Cognitive function and the risk for diabetes among young men

Visual impairment and cognitive performance: A nationwide study of 1.4 million adolescents

PURPOSE

Previous research highlights the adverse effects of visual impairment (VI) on academic achievement in children, yet its impact on cognitive performance among adolescents and young adults remains under-studied. Therefore, this investigation aimed to analyse this association in a nationwide sample of Israeli adolescents.

METHODS

A retrospective population-based cross-sectional study was conducted among 1,410,616 Israeli-born adolescents aged 16-19 years, who were assessed before mandatory military service between 1993 and 2017. The definition of VI was based on best-corrected visual acuity (BCVA) measurements using a standard Snellen chart. Adolescents with BCVA worse than 6/9 in either or both eyes were classified as having unilateral or bilateral VI, respectively. Cognitive performance was measured using the General Intelligence Score (GIS), based on a validated four-domain test. Relationships were analysed using regression models yielding adjusted odds ratios (ORs) for low (<-1 standard deviation [SD]) and high (≥1 SD) cognitive Z-scores.

RESULTS

Of 1,410,616 adolescents (56.1% men), 13,773 (1.0%) had unilateral and 3980 (0.3%) had bilateral VI. Unilateral VI was associated with adjusted ORs for low and high cognitive Z-scores of 1.24 (1.19-1.30) and 0.84 (0.80-0.89), respectively. ORs were accentuated for bilateral VI, reaching 1.62 (1.50-1.75) and 0.81 (0.74-0.90) for low and high cognitive Z-scores, respectively. Cognitive performance subscores mirrored these results, with the visual-spatial functioning subtest demonstrating the greatest effect size. These associations persisted in sub-analyses restricted to adolescents with amblyopia-related VI, mild VI and unimpaired health status.

CONCLUSIONS

Visual impairment, including mild and unilateral cases, is associated with reduced cognitive performance scores assessed in late adolescence. Further research is required to gain a comprehensive understanding of the dynamics underlying this relationship.

Intelligence among ear deformities and cleft lip and/or alveolus and/or cleft palate patients during 50 years in Israel

PURPOSE

We evaluated hearing loss and general intelligence among persons with auricle anomalies and cleft lip and/or alveolus and/or cleft palate (CLAP).

METHODS

A nationwide cross-sectional study of data recorded during 1966-2019, as mandatory pre-military recruitment of individuals.

RESULTS

Of 3 182 892 adolescents, 548 were diagnosed with auricle anomalies and 2072 with CLAP. For the latter, the adjusted odds ratios for the low, low to medium and medium general intelligence categories compared to the highest category were 1.4 [95% CI 1.5-1.2], 1.2 [95% CI 1.4-1.1] and 1.1 [95% CI 1.2-0.9] respectively. The corresponding values for the auricle anomalies were not significant.

CONCLUSIONS

General intelligence was impaired among individuals with CLAP, but no significant correlation was found among individuals suffering from auricle anomalies.

Hearing Impairment and Severe Attention Deficit/Hyperactivity Disorder: A Nationwide Study

BACKGROUND

The association between hearing impairment and attention-deficit/hyperactivity disorder (ADHD) is unclear. Therefore, we aimed to assess this association in Israel's national sample of over 1.1 million adolescents.

METHODS

We conducted a nationwide, population-based, cross-sectional study of all Israeli adolescents (n = 1,175,534, 58% males; mean age, 17 yrs) who were examined before mandatory military service during 2004 to 2020. Board-certified specialists confirmed diagnoses of hearing impairment and severe ADHD.

MAIN OUTCOMES AND MEASURES

We compared the prevalence of severe ADHD in adolescents with and without hearing impairment. Associations were analyzed using logistic regression models and sensitivity analyses accounting for hearing impairment type (sensorineural vs. conductive) and severity.

