Clinical profile of long-term survivors and nonsurvivors with type 2 diabetes

A Systematic Narrative Review on ADIPOQ Gene Variants and its Association with T2DM in the Indian Population

BACKGROUND

The prevalence of diabetes is rapidly increasing in India, even among young adult individuals. Rare adiponectin gene (ADIPOQ) variants may be predominantly present in Indians and decrease the circulatory levels of APN (Adiponectin). Studies reported that ADIPOQ gene variants were associated with type 2 diabetes mellitus (T2DM) and its complications in the Indian population.

OBJECTIVES

To review the association of specific ADIPOQ gene variants with T2DM and its associated complications.

MATERIALS & METHODS

A search of Pubmed, Chinhal, Medline, Scopus, Web of Science databases, and Google Scholar search engine was performed to retrieve articles by using the following keywords; "ADIPOQ and T2DM", "ADIPOQ and India," "ADIPOQ gene variants and T2DM", "ADIPOQ gene variants and T2DM and India", "SNPs of ADIPOQ gene and T2DM", "SNPs of ADIPOQ gene and India," SNPs of ADIPOQ gene and T2DM and India". Eligibility criteria for the inclusion of articles: Original, Case-Control Study, and Full-Text articles were published in the English language till the end of April 2023.

RESULTS

A total of 540 articles were retrieved. Out of this, only 18 articles were found suitable to include in this systematic narrative review. The most studied ADIPOQ gene variants were found to be +10211T/G (rs17846866), +45T/G (rs2241766), and +276G/T (rs1501299) in different Indian populations.

CONCLUSION

It was reviewed that ADIPOQ gene variants +10211T/G (rs17846866), +45T/G (rs2241766), and +276G/T (rs1501299) were predominantly present in the Indian population, and decreasing the circulatory levels of APN and significantly associated with T2DM and its complications.<.

Trends in lipid profile and lipid control among survivors of stroke or myocardial infarction among US adults, 2001-2018

BACKGROUND

We aim to analyze the change in lipid profile and lipid control among survivors of stroke and/or myocardial infarction among US adults from 2001-2018.

METHODS

In total, 3,736 survivors of stroke and/or myocardial infarction from the 2001-2018 National Health and Nutrition Examination Surveys were included in this study, representing a weighted total population of 110,005,898. Trends for lipid concentration and lipid control rate over time were detected via general linear regression analysis and lipid control was compared by sex and race via survey-weighted logistic regression analysis.

RESULTS

The total cholesterol, LDL, and triglyceride concentrations were significantly decreased in survivors from the 2001-2002 survey cycle to the 2017-2018 survey cycle (p for trend < 0.01). Lipid control was defined as total cholesterol < 200 mg/dL. Among survivors, the lipid control rate increased from 56.2% (95% CI: 43.9%, 67.7%) in the 2001-2002 survey cycle to 73.2% (95% CI: 64.8%, 80.2%) in the 2017-2018 survey cycle (p for trend < 0.01). Women had a higher lipid concentration and were more likely have poor lipid control compared to men. Non-Hispanic White survivors possessed better lipid control than other races survivors.

CONCLUSIONS

Lipid concentrations decreased and lipid control improved in stroke and/or myocardial infarction survivors from 2001 to 2018, with heterogeneity observed according to sex and race.

Prescribing Patterns and Response to Antihyperglycemic Agents Among Novel Clusters of Type 2 Diabetes in Asian Indians

