had lower risk of microvascular complications (aHRs (95% CI): 0.65 (0.61-0.70), p-value <0.001;0.59 (0.55-0.64) p-value<0.001, respectively)), macrovascular complications (aHRs (95% CI): 0.83 (0.75-0.92), p-value<0.001; 0.66 (0.61-0.71), p-value<0.001) and CVD events (aHRs (95% CI): 0.74(0.67-0.83), p-value<0.001; 0.67(0.61-0.73), p-vlaue<0.001). Risk of CVD outcomes were similar for Groups 2 and 3. Compared to Group 3, Group 1 (aHR: 0.82(95% CI: 0.76-0.89)) had lower risk of mortality, but Group 4 had higher risk of mortality (aHR: 1.11(95% CI: 1.03-1.19)). Risk of CVD outcomes vary by pattern of remission over time, with lowest risk for those in remission longer. People who achieve remission, even for shorter periods of time, continue to benefit from this lower exposure to hyperglycaemia, which may, in turn, lower the risk of CVD outcomes including mortality.

Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome—A Narrative Review

Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic foot have multiple prognostic implications in addition to limiting functional status and leading to decreased quality of life for these patients. We searched the electronic databases of PubMed, MEDLINE and EMBASE for studies that evaluated the role of DFS as a cardiovascular risk factor through the pathophysiological mechanisms involved, in particular the inflammatory ones and the associated metabolic changes. In the era of evidence-based medicine, the management of these cases in multidisciplinary teams of “cardio-diabetologists” prevents the occurrence of long-term disabling complications and has prognostic value for cardiovascular morbidity and mortality among diabetic patients. Identifying artificial-intelligence-based cardiovascular risk prediction models or conducting extensive clinical trials on gene therapy or potential therapeutic targets promoted by in vitro studies represent future research directions with a modulating role on the risk of morbidity and mortality in patients with DFS.

Protective effect of intensive glucose lowering therapy on all-cause mortality, adjusted for treatment switching using G-estimation method, the ACCORD trial

Previous analysis of the action to control cardiovascular risk in diabetes showed an increased risk of mortality among patients receiving intensive glucose lowering therapy using conventional regression method with intention to treat approach. This method is biased when time-varying confounder is affected by the previous treatment. We used 15 follow-up visits of ACCORD trial to compare the effect of time-varying intensive vs. standard treatment of glucose lowering drugs on cardiovascular and mortality outcomes in diabetic patients. The treatment effect was estimated using G-estimation and compared with accelerated failure time model using two modeling strategies. The first model adjusted for baseline confounders and the second adjusted for both baseline and time-varying confounders. While the hazard ratio of all-cause mortality for intensive compared to standard therapy in AFT model adjusted for baseline confounders was 1.17 (95% CI 1.01-1.36), the result of time-dependent AFT model  was compatible with both protective and risk effects. However, the hazard ratio estimated by G-estimation was 0.64 (95% CI 0.39-0.92). The results of this study revealed a protective effect of intensive therapy on all-cause mortality compared with standard therapy in ACCORD trial.

A patient-centered comparative effectiveness research study of culturally appropriate options for diabetes self-management

This project compared the effectiveness of two evidence-based models of culturally competent diabetes health promotion: The Diabetes Self-Management Support Empowerment Model (DSMS), and The Chronic Care Model (CCM). Our primary outcome was improvement in patient capacity for diabetes self-management as measured by the Diabetes Knowledge Questionnaire (DKQ) and the Patient Activation Measure (PAM). Our secondary outcome was patient success at diabetes self-management as measured by improvement in A1c, depression sores using the PHQ-9, and Body Mass Index (BMI). We also gathered data on the cultural competence of the program using the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Set (CAHPS-CC). We compared patient outcomes in two existing sites in Albuquerque, New Mexico that serve a large population of Latino diabetes patients from low-income households. Participants were enrolled as dyads-a patient participant (n=226) and a social support participant (n=226). Outcomes over time and by program were analyzed using longitudinal linear mixed modeling, adjusted for patient participant demographic characteristics and other potential confounding covariates. Secondary outcomes were also adjusted for potential confounders. Interactions with both time and program helped to assess outcomes. This study did not find a difference between the two sites with respect to the primary outcome measures and only one of the three secondary outcomes showed differential results. The main difference between programs was that depression decreased more for CCM than for DSMS. An exploratory, subgroup analysis revealed that at CCM, patient participants with a very high A1c (>10) demonstrated a clinically meaningful decrease. However, given the higher cultural competence rating for the CCM, statistically significant improvement in depression, and the importance of social support to the patients, results suggest that a culturally and contextually situated diabetes self-management and education program design may deliver benefit for patients, especially for patients with higher A1c levels.

Associations Between Mean HbA1c, HbA1c Variability, and Both Mortality and Macrovascular Complications in Patients with Diabetes Mellitus: A Registry-Based Cohort Study

Background

We investigate the association between mean HbA1c, HbA1c variability, and all-cause mortality and diabetes-related macrovascular complications in patients with diabetes.

Methods

We performed a retrospective cohort study using patients present in the Singapore Health Services diabetes registry (SDR) during 2013 to 2014. We assessed mean HbA1c using three models: a baseline mean HbA1c for 2013-14, the mean across the whole follow-up period, and a time-varying yearly updated mean. We assessed HbA1c variability at baseline using the patient's HbA1c variability score (HVS) for 2013-14. The association between mean HbA1c, HVS, and 6 outcomes were assessed using Cox proportional hazard models.

Results

We included 43,837-53,934 individuals in the analysis; 99.3% had type 2 diabetes mellitus. The data showed a J-shaped distribution in adjusted hazard ratios (HRs) for all-cause mortality, ischemic heart disease, acute myocardial infarction, peripheral arterial disease, and ischemic stroke, with an increased risk of developing these outcomes at HbA1c <6% (42 mmol/mol) and ≥8% (64 mmol/mol). With the addition of HVS, the J-shaped distribution was maintained for the above outcomes, but HRs were greater at HbA1c <6.0% (42 mmol/mol) and reduced at HbA1c ≥8.0% (64 mmol/mol) when compared to models without HVS. The risk for all outcomes increased substantially with increasing glycaemic variability.

Conclusion

Both low (<6.0% [42 mmol/mol]) and high (≥8.0% [64 mmol/mol]) levels of glycaemic control are associated with increased all-cause mortality and diabetes-related macrovascular complications. Glycaemic variability is independently associated with increased risk for these outcomes. Therefore, patients with stable glycaemic level of 6-8% (42-64mmol/mol) are at lowest risk of all-cause mortality and diabetes-related macrovascular complications.

Diabetes with poor-control HbA1c is cardiovascular disease 'risk equivalent' for mortality: UK Biobank and Hong Kong population-based cohort study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) has traditionally been considered a coronary heart disease 'risk equivalent' for future mortality, but significant heterogeneity exists across people with T2DM. This study aims to determine the risk of all-cause mortality of patients with cardiovascular disease (CVD) and T2DM in UK and Hong Kong, with stratifications for hemoglobin A1 (HbA1c) concentrations, compared with those without CVD and diabetes mellitus.

RESEARCH DESIGN AND METHODS

This is a retrospective cohort study of 3 839 391 adults from Hong Kong and a prospective cohort study of 497 779 adults from the UK Biobank. Individuals were divided into seven disease groups: (1) no T2DM and CVD, (2) T2DM only with HbA1c <7%, (3) T2DM only with HbA1c 7%-7.9%, (4) T2DM only with HbA1c 8%-8.9%, (5) T2DM only with HbA1c ≥9%, (6) CVD only, and (7) T2DM and CVD. Differences in all-cause mortality between groups were examined using Cox regression.

RESULTS

After around 10 years of median follow-up, 423 818 and 19 844 deaths were identified in the Hong Kong cohort and UK Biobank, respectively. Compared with individuals without T2DM and CVD, the adjusted HR for all-cause mortality in the other six disease groups for the Hong Kong cohort was 1.25 (95% CI 1.23 to 1.27) for T2DM only with HbA1c <7%, 1.21 (95% CI 1.19 to 1.23) for T2DM only with HbA1c 7%-7.9%, 1.36 (95% CI 1.33 to 1.39) for T2DM only with HbA1c 8%-8.9%, 1.82 (95% CI 1.78 to 1.85) for T2DM only with HbA1c ≥9%, 1.37 (95% CI 1.36 to 1.38) for CVD only, and 1.83 (95% CI 1.81 to 1.85) for T2DM and CVD, and for the UK Biobank the HR was 1.45 (95% CI 1.33 to 1.58), 1.50 (95% CI 1.32 to 1.70), 1.72 (95% CI 1.43 to 2.08), 2.51 (95% CI 2.05 to 3.08), 1.67 (95% CI 1.59 to 1.75) and 2.62 (95% CI 2.42 to 2.83), respectively. This indicates that patients with T2DM had an increased risk of mortality compared with those without T2DM and CVD, and in those with HbA1c ≥9% an even higher risk than people with CVD.