RESULTS

Of the 8,769 adolescents with hearing impairment, 57 were diagnosed with severe ADHD (prevalence = 0.65%). Of the 1,166,765 adolescents without hearing impairment, 3,936 were diagnosed with severe ADHD (prevalence = 0.29%). We found a significant association between hearing impairment and severe ADHD (odds ratio = 1.93 [95% confidence interval, 1.47-2.49]), which persisted in a multivariable model adjusted to age, sex, socioeconomic status, educational status, cognitive performance, and immigration status (odds ratio = 1.70 [95% confidence interval, 1.29-2.20]). The association also persisted when stratified by hearing impairment type (sensorineural vs. conductive) and severity.

CONCLUSIONS

Adolescents with hearing impairment had 70% increased odds of severe ADHD. Study findings suggest that active screening of patients with hearing impairment for ADHD should be considered.

Adolescent Body Mass Index and Early Chronic Kidney Disease in Young Adulthood

Importance

Despite increasing obesity rates in adolescents, data regarding early kidney sequelae are lacking.

Objective

To assess the association between adolescent body mass index (BMI) and early chronic kidney disease (CKD) in young adulthood (<45 years of age).

Design, Setting, and Participants

This cohort study linked screening data of mandatory medical assessments of Israeli adolescents to data from a CKD registry of a national health care system. Adolescents who were aged 16 to 20 years; born since January 1, 1975; medically evaluated for mandatory military service through December 31, 2019; and insured by Maccabi Healthcare Services were assessed. Individuals with kidney pathology, albuminuria, hypertension, dysglycemia, or missing blood pressure or BMI data were excluded. Body mass index was calculated as weight in kilograms divided by height in meters squared and categorized by age- and sex-matched percentiles according to the US Centers for Disease Control and Prevention. Follow-up started at the time of medical evaluation or January 1, 2000 (whichever came last), and ended at early CKD onset, death, the last day insured, or August 23, 2020 (whichever came first). Data analysis was performed from December 19, 2021, to September 11, 2023.

Main Outcomes and Measures

Early CKD, defined as stage 1 to 2 CKD by moderately or severely increased albuminuria, with an estimated glomerular filtration rate of 60 mL/min/1.73 m2 or higher.

Results

Of 629 168 adolescents evaluated, 593 660 (mean [SD] age at study entry, 17.2 [0.5] years; 323 293 [54.5%] male, 270 367 [45.5%] female) were included in the analysis. During a mean (SD) follow-up of 13.4 (5.5) years for males and 13.4 (5.6) years for females, 1963 adolescents (0.3%) developed early CKD. Among males, the adjusted hazard ratios were 1.8 (95% CI, 1.5-2.2) for adolescents with high-normal BMI, 4.0 (95% CI, 3.3-5.0) for those with overweight, 6.7 (95% CI, 5.4-8.4) for those with mild obesity, and 9.4 (95% CI, 6.6-13.5) for those with severe obesity. Among females, the hazard ratios were 1.4 (95% CI, 1.2-1.6) for those with high-normal BMI, 2.3 (95% CI, 1.9-2.8) for those with overweight, 2.7 (95% CI, 2.1-3.6) for those with mild obesity, and 4.3 (95% CI, 2.8-6.5) for those with severe obesity. The results were similar when the cohort was limited to individuals who were seemingly healthy as adolescents, individuals surveyed up to 30 years of age, or those free of diabetes and hypertension at the end of the follow-up.

Conclusions and Relevance

In this cohort study, high BMI in late adolescence was associated with early CKD in young adulthood. The risk was also present in seemingly healthy individuals with high-normal BMI and before 30 years of age, and a greater risk was seen among those with severe obesity. These findings underscore the importance of mitigating adolescent obesity rates and managing risk factors for kidney disease in adolescents with high BMI.