Aim: To assess the prescribing patterns and response to different classes of antihyperglycemic agents in novel clusters of type 2 diabetes (T2D) described in India. Materials and Methods: We attempted to replicate the earlier described clusters of T2D, in 32,867 individuals with new-onset T2D (within 2 years of diagnosis) registered between October 2013 and December 2020 at 15 diabetes clinics located across India, by means of k-means clustering utilizing 6 clinically relevant variables. Individuals who had follow-up glycated hemoglobin (HbA1c) up to 2 years were included for the drug response analysis (n = 13,247). Results: Among the 32,867 participants included in the study, 20,779 (63.2%) were males. The average age at diagnosis was 45 years and mean HbA1c at baseline was 8.9%. The same four clusters described in India earlier were replicated. Forty percent of the study participants belonged to the mild age-related diabetes cluster, followed by insulin-resistant obese diabetes (27%), severe insulin-deficient diabetes (21%), and combined insulin-resistant and insulin-deficient diabetes (12%) clusters. The most frequently used antihyperglycemic agents were sulfonylureas, metformin, and dipeptidyl peptidase-4 inhibitors apart from insulin. While there were significant differences in HbA1c reduction between drugs across clusters, these were largely driven by differences in the baseline (pretreatment) HbA1c. Conclusions: In this new cohort, we were able to reliably replicate the four subtypes of T2D earlier described in Asian Indians. Prescribing patterns show limited usage of newer antihyperglycemic agents across all clusters. Randomized clinical trials are required to establish differential drug responses between clusters.

Clinical Profile of Long-Term Survivors and Nonsurvivors with Type 1 Diabetes in India

Objective: To compare the clinical profile of long-term survivors and nonsurvivors with type 1 diabetes (T1D) in India. Research Design and Methods: This is a retrospective study of 76 individuals with T1D who had survived for at least 40 years ("survivors") and 51 individuals with T1D who had died with shorter duration of diabetes ("non-survivors"), from diabetes clinics in different cities of India. Prevalence of complications in both groups and causes of death of the nonsurvivors were analyzed. Retinopathy was diagnosed by retinal photography; chronic kidney disease (CKD) by urinary albumin excretion (micro-or macroalbuminuria) and estimated glomerular filtration rate; peripheral vascular disease (PVD) by doppler measurement of ankle-brachial pressure index; coronary artery disease (CAD) based on history of myocardial infarction or coronary revascularization, and neuropathy by biothesiometry. Results: Mean glycated hemoglobin (8.4% ± 1.5% vs. 10.7% ± 2.2%, P < 0.001), serum low-density lipoprotein cholesterol (91 ± 29 mg/dL vs. 107 ± 22 mg/dL, P = 0.004), and systolic blood pressure (135 ± 16 mmHg vs. 153 ± 37 mmHg, P = 0.003) were lower, and high-density lipoprotein cholesterol (51 ± 11 mg/dL vs. 43 ± 15 mg/dL, P = 0.002) higher, among survivors compared to nonsurvivors. Diabetic retinopathy, CKD, neuropathy, PVD, and CAD were more frequent among nonsurvivors. CAD [25.5%] and renal failure [23.5%] were the most frequent causes of death. Conclusions: In this first report of long-term survivors with T1D from India, we report that survivors had better glycemic and blood pressure control, more favorable lipid profiles and lower prevalence of complications compared to nonsurvivors. However, there could be other protective factors as well, which merit further studies.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Contrasting Associations Between Diabetes and Cardiovascular Mortality Rates in Low-, Middle-, and High-Income Countries: Cohort Study Data From 143,567 Individuals in 21 Countries in the PURE Study

OBJECTIVE

We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income.

RESEARCH DESIGN AND METHODS

The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35-70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 ± 3.0 years.

RESULTS

Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58-2.27] to 1.78 [1.36-2.34]).

CONCLUSIONS

CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.

Novel subgroups of type 2 diabetes and their association with microvascular outcomes in an Asian Indian population: a data-driven cluster analysis: the INSPIRED study

INTRODUCTION

Type 2 diabetes is characterized by considerable heterogeneity in its etiopathogenesis and clinical presentation. We aimed to identify clusters of type 2 diabetes in Asian Indians and to look at the clinical implications and outcomes of this clustering.

RESEARCH DESIGN AND METHODS

From a network of 50 diabetes centers across nine states of India, we selected 19 084 individuals with type 2 diabetes (aged 10-97 years) with diabetes duration of less than 5 years at the time of first clinic visit and performed k-means clustering using the following variables: age at diagnosis, body mass index, waist circumference, glycated hemoglobin, serum triglycerides, serum high-density lipoprotein cholesterol and C peptide (fasting and stimulated). This was then validated in a national epidemiological data set of representative individuals from 15 states across India.