CONCLUSIONS

Patients with T2DM with poor HbA1c control (8%-8.9% and ≥9%) were associated with similar and higher risk of mortality compared with patients with CVD, respectively. Optimal HbA1c, controlled for risk reduction and prevention of mortality and complications in diabetes management, remains important.

Exercise Oximetry Correlates Better With Exercise-Induced Lactate Increase, than Ankle Brachial Index or Walking Time, in Vascular Claudicants

In claudication, the correlation between walking-induced biomarkers and indices of clinical severity (e.g., walking distance or ankle brachial index (ABI)), is fair. We hypothesized that a correlation would be observed between the clinical estimation of ischemia severity with exercise transcutaneous oximetry (Ex-TcpO2) and lactate increase. A prospective study was performed among 377 patients with arterial claudication. We recorded age, sex, ABI, body mass index (BMI), systolic arterial blood pressure (SBP), and glycemia. Capillary blood lactate was measured at rest and 3 min after a constant load treadmill test. We recorded maximum walking time (MWT), heart rate (HRmax), the sum of minimal decrease from oxygen values for buttocks, thighs and calves Ex-TcpO2 (DROPmin), as well as the amplitude of chest-TcpO2 decrease. A multilinear regression model was used to assess the variables associated with lactate increase. BMI, SBP, HRmax, the amplitude of decrease in chest-TcpO2 and DROPmin, but not age, sex, ABI, MWT, diabetes mellitus nor glycemia, were significantly associated to lactate increase in the model. Because it accounts for the severity and diffusion of lower-limb exercise-induced ischemia and detects exercise induced hypoxemia, TcpO2 may be preferable to ABI or MWT to estimate the metabolic consequences of walking in claudicants.

Early and ongoing stable glycaemic control is associated with a reduction in major adverse cardiovascular events in people with type 2 diabetes: A primary care cohort study

AIM

To determine whether achieving early glycaemic control, and any subsequent glycaemic variability, was associated with any change in the risk of major adverse cardiovascular events (MACE).

MATERIALS AND METHODS

A retrospective cohort analysis from the Oxford-Royal College of General Practitioners Research and Surveillance Centre database-a large, English primary care network-was conducted. We followed newly diagnosed patients with type 2 diabetes, on or after 1 January 2005, aged 25 years or older at diagnosis, with HbA1c measurements at both diagnosis and after 1 year, plus five or more measurements of HbA1c thereafter. Three glycaemic bands were created: groups A (HbA1c < 58 mmol/mol [<7.5%]), B (HbA1c ≥ 58 to 75 mmol/mol [7.5%-9.0%]) and C (HbA1c ≥ 75 mmol/mol [≥9.0%]). Movement between bands was determined from diagnosis to 1 year. Additionally, for data after the first 12 months, a glycaemic variability score was calculated from the number of successive HbA1c readings differing by 0.5% or higher (≥5.5 mmol/mol). Risk of MACE from 1 year postdiagnosis was assessed using time-varying Cox proportional hazards models, which included the first-year transition and the glycaemic variability score.

RESULTS

From 26 180 patients, there were 2300 MACE. Compared with group A->A transition over 1 year, those with C->A transition had a reduced risk of MACE (HR 0.75; 95% CI 0.60-0.94; P = .014), whereas group C->C had HR 1.21 (0.81-1.81; P = .34). Compared with the lowest glycaemic variability score, the greatest variability increased the risk of MACE (HR 1.51; 1.11-2.06; P = .0096).

CONCLUSION

Early control of HbA1c improved cardiovascular outcomes in type 2 diabetes, although subsequent glycaemic variability had a negative effect on an individual's risk.

Intensive glycemic control and macrovascular, microvascular, hypoglycemia complications and mortality in older (age ≥60years) or frail adults with type 2 diabetes: a systematic review and meta-analysis from randomized controlled trial and observation studies

INTRODUCTION

Guidelines for type 2 diabetes (T2D) recommend individualized HbA1c targets to take into account patient age or frailty. We synthesized evidence from randomized controlled trials and observational studies for intensive glycemic control (HbA1c target ≤58 mmol/mol) versus standard care, in elderly (age ≥60 years) or frail adults with T2D.

METHODS

Searches were performed utilizing recognized terms for T2D, frailty, older age, and HbA1c control and outcomes of interest. Meta-analysis was performed where possible. Primary outcomes included all-cause mortality, severe hypoglycemia, and hospital admission rates. Vascular complications, cognitive decline, and falls/fractures were secondary outcomes.

RESULTS

7,528 studies were identified of which 15 different clinical studies were selected. No difference was noted in all-cause mortality with intensive control (pooled hazard ratio 0.96, 95% confidence interval 0.90-1.03), but risk of severe hypoglycemia increased (2.45, 2.22-2.72). Intensive control was associated reductions in microvascular (0.73, 0.68-0.79) and macrovascular complications (0.84, 0.79-0.89). Outcome data for risk of hospitalization, cognition, and falls/fractures were limited.

CONCLUSION

Intensive glycemic control was associated with reduced rates of complications but increased severe hypoglycemia. Significant heterogeneity exists and the impact of different drug regimens is unclear. Caution is needed when setting glycemic targets in elderly or frail individuals.

Glycemic Control and Risk of Sepsis and Subsequent Mortality in Type 2 Diabetes

OBJECTIVE

To investigate the nature of the relationship between HbA1c and sepsis among individuals with type 2 diabetes, and to assess the association between sepsis and all-cause mortality in such patients.

RESEARCH DESIGN AND METHODS

We included 502,871 individuals with type 2 diabetes recorded in the Swedish National Diabetes Register and used multivariable Cox regression and restricted cubic spline analyses to assess the association between time-updated HbA1c values and sepsis occurrence between 1 January 2005 and 31 December 2015. The association between sepsis and death was examined using multivariable Cox regression analysis.

RESULTS

Overall, 14,534 (2.9%) patients developed sepsis during the study period. On multivariable Cox regression analysis, compared with an HbA1c of 48-52 mmol/mol (6.5-6.9%), the adjusted hazard ratio for sepsis was 1.15 (95% CI 1.07-1.24) for HbA1c <43 mmol/mol (6.1%), 0.93 (0.87-0.99) for HbA1c 53-62 mmol/mol (7.0-7.8%), 1.05 (0.97-1.13) for HbA1c 63-72 mmol/mol (7.9-8.7%), 1.14 (1.04-1.25) for HbA1c 73-82 mmol/mol (8.8-9.7%), and 1.52 (1.37-1.68) for HbA1c >82 mmol/mol (9.7%). In the cubic spline model, a reduction of the adjusted risk was observed within the lower HbA1c range until 53 mmol/mol (7.0%), with a hazard ratio of 0.78 (0.73-0.82) per SD; it increased thereafter (P for nonlinearity <0.001). As compared with patients without sepsis, the adjusted hazard ratio for death among patients with sepsis was 4.16 (4.03-4.30).

CONCLUSIONS

In a nationwide cohort of individuals with type 2 diabetes, we found a U-shaped association between HbA1c and sepsis and a fourfold increased risk of death among those developing sepsis.

The Survival Benefit for Optimal Glycemic Control in Advanced Non-Small Cell Lung Cancer Patients With Preexisting Diabetes Mellitus

Background

Diabetes mellitus (DM) is a frequent comorbidity in patients with cancer. This study aimed to evaluate the prognosis of advanced non-small cell lung cancer (NSCLC) patients with DM and to assess whether an optimal glycemic control improves overall survival (OS).

Methods

A total of 1279 advanced NSCLC patients including 300 (23.5%) with preexisting DM were retrospectively reviewed. The continuous relationship between glycated hemoglobin A1C (HbA1c) level and OS was analyzed by restricted cubic spline (RCS) function. Optimal HbA1c cut-off point was determined using X-tile analysis. Survival was analyzed with the Kaplan–Meier method and compared among groups stratified by diabetes status and HbA1c. Multivariable Cox proportional hazards regression analysis was employed to identify prognostic factors for OS after adjusting for baseline characteristics.