Blepharoptosis and cognitive performance: a population-based study of 1.4 million adolescents

The purpose of this study is to examine the association between blepharoptosis and cognitive performance in late adolescence. This population-based, retrospective, cross-sectional study included 1,411,570 Israeli-born adolescents (620,107 women, 43.9%) aged 16-19 years who were medically examined before compulsory military service between 1993 and 2017. The diagnosis of blepharoptosis was verified by an ophthalmologist. Cognitive performance was assessed by a validated intelligence-quotient-equivalent test, comprising four domains (problem-solving, verbal abstraction and categorization, verbal comprehension, and mathematical abilities). Cognitive Z-scores were calculated and categorized as high (≥ 1 standard deviation (SD)), medium (- 1 to < 1 SD), and low (less than - 1 SD). Relationships were analyzed using regression models adjusted for sociodemographic variables including sex, year of birth, residential socioeconomic status, education level, body mass index, and familial country of origin. A total of 577 (41 per 100,000, 32.2% women) adolescents were diagnosed with blepharoptosis. The proportions of unilateral and bilateral visual impairment among adolescents with blepharoptosis were 13.0% and 3.5%, respectively. In a multivariable analysis, blepharoptosis was associated with a 0.18 SD reduction in cognitive Z-score (p < 0.001). The adjusted odds ratios for low and high cognitive Z-scores in adolescents with blepharoptosis were 1.54 (1.25-1.89) and 0.80 (0.62-1.04), respectively. This relationship persisted when adolescents with normal best-corrected visual acuity or unimpaired health status were analyzed separately.  Conclusions: Blepharoptosis is associated with reduced cognitive performance determined in late adolescence. Future prospective studies should investigate the causes of this link and their underlying mechanisms. What is Known: • While earlier investigations have examined the effects of blepharoptosis on vision and quality of life, the association between blepharoptosis and cognitive outcomes in youth has remained unexplored. What is New: • This nationwide study involving 1.4 million Israeli adolescents found a correlation between blepharoptosis and reduced cognitive performance. • Our findings suggest a potential interplay between blepharoptosis and cognitive development in the pediatric population, calling for increased focus on the educational needs of affected individuals.

Are intelligent people more likely to get vaccinated? The association between COVID-19 vaccine adherence and cognitive profiles

INTRODUCTION

Since vaccination adherence is crucial in reducing morbidity and mortality during a pandemic, we characterized the association between demographic, intelligence, and personal attributes and COVID-19 vaccination adherence among young adults.

METHODS

Cohort study including vaccination data of 185,061 personnel, collected during 13 months of COVID-19 vaccination campaign, while a wide array of vaccination incentives were offered. The effect of demographic data (age, gender and socioeconomic status), military medical fitness - fit for combat service, administrative service, or unfit (volunteering), general intelligence score (GIS) and military social score (MSS) assessing social abilities, on vaccine adherence (allocating by IMOH guidelines) was examined.

RESULTS

Adherent (vs. nonadherent) personnel presented higher GIS (mean 5.68 ± 1.84 vs. 4.72 ± 1.91) and MSS (median 26 (IQR 23-29) vs. 24 (IQR 19-26)), p < 0.001 for both. Higher intelligence was the strongest predictor for vaccine adherence (OR = 5.38, 95 %CI 5.11-5.67, p < 0.001). The probability for vaccine adherence increased in association with escalating GIS scores, with highest GIS females more likely to adhere to vaccination than same-level males (OR = 5.66, 95 %CI 5.09-6.28 vs. OR = 3.69, 95 %CI 3.45-3.94, respectively, p < 0.001 for both). Medically fit service-members were approximately three times as likely to be adherent than volunteering personnel (OR = 2.90 (95 %CI 2.65-3.17) for administrative and OR = 2.94 (95 %CI 2.70-3.21) for combative fitness, p < 0.001 for both).

CONCLUSIONS

During a COVID-19 vaccination campaign, addressing vaccine hesitancy contributing factors and providing wide vaccine availability, GIS and physical fitness had the strongest association with vaccination adherence among young adults. When planning future vaccination campaigns, implementing these insights should be considered to improve adherence.