RESULTS

We identified four clusters of patients, differing in phenotypic characteristics as well as disease outcomes: cluster 1 (Severe Insulin Deficient Diabetes, SIDD), cluster 2 (Insulin Resistant Obese Diabetes, IROD), cluster 3 (Combined Insulin Resistant and Deficient Diabetes, CIRDD) and cluster 4 (Mild Age-Related Diabetes, MARD). While SIDD and MARD are similar to clusters reported in other populations, IROD and CIRDD are novel clusters. Cox proportional hazards showed that SIDD had the highest hazards for developing retinopathy, followed by CIRDD, while CIRDD had the highest hazards for kidney disease.

CONCLUSIONS

Compared with previously reported clustering, we show two novel subgroups of type 2 diabetes in the Asian Indian population with important implications for prognosis and management. The coexistence of insulin deficiency and insulin resistance seems to be peculiar to the Asian Indian population and is associated with an increased risk of microvascular complications.

Clinical Profile of Elderly Patients (Over 90 Years) with Type 2 Diabetes Seen at a Diabetes Center in South India

Background: The current life expectancy in India is <70 years. Type 2 diabetes mellitus (T2DM) is known to reduce life expectancy by 6-8 years. Hence elderly people with T2DM in India would be rare. We report on the clinical profile of Asian Indian patients with T2DM who lived beyond 90 years of age and compared them with T2DM patients aged 50 to 60 years. Methods: From the diabetes electronic medical records of >470,000 diabetes patients, we identified T2DM patients who had lived ≥90 years and compared them with those in the 50-60 years age group, matched for gender and duration of diabetes. Clinical data included age at last visit, age at diagnosis, duration of diabetes, family history, smoking and alcohol, details of medications, body mass index (BMI), and blood pressure. Biochemical data included fasting and postprandial plasma glucose, glycated hemoglobin, fasting and stimulated C-peptide levels, lipid profile, and renal function studies. Assessment of retinopathy, nephropathy, neuropathy, coronary artery disease (CAD), and peripheral vascular disease (PVD) was also done. Results: A total of 325 T2DM patients aged ≥90 years and 278 T2DM patients aged between 50 and 60 years were selected for the study. Patients aged ≥90 years had higher systolic blood pressure (P < 0.001) and lower BMI (P < 0.001) than those between 50 and 60 years. Prevalence of retinopathy (29.7% vs. 53.5%) and macroalbuminuria (3.7% vs. 16.0%) was lower in the ≥90 years T2DM patients than in the 50-60 years age group. However, prevalence of neuropathy (89.8% vs. 50.8%), PVD (13.5% vs. 2.0%), and CAD (60.3% vs. 32.0%) was higher among the ≥90 years patients. Eighty-five percent of the T2DM aged ≥90 years were on oral hypoglycemic agents (OHAs), (of whom 64.9% were on sulfonylurea), 12% were on insulin, and 3% on diet alone. Among the 50-60 years old, 87.8% were on OHAs and 12.2% on insulin. Conclusions: This is the first report on the clinical profile of Asian Indians with T2DM aged ≥90 years, and significant differences are seen in their clinical profile compared with younger T2DM patients.

Management of Type 2 Diabetes in Developing Countries: Balancing Optimal Glycaemic Control and Outcomes with Affordability and Accessibility to Treatment

With the growing prevalence of type 2 diabetes, particularly in emerging countries, its management in the context of available resources should be considered. International guidelines, while comprehensive and scientifically valid, may not be appropriate for regions such as Asia, Latin America or Africa, where epidemiology, patient phenotypes, cultural conditions and socioeconomic status are different from America and Europe. Although glycaemic control and reduction of micro- and macrovascular outcomes remain essential aspects of treatment, access and cost are major limiting factors; therefore, a pragmatic approach is required in restricted-resource settings. Newer agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists in particular, are relatively expensive, with limited availability despite potentially being valuable for patients with insulin resistance and cardiovascular complications. This review makes a case for the role of more accessible second-line treatments with long-established efficacy and affordability, such as sulfonylureas, in the management of type 2 diabetes, particularly in developing or restricted-resource countries.