Results

DM and non-DM patients had similar OS (median (95% CI): 22.85 (20.05-26.73) vs. 22.22 (20.35-24.76) months, P=0.950). The multivariate Cox regression analyses showed that DM status was not a prognostic factor for OS (HR: 0.952, 95% CI: 0.808-1.122, P=0.559). However, there existed a non-linear but generally positive relationship between the elevated HbA1c level and increased risk of overall mortality. HbA1c > 6.6% was a negative prognostic factor for OS (HR: 1.593, 95% CI: 1.113-2.280, P=0.011). The median OS (95% CI) for nondiabetic patients, DM patients with HbA1c ≤6.6% and those with HbA1c > 6.6% was 22.22 (20.01-24.43), 25.28 (21.79-28.77) and 15.45 (7.57-23.33) months, respectively. Well-controlled DM patients had a comparable crude OS (HR (95% CI): 0.90 (0.76-1.08), P=0.273] compared to nondiabetic patients while patients with HbA1c>6.6% had a worse crude OS than patients without DM (HR (95% CI): 1.70 (1.24-2.34), P=0.001]. The survival benefit of good HbA1c control was prominent in all subgroups.

Conclusion

Impaired glycemic level negatively affects survival for patients with advanced NSCLC while proper glycemic control with HbA1c ≤6.6% improves the OS.

Association of glycated hemoglobin A1c levels with cardiovascular outcomes in the general population: results from the BiomarCaRE (Biomarker for Cardiovascular Risk Assessment in Europe) consortium

BACKGROUND

Biomarkers may contribute to improved cardiovascular risk estimation. Glycated hemoglobin A1c (HbA1c) is used to monitor the quality of diabetes treatment. Its strength of association with cardiovascular outcomes in the general population remains uncertain. This study aims to assess the association of HbA1c with cardiovascular outcomes in the general population.

METHODS

Data from six prospective population-based cohort studies across Europe comprising 36,180 participants were analyzed. HbA1c was evaluated in conjunction with classical cardiovascular risk factors (CVRFs) for association with cardiovascular mortality, cardiovascular disease (CVD) incidence, and overall mortality in subjects without diabetes (N = 32,496) and with diabetes (N = 3684).

RESULTS

Kaplan-Meier curves showed higher event rates with increasing HbA1c levels (log-rank-test: p < 0.001). Cox regression analysis revealed significant associations between HbA1c (in mmol/mol) in the total study population and the examined outcomes. Thus, a hazard ratio (HR) of 1.16 (95% confidence interval (CI) 1.02-1.31, p = 0.02) for cardiovascular mortality, 1.13 (95% CI 1.03-1.24, p = 0.01) for CVD incidence, and 1.09 (95% CI 1.02-1.17, p = 0.01) for overall mortality was observed per 10 mmol/mol increase in HbA1c. The association with CVD incidence and overall mortality was also observed in study participants without diabetes with increased HbA1c levels (HR 1.12; 95% CI 1.01-1.25, p = 0.04) and HR 1.10; 95% CI 1.01-1.20, p = 0.02) respectively. HbA1c cut-off values of 39.9 mmol/mol (5.8%), 36.6 mmol/mol (5.5%), and 38.8 mmol/mol (5.7%) for cardiovascular mortality, CVD incidence, and overall mortality, showed also an increased risk.

CONCLUSIONS

HbA1c is independently associated with cardiovascular mortality, overall mortality and cardiovascular disease in the general European population. A mostly monotonically increasing relationship was observed between HbA1c levels and outcomes. Elevated HbA1c levels were associated with cardiovascular disease incidence and overall mortality in participants without diabetes underlining the importance of HbA1c levels in the overall population.

Hemoglobin A1c-levels and subsequent risk of depression in individuals with and without diabetes

BACKGROUND

It has been suggested that long-term glycemic load as reflected in plasma levels of Glycosylated Hemoglobin, Type A1C (HbA1c) is associated with higher risk of depression, however results have been conflicting. We examined the potential association between HbA1c and risk of depression in a large population-based cohort without baseline diabetes (the Glostrup cohort) defined by either self-reported diabetes, registry diagnosis of diabetes or use of antidiabetic medication at baseline and in a national diabetes cohort (the Danish Adult Diabetes Database).

METHODS

A total of 16,124 middle-aged individuals from the Glostrup cohort and 93,544 patients registered in the Danish Adult Diabetes Database were followed from the first registered HbA1c measurement (1999-2014) for subsequent diagnosis of depression or use of antidepressant medication in nation-wide Danish registers. The association was analyzed using a Cox proportional hazards regression model with HbA1c on both a continuous scale using restricted cubic splines and categorized based on the groups found in the spline model. We adjusted for relevant sociodemographic and clinical variables including previous depression and tested for interaction of both gender, insulin use and diabetes type.

RESULTS

During follow-up, 2694 (17%) in the Glostrup cohort and 29,234 (31%) in the diabetes cohort developed depression. In the Glostrup cohort, we found an indication of a positive linear association between HbA1c and depression in women, while no clear association was found in men. In patients with diabetes, we found a U-shaped association between HbA1c and depression in both men and women with the lowest risk estimates for HbA1c levels of 58 mmol/mol (7.5%) in men and of 60 mmol/mol (7.6%) in women. When HbA1c was categorized, men with the highest HbA1c-levels had significantly elevated risk of depression (HR_HbA1c>9.4 1.16 (95%CI 1.10-1.23)) after multifactorial adjustment compared to the reference group with HbA1c of 42.1-56.2 mmol/mol (6.0-7.3%). Women in the lowest and highest category of HbA1c had significantly higher risk of depression HR_HbA1c<6.0 1.15 (95% CI 1.09-1.22) and HR_HbA1c>9.3 1.10 (95% CI 1.04-1.16), respectively, compared to the reference group with HbA1c 42.1-55.0 mmol/mol (7.2-9.3%). There was a significant interaction with gender, but no interaction for insulin use or diabetes type.

CONCLUSIONS

In a population without baseline diabetes, higher HbA1c levels seemed associated with higher depression risk in women, whereas a U-shaped association was found in patients with known diabetes.

Both high and low pre-infection glucose levels associated with increased risk for severe COVID-19: New insights from a population-based study

Importance

Patients with diabetes are known to be at increased risk for infections including severe coronavirus disease 2019 (COVID-19) but the relationship between COVID-19 severity and specific pre-infection glucose levels is not known.

Objective

To assess the differential effects of pre-infection glucose levels on the risk for severe COVID-19 amongst patients with and without diabetes.

Design

Population based historical cohort study.

Setting

National state-mandated HMO.

Patients

All adult patients with a positive SARS-COV2 test between March-October 2020.

Exposure

Recent fasting blood glucose (FBG) and glycated hemoglobin (HBA1C), age, gender, body mass index (BMI) and diagnoses of diabetes, hypertension, ischemic heart disease.

Outcome

Risk for severe COVID-19, defined as resulting in ≥10 hospitalization days, ICU admission or death.

Results

37,121 patients with a positive SARS-COV2 test were identified; 707 defined as severe (1.9%). Unadjusted risk factors for severe disease were age (OR = 1.1 for every year increase; 95% CI 1.09–1.11, p < 0.001), male gender (OR = 1.34, 95% CI 1.06–1.68, p = 0.012); BMI (OR = 1.02 for 1 kg/m² increase, 95% CI 1.00–1.04, p = 0.025). Controlling for these factors, we found an association between pre-infection FBG and the risk of severe COVID-19, with a differential effect in patients with and without a diagnosis of diabetes. For patients without diabetes, elevated FBG in the pre-diabetes range (106–125 mg/dl) was associated with severe COVID-19 (OR 1.55 95% CI 1.04–2.26 p = 0.027). For patients with a diagnosis of diabetes, we found a J-shaped association between pre-infection glucose control and the risk for severe COVID-19 where the lowest risk for was for patients with FBG 106–125 mg/dl; the risk increased with higher pre-infection glucose levels but strikingly also for patients with a low pre-infection FBG (<100mg/dl) or HbA1C (<5.7%).

Conclusions and relevance

Elevated pre-infection blood glucose is a risk factor for severe COVID-19 even in non-diabetics. For patients with a diagnosis of diabetes both high as well as low pre-infection glucose levels are risk factors for severe COVID-19. Further research is required to assess whether these associations are causal, but we believe these findings can already have clinical implications for COVID-19 risk assessment and stratification.

Impact of type 2 diabetes and microvascular complications on mortality and cardiovascular outcomes in a multiethnic Asian population

INTRODUCTION

Diabetes mellitus is a growing public health epidemic in Asia. We examined the impact of type 2 diabetes, glycemic control and microvascular complications on mortality and cardiovascular outcomes in a multiethnic population-based cohort of Asians without prior cardiovascular disease.

RESEARCH DESIGN AND METHODS

This was a prospective population-based cohort study in Singapore comprising participants from the three major Asian ethnic groups: Chinese, Malays and Indians, with baseline examination in 2004-2011. Participants with type 1 diabetes and those with cardiovascular disease at baseline were excluded. Type 2 diabetes, Hemoglobin A1c (HbA1c) levels and presence of microvascular complications (diabetic retinopathy and nephropathy) were defined at baseline. The primary outcome was all-cause mortality and major adverse cardiovascular events (MACEs), defined as a composite of cardiovascular mortality, myocardial infarction, stroke and revascularization, collected using a national registry.