Association Between Body Mass Index and Nonspecific Recurrent Low Back Pain in Over 600,000 Healthy Young Adults

An association between body mass index (BMI; weight (kg)/height (m)2) and low back pain (LBP) has long been debated, but inconsistent measurements of BMI and varying definitions of LBP have produced conflicting findings. We explored this association using measured BMI and physician documentation of recurrent LBP among healthy young adults. Data were extracted from the Israel Defense Forces electronic medical record system. All Israeli citizens with compulsory military service during January 2008-March 2019 were included (n = 705,840). Exclusion criteria were spine deformities, disc pathologies, spinal surgeries, arthropathies, connective tissue diseases, pain syndromes, low bone density disorders, cancers, and psychiatric illnesses. LBP was defined as electronic medical record system documentation of 1) 2 medical visits at least 6 weeks apart with a diagnosis of LBP or "LBP with radiation" or 2) 1 medical visit resulting in referral to an orthopedic surgeon. Logistic regression models were used to explore the association between BMI category and LBP; 619,969 (87.8%) individuals (mean age = 18.9 (standard deviation, 0.97) years; 56.9% male) were included. LBP prevalence was 9.2% (n = 56,918) and higher among males (9.7%) than females (8.5%). Overweight (odds ratio = 1.123, 95% confidence interval: 1.096, 1.151) and obesity (odds ratio = 1.137, 95% confidence interval: 1.096, 1.179) were associated with LBP. The association remained significant after accounting for various sociodemographic factors. Maintaining a healthy BMI may aid in the prevention of LBP in young adults.

Associations among multidomain lifestyles, chronic diseases, and dementia in older adults: a cross-sectional analysis of a cohort study

Background

Unhealthy lifestyles and chronic diseases are commonly seen and treatable factors in older adults and are both associated with dementia. However, the synergistic effect of the interaction of lifestyles and chronic diseases on dementia is unknown.

Methods

We determined independent associations of multidomain lifestyles and chronic diseases (cerebrovascular disease, diabetes, and hypertension) with dementia and examined their synergistic impact on dementia among older adults. The data were drawn from the Hubei Memory and Aging Cohort Study. We created a summary score of six factors for multidomain lifestyles. Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders IV. Logistic regression and multiple correspondence analyses were used to explore the relationships among multidomain lifestyles, chronic diseases, and dementia. A sensitivity analysis was performed to minimize the interference of reverse causality and potential confounders.

Results

Independent associations with dementia were found in unhealthy (OR = 1.90, 95% CI: 1.38-2.61) and intermediate healthy lifestyles (OR, 3.29, 2.32-4.68), hypertension (OR, 1.21, 1.01-1.46), diabetes (OR, 1.30, 1.04-1.63), and cerebrovascular disease (OR, 1.39, 1.12-1.72). Interactions of diabetes (p = 0.004), hypertension (p = 0.004), and lifestyles were significant, suggesting a combined impact on dementia. Sensitivity analysis supported the strong association among multidomain lifestyles, chronic diseases, and dementia prevalence.

Conclusion

An unhealthy lifestyle was associated with a higher prevalence of dementia, regardless of whether the participants had chronic diseases; however, this association was stronger in individuals with chronic diseases. Multidomain lifestyles and chronic diseases may have an enhanced impact on dementia.

Effects of hypoglycaemic therapy on frailty: a multi-dimensional perspective

INTRODUCTION

The prevalence of diabetes is increasing in older people. With increasing age, frailty emerges as a new complication leading to disability. Frailty does not only include physical dysfunction but also involves negative impact on cognition and mood. Triad of impairments (TOI) is a new concept that includes physical frailty, dementia and depression to reflect the wider spectrum of frailty.

AREAS COVERED

Little is known about effects of hypoglycaemic agents on frailty syndrome. A literature search was performed on studies, which reported effects of hypoglycaemic agents on the component of the TOI.