The Standard of Care in Type 2 Diabetes: Re-evaluating the Treatment Paradigm

There is currently a worldwide epidemic of type 2 diabetes (T2D) that is predicted to increase substantially in the next few years. With 80% of the global T2D population living in low to middle-income countries, there are issues with cost and of access to appropriate medicines. The objective of this symposium was to provide an overview of the efficacy and safety of glucose-lowering drugs, focussing in particular on sulfonylureas (SUs) in patients with T2D using data taken from both randomised controlled trials (RCTs) and real-world studies, the application of strategies to ensure optimal patient adherence and clinical outcomes, and the optimal use of SUs in terms of dose adjustment and agent choice to ensure the best clinical outcome. The symposium began by exploring a profile of the typical patient seen in diabetes clinical practice and the appropriate management of such a patient in the real world, before moving on to an overview of the risks associated with T2D and how the currently available agents, including newer antidiabetic medications, mitigate or exacerbate those risks. The final presentation provided an overview of real-world studies, the gap between RCTs and the real world, and the use of available glucose-lowering agents in daily clinical practice. Clinical evidence was presented demonstrating that tight glucose control improved both microvascular and macrovascular outcomes, but that aggressive treatment in patients with a very high cardiovascular risk could lead to adverse outcomes. Real-world data suggest that older agents such as SUs and metformin are being used in a large proportion of patients with T2D with demonstrable effectiveness, indicating that they still have a place in modern T2D management. The symposium, while acknowledging the need for newer antidiabetic drugs in specific situations and patient groups, recommended the continuation of SUs and metformin as the primary oral antidiabetic agents in resource-constrained regions of the world.Funding:Servier.

Bone turnover and bone mineral density in old persons with type 2 diabetes

AIMS

To understand the paradox of an increased fracture risk despite increased bone mineral density (BMD) in persons with type 2 diabetes (DM2).

PATIENTS AND METHODS

We studied 80 old persons with DM2. Mineral metabolism, parathyroid hormone (PTH), 25-hydroxyvitamin D (25OHD), bone turnover - osteocalcin, procollagen type 1 N-terminal propeptide (P1NP) and C-terminal telopeptide of type 1 collagen (CTX) - were measured and BMD was assessed at the lumbar spine (LS) and femoral neck (FN). Data was analyzed with the Statistical Package for the Social Sciences Program.

RESULTS

Low levels of 25OHD (84%) and high values of PTH (20%) were found. Osteocalcin was directly related to CTX, p < 0.001, with increased bone formation and increased BMD (z-score) at LS and FN. PTH was directly related to osteocalcin and CTX and inversely related to BMD at the FN, p < 0.05. Patients with dyslipidemia presented higher P1NP, p < 0.05 and patients with hypertension presented higher BMD at LS and FN, p < 0.01.

CONCLUSION

Old type 2 diabetics present increased bone formation, PTH-driven. Low grade secondary hyperparathyroidism may explain the paradox of an increased fracture risk despite increased BMD.

My 40-year journey in diabetes research: The power of collaboration

This article describes a 40 year journey in diabetes research of an Indian diabetologist, starting as an undergraduate medical student. The article describes how collaborations with multiple stake-holders is necessary if one is to advance one's research from the simple studies that one starts with and take it to higher and higher levels. It is also essential that the seeds for doing research are planted early in a medico's life even during undergraduate days, as only then will more doctors take up medical research as a career. Finally, the article demonstrates how it is possible to do good quality research in India if one has the passion and sustained interest in the field even if one is not in a university or academic setup.

Younger-onset versus older-onset type 2 diabetes: Clinical profile and complications

AIMS

To compare the clinical profile and complications between younger and older onset type 2 diabetes (T2DM) patients at a tertiary care diabetes center in south India.