RESULTS

A total of 8541 subjects were included, of which 1890 had type 2 diabetes at baseline. Subjects were followed for a median of 6.4 (IQR 4.8-8.8) years. Diabetes was a significant predictor of mortality (adjusted HR 1.74, 95% CI 1.45 to 2.08, p<0.001) and MACE (adjusted HR 1.64, 95% CI 1.39 to 1.93, p<0.001). In those with diabetes, higher HbA1c levels were associated with increased MACE rates (adjusted HR (per 1% increase) 1.18, 95% CI 1.11 to 1.26, p<0.001) but not mortality (p=0.115). Subjects with two microvascular complications had significantly higher mortality and MACE compared with those with only either microvascular complication (adjusted p<0.05) and no microvascular complication (adjusted p<0.05).

CONCLUSION

Diabetes is a significant predictor of mortality and cardiovascular morbidity in Asian patients without prior cardiovascular disease. Among patients with type 2 diabetes, poorer glycemic control was associated with increased MACE but not mortality rates. Greater burden of microvascular complications identified a subset of patients with poorer outcomes.

Effectiveness of a multifaceted prevention programme for melioidosis in diabetics (PREMEL): A stepped-wedge cluster-randomised controlled trial

Background

Melioidosis, an often-fatal infectious disease caused by the environmental Gram-negative bacillus Burkholderia pseudomallei, is endemic in tropical countries. Diabetes mellitus and environmental exposure are important risk factors for melioidosis acquisition. We aim to evaluate the effectiveness of a multifaceted prevention programme for melioidosis in diabetics in northeast Thailand.

Methodology/Principal findings

From April 2014 to December 2018, we conducted a stepped-wedge cluster-randomized controlled behaviour change trial in 116 primary care units (PCUs) in Ubon Ratchathani province, northeast Thailand. The intervention was a behavioural support group session to help diabetic patients adopt recommended behaviours, including wearing rubber boots and drinking boiled water. We randomly allocated the PCUs to receive the intervention starting in March 2016, 2017 and 2018. All diabetic patients were contacted by phone yearly, and the final follow-up was December 2018. Two primary outcomes were hospital admissions involving infectious diseases and culture-confirmed melioidosis. Of 9,056 diabetics enrolled, 6,544 (72%) received a behavioural support group session. During 38,457 person-years of follow-up, we observed 2,195 (24%) patients having 3,335 hospital admissions involved infectious diseases, 80 (0.8%) melioidosis, and 485 (5%) deaths. In the intention-to-treat analysis, implementation of the intervention was not associated with primary outcomes. In the per-protocol analysis, patients who received a behavioural support group session had lower incidence rates of hospital admissions involving infectious diseases (incidence rate ratio [IRR] 0.89; 95%CI 0.80–0.99, p = 0.03) and of all-cause mortality (IRR 0.54; 95%CI 0.43–0.68, p<0.001). However, the incidence rate of culture-confirmed melioidosis was not significantly lower (IRR 0.96, 95%CI 0.46–1.99, p = 0.66).

Conclusions/Significance

Clear benefits of this multifaceted prevention programme for melioidosis were not observed. More compelling invitations for the intervention, modification of or addition to the behaviour change techniques used, and more frequent intervention may be needed.

Trial registration

This trial is registered with ClinicalTrials.gov, number NCT02089152.

Melioidosis, an infectious disease caused by environmental bacterium Burkholderia pseudomallei, is endemic in tropical countries. Diabetes mellitus is the most important risk factor, and routes of infection include skin inoculation, ingestion and inhalation. Prevention guidelines recommend that residents, rice farmers and visitors should wear protective gear such as rubber boots when in direct contact with soil and environmental water, and consume only boiled or bottled water. Here, we conducted a cluster randomized controlled trial to evaluate effectiveness of a multifaceted prevention programme for melioidosis in diabetic patients in northeast Thailand. We enrolled 9,056 diabetic patients in 2014. We randomly allocated primary care units as the unit of randomization to receive the intervention starting in March 2016, 2017 and 2018. All diabetic patients were contacted by phone yearly. We found that diabetic patients who received a behavioural support group session had lower incidence rates of hospital admissions involving infectious diseases and of all-cause mortality, but not of culture-confirmed melioidosis. In conclusion, clear benefits of this multifaceted prevention programme for melioidosis were not seen. We propose that more compelling invitations for the intervention, modification of or addition to the behaviour change techniques used, and more frequent intervention may be needed.

Inconvenient relationship of haemoglobin A1c level with endothelial function in type 2 diabetes in a cross-sectional study

OBJECTIVE

The aim of this study was to determine the relationship of haemoglobin A1c (HbA1c) level with flow-mediated vasodilation (FMD) and nitroglycerine-induced vasodilation (NID) in patients with type 2 diabetes.

DESIGN

Cross-sectional study.

SETTING

22 university hospitals and affiliated clinics in Japan.

PARTICIPANTS

1215 patients with type 2 diabetes including 349 patients not taking antidiabetic drugs.

MEASURES

We evaluated FMD and HbA1c level. All patients were divided into four groups based on HbA1c level: <6.5%, 6.5%-6.9%, 7.0%-7.9% and ≥8.0%.

RESULTS

An inverted U-shaped pattern of association between HbA1c level and FMD was observed at the peak of HbA1c of about 7%. FMD was significantly smaller in the HbA1c <6.5% group than in the HbA1c 6.5%-6.9% group and HbA1c 7.0%-7.9% group (p<0.001 and p<0.001), and FMD values were similar in the HbA1c <6.5% group and HbA1c ≥8.0% group. There were no significant differences in NID values among the four groups. After adjustments for confounding factors, FMD was significantly smaller in the HbA1c <6.5% group than in the HbA1c 6.5%-6.9% and HbA1c 7.0%-7.9% group (p=0.002 and p=0.04). In patients not taking antidiabetic drugs, FMD was also significantly smaller in the HbA1c <6.5% group than in the HbA1c 6.5%-6.9% group and HbA1c 7.0%-7.9% group (p<0.001 and p=0.02), and there were no significant differences in NID values among the four groups.

CONCLUSIONS

These findings suggest that there is an inverted U-shaped pattern of association between FMD and HbA1c and that a low HbA1c level of <6.5% is associated with endothelial dysfunction.

TRIAL REGISTRATION NUMBER

UMIN000012950, UMIN000012951, UMIN000012952 and UMIN000003409.

Glycemic and lipid variability for predicting complications and mortality in diabetes mellitus using machine learning

INTRODUCTION

Recent studies have reported that HbA1c and lipid variability is useful for risk stratification in diabetes mellitus. The present study evaluated the predictive value of the baseline, subsequent mean of at least three measurements and variability of HbA1c and lipids for adverse outcomes.

METHODS

This retrospective cohort study consists of type 1 and type 2 diabetic patients who were prescribed insulin at outpatient clinics of Hong Kong public hospitals, from 1st January to 31st December 2009. Standard deviation (SD) and coefficient of variation were used to measure the variability of HbA1c, total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglyceride. The primary outcome is all-cause mortality. Secondary outcomes were diabetes-related complications.

RESULT

The study consists of 25,186 patients (mean age = 63.0, interquartile range [IQR] of age = 15.1 years, male = 50%). HbA1c and lipid value and variability were significant predictors of all-cause mortality. Higher HbA1c and lipid variability measures were associated with increased risks of neurological, ophthalmological and renal complications, as well as incident dementia, osteoporosis, peripheral vascular disease, ischemic heart disease, atrial fibrillation and heart failure (p <  0.05). Significant association was found between hypoglycemic frequency (p <  0.0001), HbA1c (p <  0.0001) and lipid variability against baseline neutrophil-lymphocyte ratio (NLR).

CONCLUSION

Raised variability in HbA1c and lipid parameters are associated with an elevated risk in both diabetic complications and all-cause mortality. The association between hypoglycemic frequency, baseline NLR, and both HbA1c and lipid variability implicate a role for inflammation in mediating adverse outcomes in diabetes, but this should be explored further in future studies.