EXPERT OPINION

It appears that most hypoglycaemic agents have some effects on frailty, although the results of clinical studies are inconsistent. Metformin seems to have a consistent and a positive effect on physical frailty. Its effects on cognitive function, however, are inconclusive but tend to be positive. Metformin appeared to improve depressive symptoms. Other agents such as incretins, thiazolidinediones, and sodium glucose transporter-2 inhibitors have some positive effects on cognition and depression. Sulfonylureas, glinides, or insulin have either negative or neutral effects on TOI components. The negative effects of insulin could be partially explained by the negative psychological factors and the frequent episodes of hypoglycemia associated with such therapy.

Trajectories of Cognition and Daily Functioning Before and After Incident Diabetes

OBJECTIVE

The temporal pattern of cognitive and functional change before and after incident diabetes remains unknown.

RESEARCH DESIGN AND METHODS

Data from wave 2 to wave 9 (2004-2018) of the English Longitudinal Study of Ageing were used. Global cognition (assessed by orientation, memory, and executive function) and daily functioning (calculated as the sum of impaired basic and instrumental activities of daily living) were measured in each wave. Incident diabetes was defined as glycated hemoglobin A1c ≥6.5% (47.5 mmol/mol), self-reported doctor diagnosis of diabetes, or glucose-lowering medication use during follow-up.

RESULTS

Among the 6,342 participants (mean age 65.0 years, 57.8% women) included, 576 participants (9.1%) with incident diabetes were identified during a median follow-up of 13.3 years. The annual rates of change in global cognition (β = -0.035 SD/year; 95% CI -0.054 to -0.015), orientation (-0.031 SD/year; -0.060 to -0.002), memory (-0.016 SD/year; -0.029 to -0.003), and executive function (-0.027 SD/year; -0.042 to -0.013) were accelerated after diabetes diagnosis compared with before the event. The postdiabetes annual changes in daily functioning (0.093 points/year; 95% CI 0.056-0.131) were also accelerated compared with the prediabetes diagnosis. However, the rate of cognitive and functional decline before the diabetes diagnosis in participants with future incident diabetes was similar to the rate in participants without diabetes. Also, no significant acute change was observed during its onset.

CONCLUSIONS

Incident diabetes is associated with accelerated cognitive and functional decline after, but not before, the event. We suggest careful monitoring for cognitive and physical dysfunction after a diabetes diagnosis.

Glucose Intolerance in Pregnancy and Offspring Obesity in Late Adolescence

OBJECTIVE

Gestational hyperglycemia is associated with deleterious neonatal outcomes, but long-term risks for offspring obesity are less clear. We estimated the odds for offspring adolescent overweight and obesity among mothers with gestational glucose intolerance.

RESEARCH DESIGN AND METHODS

In a mother-offspring historical cohort, the Israel military conscription data set was linked to a large health maintenance organization. Included were women who were evaluated at adolescence and underwent two-step gestational diabetes screening (mean age, 31 years) with a 50-g glucose challenge test (GCT), followed by a 100-g oral glucose tolerance test (OGTT) if the result was abnormal. Glucose tolerance categories included gestational normoglycemia, abnormal GCT with normal OGTT, impaired glucose tolerance (IGT; one abnormal OGTT value), and gestational diabetes. The primary outcome was offspring overweight/obesity (BMI ≥85th percentile) at adolescence, measured prior to military conscription. Logistic regression models were applied.

RESULTS

Of 33,482 mother-offspring pairs, overweight and obesity were observed in 6,516 offspring. Across increasing categories of pregnancy glycemia, the proportions of offspring with adolescent overweight/obesity increased: normoglycemia, 19%; abnormal GCT with normal OGTT, 22%; gestational IGT, 24%; and gestational diabetes, 25% (P < 0.0001). Corresponding odds ratios after adjustment for the mother's late adolescent characteristics (sociodemographic confounders and BMI) and pregnancy age were 1.2 (95% CI 1.1-1.4), 1.3 (1.2-1.5), and 1.4 (1.3-1.6), respectively. Further adjustment for offspring birth weight percentile and sociodemographic variables did not materially change results. Associations were more pronounced with increasing obesity severity.