METHODS

We compared individuals with T2DM detected at age ≤25years (n=267) and at age≥50years (n=267), matched for gender and duration of diabetes. We reviewed electronic patient charts and extracted data on biochemical parameters (plasma glucose, serum lipids and glycated hemoglobin). We estimated prevalence of complications (retinopathy, nephropathy, neuropathy, and peripheral vascular disease). We examined odds of having each complication, after adjusting for clinical differences between younger- and older-onset T2DM.

RESULTS

Individuals with younger-onset T2DM had significantly greater glycated hemoglobin (8.7 vs. 7.5%), serum cholesterol (160 vs. 148mg/dl), serum triglycerides (147 vs. 128mg/dl), LDL cholesterol (92 vs. 82mg/dl) and lower HDL cholesterol levels (39 vs. 42mg/dl). However, waist circumference (90.4 vs. 92.6cm) and systolic blood pressure (125 vs. 133mmHg) were significantly higher in older onset T2DM. Prevalence of retinopathy (47.6 vs. 31.0%) was higher in younger onset T2DM while neuropathy (41.8 vs. 9.2%) and peripheral vascular disease (6.2 vs. 1.2%) were higher in older onset T2DM. In multiple logistic regression analysis, after adjusting for glycated hemoglobin, hypertension, and hypercholesterolemia, younger onset T2DM had a higher odds of developing retinopathy [Odds Ratio: 2.19; Confidence Intervals: 1.42-3.38] when compared to older onset T2DM.

CONCLUSIONS

Younger onset T2DM patients have worse glycemic and lipid control, and higher prevalence of retinopathy compared to older onset T2DM patients. This underscores the need for more aggressive metabolic control in young-onset T2DM.

Clinical characteristics of Chinese patients with duration of type 2 diabetes >40 years

BACKGROUND

Although type 2 diabetes mellitus (T2DM) shortens life expectancy by 10-12 years, some patients survive extremely long durations of diabetes. The clinical characteristics of Chinese patients with >40 years T2DM remain unknown. Thus, the aim of the present study was to document the clinical profile of patients with T2DM for ≥40 years.

METHODS

The present study evaluated 157 survivors with >40 years T2DM from a total of 582 773 patients with T2DM enrolled in a Chinese national survey of HbA1c. Two matched case-control studies were performed on long T2DM survivors (cases) separately matched according to: (1) survey day, sex, and survey hospital; and (2) age, sex, and survey hospital. Conditional logistic regression analysis was performed to obtain odds ratios (ORs) for long survival.

RESULTS

Patients with a long duration of T2DM had a mean (± SD) age of 75 ± 10 years. Their T2DM had been diagnosed at a mean age of 32 years and the median duration of diabetes was 41 years. In both case-control studies, long-duration T2DM was associated with an increased risk of hyperglycemia (OR 6.31; 95% confidence interval [CI] 1.89-21.09) and coronary heart disease (CHD; OR 2.18 95% CI 1.01-4.70). However, long-duration T2DM was not associated with a higher likelihood of abnormal lipids, diabetic nephropathy (DN), or stroke compared with patients with a shorter duration of T2DM.

CONCLUSIONS

The present study suggests that Chinese patients with long-term T2DM also had increased risks of hyperglycemia and non-fatal CHD. Further studies are needed to investigate whether survival of these patients was associated with non-increased risk of DN.

Incidence of complications in young-onset diabetes: Comparing type 2 with type 1 (the young diab study)

BACKGROUND

There is little data on the incidence of diabetes complications in young onset type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in non European populations.

METHODS

From a tertiary diabetes centre, Chennai, India, we recruited 108 T1DM (defined by abrupt onset of symptoms or diabetic ketoacidosis, absent insulin reserve requiring insulin treatment) and 90 T2DM participants (defined by absence of ketosis, good beta-cell reserve, and good response to oral agents) who were diagnosed between the ages of 10 and 25years, and without any evidence of diabetes complications at diagnosis. We estimated the incidence of various complications (median follow up of five years); retinopathy was defined by presence of at least one definite microaneurysm by retinal photography, nephropathy by urinary albumin excretion ⩾30μg/mg of creatinine, neuropathy by vibration perception threshold ⩾20V on biothesiometry, peripheral vascular disease by an ankle-brachial index <0.9, and ischemic heart disease (IHD) by history of myocardial infarction or coronary revascularization or Q waves on ECG or on drug treatment for IHD.