Differences in glycated hemoglobin levels and cholesterol levels in individuals with diabetes according to Helicobacter pylori infection

This study examined differences in glycated hemoglobin (HbA1c), fasting plasma glucose and cholesterol levels between H. pylori infected and uninfected persons with diabetes. Anonymized data of Maccabi Healthcare Services in Israel were analyzed, of 12,207 individuals (50.0% H. pylori positive) aged 25–95 years who underwent the urea breath test. The data included HbA1c, fasting plasma glucose and cholesterol levels. The inverse probability of treatment weighting approach was used to account for confounders. Differences between individuals who were H. pylori positive and negative, in HbA1c (> or ≤ 7.0%) and in cholesterol levels were assessed using weighted generalized estimating equations. For men, but not women, the likelihood of having HbA1c > 7.0% was increased in those infected than uninfected with H. pylori: prevalence ratio 1.11 (95% CI 1.00, 1.24), P = 0.04. For both sexes, total cholesterol (P = 0.004) and low-density lipoprotein (LDL) levels (P = 0.006) were higher among those infected than uninfected with H. pylori. No significant differences were found in glucose and HDL levels according to H. pylori infection. The results were consistent in unweighted multivariable analyses. In conclusion, H. pylori infection might be related to worse glycemic control in men, and higher total cholesterol and LDL cholesterol levels in both sexes.

The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus

AIMS

Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis.

PATIENTS AND METHODS

A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records.

RESULTS

A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%.

CONCLUSION

The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.

Associations between haemoglobin A1c and mortality rate in the KORA S4 and the Heinz Nixdorf Recall population-based cohort studies

BACKGROUND

There is limited knowledge about mortality risk in persons with increased haemoglobin A_1c (HbA_1c ) levels below the diabetes threshold. Moreover, little is known about how associations between increased HbA_1c and mortality depend on the length of follow-up. Therefore, we studied associations between HbA_1c and mortality over long-term follow-up in persons with and without known diabetes.

METHODS

We used data from two German population-based cohort studies: KORA S4 Study (Southern Germany, n = 1458, baseline visits in 1999 to 2001, baseline age 55 to 74 years, mortality follow-up 16.8 years) and Heinz Nixdorf Recall (HNR) Study (Ruhr area, n = 4613, baseline visits in 2000 to 2003, baseline age 45 to 75 years, mortality follow-up 17.8 years). Adjusted log-linear models were fitted to estimate relative risks (RRs) with 95% confidence intervals (CI).

RESULTS

In both cohorts, participants with HbA_1c 39 to 41 mmol/mol (5.7%-5.9%) and HbA_1c 42 to 46 mmol/mol (6.0% to 6.4%) did not have a larger overall mortality risk than participants with HbA_1c  < 39 mmol/mol (5.7%): the corresponding adjusted RRs were 1.00 (95% CI: 0.83-1.21) and 1.01 (0.80-1.27) in KORA and 0.99 (0.82-1.21) and 0.83 (0.65-1.07) in the HNR Study. For the pooled cohorts, the RR for HbA_1c 39 to 46 mmol/mol (5.7%-6.4%) was 0.96 (0.85-1.07). Associations between newly detected diabetes (HbA_1c  ≥ 6.5%) and mortality were weak after 4 and 8 years of follow-up, but were stronger after 12 years of follow-up, whereas associations between previously known diabetes (baseline) and mortality decreased.

CONCLUSIONS

HbA_1c -defined pre-diabetes is not associated with overall mortality. For newly detected and previously known diabetes, mortality risks vary with length of follow-up.

Predictions of diabetes complications and mortality using hba1c variability: a 10-year observational cohort study

INTRODUCTION

Emerging evidence suggests that HbA1c variability, in addition to HbA1c itself, can be used as a predictor for mortality. The present study aims to examine the predictive power of mean HbA1c and HbA1c variability measures for diabetic complications as well as mortality.

METHODS

The retrospective observational study analyzed diabetic patients who were prescribed insulin at outpatient clinics of the Prince of Wales Hospital and Shatin Hospital, Hong Kong, from 1 January to 31 December, 2009. Standard deviation (SD), root mean square (RMS), and coefficient of variation were used as measures of HbA1c variability. The primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes were diabetes-related complications.

RESULTS

The study cohort consists of 3424 patients, including 3137 patients with at least three HbA1c measurements. The low mean HbA1c subgroup had significantly shorter time-to-death for all-cause mortality (P < 0.001) but not cardiovascular mortality (P = 0.920). The high Hba1c subgroup showed shorter time-to-death for all-cause (P < 0.001) and cardiovascular mortality (P < 0.001). Mean Hba1c and Hba1c variability predicted all-cause as well as cardiovascular-specific mortality. In terms of secondary outcomes, mean HbA1c and HbA1c variability significantly predicted diabetic ketoacidosis/hyperosmolar hyperglycemic state/diabetic coma, neurological, ophthalmological, and renal complications. A significant association between dichotomized HbA1c variability and hypoglycemia frequency was found (P < 0.0001).

CONCLUSION

High HbA1c variability is associated with increased risk of all-cause and cardiovascular mortality, as well as diabetic complications. The association between hypoglycemic frequency, HbA1c variability, and mortality suggests that intermittent hypoglycemia resulting in poorer outcomes in diabetic patients.

The Identification of Diabetes Mellitus Subtypes Applying Cluster Analysis Techniques: A Systematic Review

Diabetes Mellitus is a chronic and lifelong disease that incurs a huge burden to healthcare systems. Its prevalence is on the rise worldwide. Diabetes is more complex than the classification of Type 1 and 2 may suggest. The purpose of this systematic review was to identify the research studies that tried to find new sub-groups of diabetes patients by using unsupervised learning methods. The search was conducted on Pubmed and Medline databases by two independent researchers. All time publications on cluster analysis of diabetes patients were selected and analysed. Among fourteen studies that were included in the final review, five studies found five identical clusters: Severe Autoimmune Diabetes; Severe Insulin-Deficient Diabetes; Severe Insulin-Resistant Diabetes; Mild Obesity-Related Diabetes; and Mild Age-Related Diabetes. In addition, two studies found the same clusters, except Severe Autoimmune Diabetes cluster. Results of other studies differed from one to another and were less consistent. Cluster analysis enabled finding non-classic heterogeneity in diabetes, but there is still a necessity to explore and validate the capabilities of cluster analysis in more diverse and wider populations.

New Possibilities to Reduce the Residual Risk in Patients with Ischemic Heart Disease

Despite a significant progress of the recent decades, incidence of cardiovascular complications in patients with manifest, stable ischemic heart disease (IHD) is still high. Furthermore, this patient group is heterogenous; individuals with a higher risk of cardiovascular complications can be isolated from this group based on the presence of comorbidities and acute IHD on the background of the therapy. Such patients require a more aggressive treatment to influence major components of the increased risk. Even after administration of an optimum therapy, the risk for complications in such patients remains high (residual risk). The article discusses the lipid, inflammatory, and thrombotic components of residual risk in IHD patients and possibilities of their control with drugs with a special focus on possibilities of pharmaceutical correction of the risk thrombotic component in IHD patients with diabetes mellitus.

The validity of the diabetes self-management questionnaire (DSMQ) in Hungarian patients with type 2 diabetes

BACKGROUND

A wide range of measuring instruments are available for diabetes self-management. According to several studies, a relatively new instrument, the diabetes self-management questionnaire (DSMQ), shows a consistent relationship with outcomes of diabetes treatment as well, such as glycated hemoglobin (HbA1c). Furthermore, the questionnaire is short, but covers the main aspects of diabetes management. Given the increasing prevalence of diabetes in Hungary, our goal was to adapt this user-friendly questionnaire and analyze its validity.

METHODS

After the standard translation process, we analyzed a sample of 221 people. The construct validity of the questionnaire was tested with HbA1c and body mass index. Morisky Medication Adherence Scale-8 values were tested via Pearson correlations. Known-groups validity of the DSMQ in relation to groups based on glycemic control levels was investigated using one-way ANOVA.

RESULTS

The "sum scale" of the questionnaire and the HbA1c values show an inverse relationship (r = - 0.253, p < 0.01). Body mass index was related to the "sum scale" (r = - 0.214, p < 0.01) and to the "physical activity" (r = - 0.219, p < 0.01), while questionnaire results reflecting medication adherence correlated with the "glucose management" (r = - 0.291, p < 0.01), "health-care use" subscale (r = 0.236, p < 0.01) and the "sum scale" (r = 0.281, p < 0.01). A significant difference (F = 6.225, p = 0.002) was found between the DSMQ mean scores of the three groups, defined by good, medium, and poor glycemic control levels.

CONCLUSIONS

The Hungarian version of the DSMQ was considered a valid tool for the measurement of diabetes self-management. With its help, problematic areas of self-management could be uncovered, and interventions can be improved.

Ambient air pollution exposure association with diabetes prevalence and glycosylated hemoglobin (HbA1c) levels in China. Cross-sectional analysis from the WHO study of AGEing and adult health wave 1

Over the past decades, air pollution has become one of the critical environmental health issues in China. The present study aimed to evaluate links between ambient air pollution and the prevalence of type 2 diabetes mellitus (T2DM) and the levels of glycosylated hemoglobin (HbA1c). A multilevel linear and logistic regression was used to assess these associations among 7,770 participants aged ≥50 years from the WHO Study on global AGEing and adult health (SAGE) in China in 2007-2010. The average exposure to each of pollutants (particulate matter with an aerodynamic diameter of ≤10 μm/≤2.5 μm/≤1 μm [PM₁₀/PM_2.5/PM₁] and nitrogen dioxide [NO₂]) was estimated using a satellite-based spatial statistical model. In logistic models, a 10 µg/m³ increase in PM₁₀ and PM_2.5 was associated with increased T2DM prevalence (Prevalence Odds Ratio, POR: 1.27; 95% CI: 1.11, 1.45 and POR: 1.23; 95% CI: 1.03, 1.46). Similar increments in PM₁₀, PM_2.5, PM₁ and NO₂ were associated with increase in HbA1c levels of 1.8% (95% CI: 1.3, 2.3), 1.3% (95% CI: 1.1, 1.5), 0.7% (95% CI: 0.1, 1.3), and 0.8% (95% CI: 0.4, 1.2), respectively. In a large cohort of older Chinese adults, air pollution was liked to both higher T2DM prevalence and elevated HbA1c levels.

Regional variability in Canadian routine care of type 2 diabetes, hypercholesterolemia, and hypertension: Results from the The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry

BACKGROUND

Regional differences in the profile and treatment strategies of patients with cardiometabolic diseases have been studied in several different countries. The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry was designed to evaluate patient profiles and medical management of cardiometabolic diseases in routine clinical care settings across Canada. Primary objectives were to (1) evaluate regional variability of patient profiles with cardiometabolic disease(s) and (2) assess treatment differences of patients treated for type 2 diabetes (T2D), hypercholesterolemia (HCh), and hypertension (HTN) across Canada.

METHODS

CV-CARE is a multi-center, observational, prospective registry that enrolled Canadian patients treated with metformin-extended release (MetER) for T2D, colesevelam (C) for HCh, azilsartan (AZI) for mild-to-moderate essential HTN and azilsartan/chlorthalidone (AZI/CHL) for severe, essential HTN. Patient characteristics and treatments were assessed at baseline.

RESULTS

The registry enrolled 6960 patients, with a total of 4194 patients making up the primary analysis population [MetER (n=995); C (n=1639); AZI (n=1364); AZI/CHL (n=498)]. First-line use of MetER was more common in British Columbia (BC; 45.5%) compared to Ontario (ON; 29.8%), and Quebec (QC; 12.9%). C treatment for HCh was used as monotherapy most readily in BC (68.7%) compared with QC (59.7%) and ON (35.8%). Dual action of low-density lipoprotein cholesterol and hemoglobin A1c reduction was the predominant reason for C add-on therapy (46.8%), with highest usage seen in ON (62.9%). AZI treatment for HTN was most frequently used in BC (43.8%), and AZI/CHL was most commonly used in ON (12.0%). First-line use of AZI was more common in QC (50%) vs. ON (34.9%) and BC (24.1%). The primary reason for switching to AZI and AZI/CHL from prior treatment was lack of efficacy across provinces.

CONCLUSION

This is the first regional description of the CV-CARE cohort. Significant variations in both baseline profile and treatments were observed which could have an impact on long-term outcomes.

Evidence and indications for systemic treatment in diabetic retinopathy: a systematic review

Eye screening is mandatory in diabetes, but treatment is only indicated at the sight-threatening stages of diabetic retinopathy (DR). Treatments include intravitreal injections, laser photocoagulation and vitrectomy, which are all invasive options. In order to prevent or delay DR, it is important to investigate earlier, non-invasive managements prior to sight-threatening DR. The aim of this study is to evaluate the effect of systemic treatment on incident and progressive DR. The search in this systematic review was performed in PubMed and Embase using the keywords 'diabetic retinopathy' AND 'systemic therapy'. Two independent researchers identified 619 studies; 26 duplicates were removed, 579 articles were excluded based on title and abstract, and six were removed after full-text assessment. Five articles were added from reference screening, resolving in a total of 13 eligible articles. These were quality-assessed using the Cochrane Risk of Bias tool. Twelve randomized control trials and one follow-up study were included. Intensive glycaemic control (IGC), antihypertensive and lipid-lowering treatments were some of the main interventions tested in the studies. Three studies found statistically significant reduction of progression of DR by IGC, three by antihypertensive, and two by the lipid-lowering drug fenofibrate. Systemic intervention appears important in different stages of DR. While IGC seems effective in relation to incident and progressive DR, antihypertensive treatments may be valuable in the early stages of DR, as opposed to fenofibrate, which could benefit at a later stage.

Advances in the management of diabetes: therapies for type 2 diabetes

The incidence of type 2 diabetes is rapidly rising worldwide leading to an increasing burden of cardiovascular and microvascular complications. The aim of treatment of the condition is to improve quality of life and reduce such complications. To this end, improvement in glucose control remains an important consideration. In recent years, important therapeutic advances have occurred in the management of hyperglycaemia in people with type 2 diabetes. These include the use of dipeptidylpeptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists and sodium glucose transporter-2 inhibitors. The latter two classes appear to have some specific beneficial effects on cardiovascular and renal outcomes, independent of their antihyperglycaemic effects. This review aims to outline the current state of diagnosis and management of diabetes for the general physician, with a particular focus on new therapeutic agents for management of glucose in patients with type 2 diabetes.

Impact of Baseline Glycemic Control on Residual Cardiovascular Risk in Patients With Diabetes Mellitus and High-Risk Vascular Disease Treated With Statin Therapy

Background

The contemporary impact of glycemic control on patients with diabetes mellitus at high cardiovascular risk remains unclear. We evaluated the utility of hemoglobin A1c (HbA1c) as a marker of risk on the composite end point of cardiovascular death, nonfatal myocardial infarction, stroke, hospitalization for unstable angina, and coronary revascularization in an optimally treated population with diabetes mellitus and established coronary artery disease enrolled in the ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibition With Evacetrapib in Patients at a High Risk for Vascular Outcomes) trial.

Methods and Results

We included all patients with established diabetes mellitus and measured HbA1c (N=8145) and estimated Kaplan‐Meier (KM) events rates, stratified by increasing baseline HbA1c levels censored at 30 months. We then performed a multivariable regression for the primary end point. Increasing baseline HbA1c was strongly associated with the occurrence of the primary end point (KM estimate, 12.6–18.2; P<0.001). Increasing baseline HbA1c was also associated with the triple end point of death, nonfatal myocardial infarction, and stroke (KM estimate, 7.8–11.3; P=0.003) as well as the individual end points of nonfatal myocardial infarction (KM estimate, 3.1–7.0; P<0.001), hospitalization for unstable angina (KM estimate, 1.8–5.0; P=0.003), and revascularization (KM estimate, 7.3–11.1; P=0.001), although not stroke (KM estimate, 1.4–2.4; P=0.45). The rates of cardiovascular mortality (KM estimate, 2.6–4.3; P=0.21) and all‐cause mortality (KM estimate, 4.8–5.9; P=0.21) were similar regardless of baseline HbA1c levels. When adjusting for relevant baseline characteristics, baseline HbA1c was an independent predictor for the primary end point (hazard ratio, 1.06; 95% CI, 1.02–1.11; P=0.003).

Conclusions

Glycemic control, as measured by HbA1c, remains strongly and independently associated with cardiovascular outcomes in high‐risk patients with diabetes mellitus on statin therapy.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01687998.

Inulin-type fructans supplementation improves glycemic control for the prediabetes and type 2 diabetes populations: results from a GRADE-assessed systematic review and dose-response meta-analysis of 33 randomized controlled trials

Background

Currently, many clinical trials have shown that inulin-type fructans (ITF) supplementation is associated with glycemic control; nevertheless, the results are inconclusive. The aim of this meta-analysis of randomized controlled trials was to assess the effects of ITF supplementation on glycemic control.

Methods

PubMed, EMBASE and the Cochrane Library were searched for eligible articles up to March 6, 2019. A random-effects model was used to analyze the pooled results, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to assess the quality of evidence. The dose–response model was used to recommend the daily dose and duration for ITF supplementation.