RESULTS

The mean ages at diagnosis of T1DM and T2DM participants were 17.1±4.2vs. 21.6±3.6years respectively. The incidence of various complications reported in numbers/1000 person years of follow up of T1DM and T2DM were: retinopathy 77.4vs. 78.0/1000 person years, nephropathy, 62.0vs. 58.8, neuropathy 7.8 vs. 13.9 and ischemic heart disease 1.2vs. 5.4. In Cox regression analysis, after adjustment for age, glycated hemoglobin, systolic blood pressure and serum cholesterol, T2DM participants had 2.11 times (95%CI: 1.27-3.51) higher risk of developing any diabetes complication, compared to T1DM.

CONCLUSIONS

Young-onset T2DM have a more aggressive disease course than T1DM.

Association of TCF7L2 Polymorphism with Diabetic Nephropathy in the South Indian Population

The transcription factor 7-like 2 (TCF7L2) gene plays a significant role in the development of type 2 diabetes and diabetic nephropathy. The aim of this study was to investigate the association of TCF7L2 rs12255372 (G/T)polymorphism with type 2 diabetic nephropathy in the South Indian population. A total of 2102 subjects, 927 normal glucose tolerant (NGT) subjects, 598 type 2 diabetic subjects without nephropathy (DM), and 577 type 2 diabetic subjects with nephropathy (DN) were genotyped by MassARRAY. As compared to the NGT group, the odds ratio (adjusted for age, sex, BMI, HbA1c, and systolic BP) computed for the GT/TT genotype taking the GG genotype as reference was found to be 2.02 (95% CI: 1.16-3.51, p = 0.013) for DN and 1.94 (95% CI: 1.36-2.78, p = 0.0002) for DM. The genotype frequency was not significantly different between the DM and DN groups. In conclusion, the rs12255372 polymorphism in the TCF7L2 gene is associated with type 2 diabetes and DN but its association with DN is mediated through diabetes.

Regularity of follow-up, glycemic burden, and risk of microvascular complications in patients with type 2 diabetes: a 9-year follow-up study

AIMS

To assess the relationship between regularity of follow-up and risk of complications in patients with type 2 diabetes (T2DM) followed up for 9 years at a tertiary diabetes center in India.

METHODS

We compared glycemic burden [cumulative time spent above a HbA1c of 53 mmol/mol (7 %)] and incidence of diabetes complications (retinopathy, neuropathy, nephropathy, peripheral arterial disease, coronary heart disease) between 1,783 T2DM patients with "regular follow-up" (minimum of three visits and two HbA1c tests every year from 2003 to 2012), and 1,798 patients with "irregular follow-up" (two visits or less and one HbA1c or less per year during the same time period), retrospectively identified from medical records. Cox proportional hazards models were used to estimate risk associated with diabetes complications.

RESULTS

Compared to those with regular follow-up, the irregular follow-up group had significantly higher mean fasting and postprandial plasma glucose, HbA1c, glycemic burden, total and LDL cholesterol, and triglycerides at every time point during the 9 years of follow-up. Those with irregular follow-up had double the total and mean monthly glycemic burden and 1.98 times higher risk of retinopathy (95 % CI 1.62, 2.42) and 2.11 times higher risk of nephropathy (95 % CI 1.73, 2.58) compared to those with regular follow-up, even after adjusting for time-varying confounding variables. Complications tended to develop significantly earlier and were more severe in those with irregular follow-up.

CONCLUSION

Among patients with type 2 diabetes, regular follow-up was associated with significantly lower glycemic burden and lower incidence of retinopathy and nephropathy over a 9-year period.