Results

Thirty-three trials involving 1346 participants were included. Overall, ITF supplementation could significantly reduce concentrations of fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), fasting insulin (FINS) and homeostasis model assessment-insulin resistance (HOMA-IR). In the prediabetes and type 2 diabetes (T2DM) population, a more significant reduction in FBG [weighted mean difference (WMD): − 0.60 mmol/l; 95% CI − 0.71, − 0.48 mmol/l; high rate], HbA1c (WMD: − 0.58%; 95% CI − 0.83, − 0.32%; high rate), FINS (WMD: − 1.75 µU/ml; 95% CI − 2.87, − 0.63 µU/ml; low rate), and HOMA-IR (WMD: − 0.69; 95% CI − 1.10, − 0.28; low rate) were observed, and ITF supplementation with a daily dose of 10 g for a duration of 6 weeks and longer was recommended. Moreover, subgroup analyses suggested that the effects of glycemic control were significantly influenced by the sex of the subjects and the type and the method of intake of ITF.

Conclusions

Our analyses confirmed that these four main glycemic indicators were significantly reduced by ITF supplementation, particularly in the prediabetes and T2DM population. Evidence supports that reasonable administration of ITF supplementation may have potential clinical value as an adjuvant therapy for prediabetes and T2DM management.

Trial registration The trial was registered at PROSPERO as CRD42018115875 on November 23, 2018.

Comparison of the Effects of Fasting Glucose, Hemoglobin A1c, and Triglyceride-Glucose Index on Cardiovascular Events in Type 2 Diabetes Mellitus

The triglyceride–glucose (TyG) index has been correlated with insulin resistance. We aim to investigate the role of the TyG index on cardiovascular (CV) events in type 2 diabetes mellitus and compare the roles of fasting glucose, hemoglobin A_1c, and the TyG index in predicting CV events. This retrospective study enrolled 3524 patients with type 2 diabetes from the Kaohsiung Medical University Research Database in 2009 in this longitudinal study and followed them until 2015. The TyG index was calculated as log (fasting triglyceride level (mg/dL) × fasting glucose level (mg/dL)/2). CV events included myocardial infarction, unstable angina, stroke, hospitalization for coronary artery disease, peripheral artery disease, and CV-related death. The association between variables and CV events was assessed using a multivariable stepwise Cox proportional hazard analysis. Two hundred and fifteen CV events (6.1%) were recorded during a follow-up period of 5.93 years. The multivariable stepwise analysis showed that high fasting glucose (HR, 1.007; p < 0.001) and a high TyG index (HR, 1.521; p = 0.004) but not hemoglobin A_1c or triglycerides were associated with a higher rate of CV events. Adding fasting glucose and the TyG index to the basic model improved the predictive ability of progression to a CV event (p < 0.001 and p = 0.018, respectively), over that of hemoglobin A_1c (p = 0.084) and triglyceride (p = 0.221). Fasting glucose and the TyG index are useful parameters and stronger predictive factors than hemoglobin A_1c and triglyceride for CV events and may offer an additional prognostic benefit in patients with type 2 diabetes.

Access to care, nativity and disease management among Latinos with diabetes in a safety-net healthcare setting

Introduction

Latinos in the U.S. are disproportionately affected by diabetes and its complications. The role of access to care and nativity in diabetes management are important areas of research, as these findings can help direct tailored interventions.

Methods

We examined associations between access to care, acculturation and glycemic control among Latino patients with diabetes seen in a safety net emergency department. We used regression models to estimate the individual predictors' associations with glycemic control and then estimated adjusted associations by controlling for all relevant predictors. We tested for a moderating role of nativity in the associations between access to care and glycemic control.

Results

In unadjusted analysis, we found the most significant predictors of glycemic control to be access to primary care (β = −0.89, p = 0.011), capacity for self-monitoring glucose (β = −0.68, p = 0.022), mental health comorbidities (β = 0.95, p = 0.013), male gender (β = −0.49, p = 0.091) and nativity (β = −0.81, p = 0.034). In adjusted analysis, nativity was no longer a significant predictor of glycemic control (β = −0.32, p = 0.541). Nativity did not significantly moderate the association of access to care and glycemic control.

Conclusions

Our findings show a direct association between access to care and glycemic control among low-income Latinos seeking care in the emergency department. This supports concerns that many researchers, clinicians and policy analysts have expressed regarding access to care for immigrants. The importance of primary care and access to supplies to perform self-management in achieving glycemic control and reducing risk of complications indicate that ensuring access to quality care is critical to the health of this vulnerable group.

Diabetes, dysglycemia, and vascular surgery

BACKGROUND

Abnormalities in glucose metabolism are common in patients with arterial disease. Chronic hyperglycemia and insulin resistance contribute to the complexity of vascular disorders. They also overlap with the effects of perioperative hyperglycemia on adverse perioperative outcomes. We provide an overview of the pathophysiologic consequences of dysglycemia and the evidence behind glycemic control in patients undergoing vascular surgery.

METHODS

We searched the literature for major studies evaluating the pathophysiology of hyperglycemia in microvascular and macrovascular beds, randomized trials in perioperative populations, and meta-analyses. The literature was summarized to guide therapy in the population of vascular patients and for the perioperative period.

RESULTS

National standards for glycemic control after vascular interventions were not identified. Mounting evidence exists for the long-term consequences of poor glycemic control on the progression of vascular disease. Similarly, there is a large body of evidence supporting tight control of hyperglycemia after general and cardiac surgery during the critical perioperative period. The absolute glucose target remains controversial. Randomized controlled studies are lacking in vascular surgery patients, but the current evidence can be extrapolated to guide management after vascular interventions. Glycated hemoglobin is a biomarker for increased mortality and vascular morbidity after vascular surgery.

CONCLUSIONS

Hyperglycemia contributes to poor outcome in the vascular patient. Further vascular focused studies are required to determine the proper perioperative serum glucose target and the long-term glycated hemoglobin range.

Erythropoietin (EPO) haplotype associated with all-cause mortality in a cohort of Italian patients with Type-2 Diabetes

Type-2 Diabetes (T2D), diabetic complications, and their clinical risk factors harbor a substantial genetic component but the genetic factors contributing to overall diabetes mortality remain unknown. Here, we examined the association between genetic variants at 21 T2D-susceptibility loci and all-cause mortality in an elderly cohort of 542 Italian diabetic patients who were followed for an average of 12.08 years. Univariate Cox regression analyses detected age, waist-to-hip ratio (WHR), glycosylated haemoglobin (HbA1c), diabetes duration, retinopathy, nephropathy, chronic kidney disease (CKD), and anaemia as predictors of all-cause mortality. When Cox proportional hazards multivariate models adjusted for these factors were run, three erythropoietin (EPO) genetic variants in linkage disequilibrium (LD) with each other (rs1617640-T/G, rs507392-T/C and rs551238-A/C) were significantly (False Discovery Rate < 0.1) associated with mortality. Haplotype multivariate analysis revealed that patients carrying the G-C-C haplotype have an increased probability of survival, while an opposite effect was observed among subjects carrying the T-T-A haplotype. Our findings provide evidence that the EPO gene is an independent predictor of mortality in patients with T2D. Thus, understanding the mechanisms by which the genetic variability of EPO affects the mortality of T2D patients may provide potential targets for therapeutic interventions to improve the survival of these patients.

Challenges to hemoglobin A1c as a therapeutic target for type 2 diabetes mellitus

Glycated hemoglobin (HbA1c) is widely accepted as the most reliable measure of long-term glycemia. However, there is disagreement among professional medical societies on a proper glycemic target for long-term benefits in type 2 diabetes (T2D). The use of some glucose-lowering drugs was associated with heart failure despite substantial lowering of HbA1c. The failure of intensive glycemic control to reduce cardiovascular risk in some trials again brought into question the usefulness of HbA1c as a therapeutic target in T2D. In large cardiovascular outcome trials, some newer glucose-lowering drugs were associated with higher risks of heart failure or amputation despite comparable glycemic control between the test and placebo groups. Here, we provide evidence that variation in hemoglobin glycation between individuals is responsible for these inconsistencies. We suggest that further research be conducted in this area and that the findings be applied to clinical trials and practice.

Meta-analysis of metabolic surgery versus medical treatment for macrovascular complications and mortality in patients with type 2 diabetes

BACKGROUND

Although research has shown that metabolic surgery is superior to medical therapy in terms of glycemic control and other cardiovascular risk factors, it remains unclear whether these beneficial effects ultimately result in a reduced incidence of macrovascular complications or mortality in patients with type 2 diabetes.

OBJECTIVE

This meta-analysis assesses the impact of metabolic surgery versus medical therapy on mortality and macrovascular complications in patients with type 2 diabetes.

SETTING

Academic centers in the United States, Europe, and Asia.

METHODS

An unrestricted systematic literature search of MEDLINE, Web of Science, and Cochrane Central Register of Controlled Trials was performed. Randomized controlled trials (RCTs), case-control trials, and cohort studies comparing the effect of metabolic surgery on mortality and the incidence of diabetes-associated macrovascular complications to a medically treated control group were identified. The last search was performed on June 15, 2018.

RESULTS

The literature search yielded 3721 potentially eligible articles. Nineteen studies (6 RCTs, 13 nonrandomized studies) were ultimately included. Metabolic surgery was found to be associated with reduced mortality (odds ratio .34, 95% confidence interval [.25-.46], P < .00001) and macrovascular complication rates (odds ratio .38, 95% confidence interval [.22-.67], P = .0008).

CONCLUSIONS

Because metabolic surgery is associated with lower mortality and macrovascular complication rates than medical therapy, it seems to be the superior treatment choice for patients with type 2 diabetes. Additional, high-quality RCTs with adequate follow-up comparing state of the art surgical and medical therapies including glifozins and liraglutide are nevertheless needed to identify which patients would benefit most from metabolic surgery.

The risk of mortality among people with type 2 diabetes in Latin America: A systematic review and meta-analysis of population-based cohort studies

Type 2 diabetes mellitus (T2DM) is associated with a high mortality risk, although the magnitude of this association remains unknown in Latin America (LA). We aimed to assess the strength of the association between T2DM and all-cause and cause-specific mortality in population-based cohort studies in LA. Systematic review and meta-analysis: inclusion criteria were (1) men and women 18 years old and above with T2DM; (2) study outcomes all-cause and/or cause-specific mortality; and (3) using people without T2DM as comparison group. Five databases (Scopus, Medline, Embase, Global Health, and LILACS) were searched. Risk of bias was evaluated with the ROBINS-I criteria. Initially, there were 979 identified studies, of which 17 were selected for qualitative synthesis; 14 were included in the meta-analysis (N = 416 821). Self-reported T2DM showed a pooled relative risk (RR) of 2.49 for all-causes mortality (I-squared [I² ] = 85.7%, p < 0.001; 95% confidence interval [CI], 1.96-3.15). T2DM based on a composite definition was associated with a 2.26-fold higher all-cause mortality (I²  = 93.9%, p < 0.001; 95% CI, 1.36-3.74). The pooled risk estimates were similar between men and women, although higher at younger ages. The pooled RR for cardiovascular mortality was 2.76 (I²  = 59.2%; p < 0.061; 95% CI, 1.99-3.82) and for renal mortality 15.85 (I²  = 0.00%; p < 0.645; 95% CI, 9.82-25.57). Using available population-based cohort studies, this work has identified and estimated the strength of the association between T2DM and mortality in LA. The higher mortality risk compared with high-income countries deserves close attention from health policies makers and clinicians to improve diabetes care and control hence preventing complications and delaying death.

The effects of glycemic control on morbidity and survival among diabetic patients

AIMS

The study intended to investigate the impact of controlled glycemia on morbidity and estimated 10-year survival (ES-10Y).

METHODS

A cross-sectional investigation was conducted at General Penang Hospital, Malaysia. Demographic criteria and laboratory tests of patients were investigated. Controlled glycemia (CG) was recognized as glycated hemoglobin (HbA1c) ≤7% depending on American Diabetes Association guidelines 2018. Charlson Comorbidity Index (CCI) was used to estimate the confounding influence of co-morbidities and predict ES-10Y. Data was managed by IBM-SPSS 23.0.

RESULTS

A total of 400 cases categorized to (44.25%) patients with CG, and (55.75%) cases had uncontrolled glycemia (UCG). HbA1c mean in CG and UCG group was (6.8 ± 0.9 vs 9.5 ± 1.6, P-value: 0.001). Fasting blood glucose was (7 ± 2.3 vs. 9.9 ± 4.3, P-value: 0.001) in CG and UCG group. CCI was (3.38 ± 2.38 vs. 4.42 ± 2.70, P-value: 0.001) and, ES-10Y was (62% vs 46.2%, p-value: 0.001) in CG vs. UCG respectively. Spearman test indicates a negative correlation between CG and CCI (r: 0.19, p-value: 0.001). Logistic regression confirmed HbA1c as a significant predictor of CCI (r²: 0.036, P-value: 0.001). CG has a positive correlation with survival (r: 0.16, P-value: 0.001) and logistic regression of survival (r²: 0.26, P-value: 0.001).

CONCLUSIONS

More than one-half of the investigated persons had UCG. Controlled HbA1c was associated with lower co-morbidities and higher ES-10Y.

Association of Low Fasting Glucose and HbA1c With Cardiovascular Disease and Mortality: The MESA Study

Trials of intensive glucose control have not improved cardiovascular disease (CVD) risk in populations with type 2 diabetes; however, in the general population, reports are inconsistent about the effects of maintaining lower glucose levels. Some speculate that low glycemic values are associated with increased glycemic variability, which is in turn associated with higher CVD risk. It has also been suggested that fasting glucose and hemoglobin A1c (HbA1c) in the lower ranges have a different relationship with CVD and mortality. In 4990 participants from the Multi-Ethnic Study of Atherosclerosis, we used logistic regression to investigate associations of low fasting glucose (<80 mg/dL) and HbA1c (<5.0%) from baseline and averaged across follow-up with incident CVD and mortality over 13 years. We used normal glycemic ranges (80 to <100 mg/dL and 5.0 to <5.7%) as references and analyzed glycemic levels with visit-matched covariates. We adjusted for potential confounding by age, sex, race/ethnicity, education, income, smoking status, body mass index, total cholesterol level, cholesterol medications, high-density lipoprotein cholesterol, and hypertension. Low baseline glucose and HbA1c were positively, but not significantly, associated with mortality, whereas low average fasting glucose and HbA1c were strongly and significantly associated with incident CVD [glucose OR, 2.04 (95% CI, 1.38-3.00); HbA1c OR, 2.01 (95% CI, 1.58-2.55)] and mortality [glucose OR, 1.93 (95% CI, 1.33-2.79); HbA1c OR, 2.51 (95% CI, 2.00-3.15)]. These results were not due to type 2 diabetes or medication use. Glucose variability did not explain CVD risk beyond average glucose levels. Chronic low fasting glucose and HbA1c may be better indicators of risk than a single low measurement.

The association between hypoglycemia and hospital use, food insufficiency, and unstable housing conditions: a cross-sectional study among patients with type 2 diabetes in Sudan

Objectives

Hypoglycemia is associated with mortality and healthcare utilization. We aimed to assess hypoglycemia risk and Hospital use among Sudanese patients with type 2 diabetes.

Results

One hundred and fifty-nine patients with type 2 diabetes attending a diabetes center in Omdurman, Sudan during the period from June to September 2018were approached. A structured questionnaire based on hypoglycemia risk and Hospital use, Fasting plasma glucose (FPG) and the glycated hemoglobin (HbA_1c) was used to interview the patients. Participants (age 58.13 ± 9.96 years), 4.4%, 14.5%, and 81.1% were at high, moderate, and low hypoglycemia respectively, 66% reported food insufficiency, while 15.1% had unstable housing conditions. No relationship was evident between the hypoglycemia risk, gender, unstable housing conditions, food insufficiency, fasting plasma glucose,HbA_1c, and the duration since the diagnosis of diabetes. A considerable number (18.9%) of Sudanese patients with diabetes were at moderate/high risk of hypoglycemia and Hospital use, including hypoglycemia risk and hospital use assessment in the holistic care of diabetes are recommended.

Development of a risk score to identify patients with type 2 diabetes mellitus and multivessel coronary artery disease who can defer bypass surgery

BACKGROUND

Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines provide a class I recommendation for patients with type 2 diabetes mellitus and multivessel coronary artery disease (CAD) to be treated with coronary artery bypass graft surgery (CABG). However, these patients are heterogeneous in terms of the risks and benefits associated with CABG. We sought to develop a risk score to identify low-risk patients with diabetes and multivessel CAD in whom CABG can be safely deferred.

METHODS

Patients in the CABG strata randomized to intensive medical therapy (IMT) in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial who experienced death, myocardial infarction (MI), or stroke were compared with those who did not. We developed a risk score for death, MI, or stroke using a Cox proportional hazards model that included the following variables: age, history of heart failure, history of hypercholesterolemia, history of stroke, transient ischemic attack, serum creatinine, insulin use, myocardial jeopardy index, and HbA1c.

RESULTS

Among patients with a risk score less than the median, those randomized to IMT or prompt CABG experienced similar rates of event-free survival at 5 years (77.8% vs. 83.2%, logrank P = 0.24). Among patients with a risk score greater than the median, those randomized to IMT experienced worse rates of event-free survival at 5 years than those randomized to prompt CABG (60.3% vs 73.2%, logrank P = 0.01).

CONCLUSIONS

A novel risk score identifies low-risk patients with diabetes and stable, symptomatic multivessel CAD in whom CABG can be safely deferred.