CONCLUSIONS

Gestational glucose intolerance, including categories not meeting the gestational diabetes threshold, was associated with increased odds for offspring overweight/obesity at late adolescence.

Personality disorders and cause-specific mortality: a nationwide study of 2 million adolescents

BACKGROUND

Personality disorders are prevalent in 6-10% of the population, but their risk for cause-specific mortality is unclear. The aim of the study was to assess the association between personality disorders diagnosed in late adolescence and all-cause as well as cause-specific (cardiovascular-related, external-related) mortality.

METHODS

We performed a longitudinal study on a historical prospective cohort based on nationwide screening prior to recruitment to the Israeli army. The study participants were 16-19-year-old persons who attended the army screening (medical and cognitive, including screening for psychiatric disorders) between 1967 and 2006. Participants were followed from 1967 till 2011.

RESULTS

The study included 2 051 606 subjects, of whom 1 229 252 (59.9%) were men and 822 354 (40.1%) were women, mean age 17.36 years. There were 55 508 (4.5%) men and 8237 (1.0%) women diagnosed with personality disorders. The adjusted hazard ratio (HRs) for coronary, stroke, cardiovascular, external-related causes and all-cause mortality among men with personality disorders were 1.34 (1.03-1.74), 1.82 (1.20-2.76), 1.45 (1.23-1.71), 1.41 (1.30-1.53) and 1.44 (1.36-1.51), respectively. The absolute rate difference for all-cause mortality was 56.07 and 13.19 per 10⁵ person-years among men and women, respectively. Among women with personality disorders, the adjusted HRs for external-related causes and all-cause mortality were 2.74 (1.87-4.00) and 2.01 (1.56-2.58). Associations were already evident within 10 years of follow-up.

CONCLUSIONS

Personality disorder in late adolescence is associated with increased risk of cardiovascular, external- and all-cause mortality. Increased cardiovascular mortality is evident before the age of 40 years and may point to the importance of lifestyle education already in youth.

Association of functional health literacy and cognitive ability with self-reported diabetes in the English Longitudinal Study of Ageing: a prospective cohort study

OBJECTIVES

We investigated whether functional health literacy and cognitive ability were associated with self-reported diabetes.

DESIGN

Prospective cohort study.

SETTING

Data were from waves 2 (2004-2005) to 7 (2014-2015) of the English Longitudinal Study of Ageing (ELSA), a cohort study designed to be representative of adults aged 50 years and older living in England.

PARTICIPANTS

8669 ELSA participants (mean age=66.7, SD=9.7) who completed a brief functional health literacy test assessing health-related reading comprehension, and 4 cognitive tests assessing declarative memory, processing speed and executive function at wave 2.

PRIMARY OUTCOME MEASURE

Self-reported doctor diagnosis of diabetes.

RESULTS

Logistic regression was used to examine cross-sectional (wave 2) associations of functional health literacy and cognitive ability with diabetes status. Adequate (compared with limited) functional health literacy (OR 0.71, 95% CI 0.61 to 0.84) and higher cognitive ability (OR per 1 SD=0.73, 95% CI 0.67 to 0.80) were associated with lower odds of self-reporting diabetes at wave 2. Cox regression was used to test the associations of functional health literacy and cognitive ability measured at wave 2 with self-reporting diabetes over a median of 9.5 years follow-up (n=6961). Adequate functional health literacy (HR 0.64; 95% CI 0.53 to 0.77) and higher cognitive ability (HR 0.77, 95% CI 0.69 to 0.85) at wave 2 were associated with lower risk of self-reporting diabetes during follow-up. When both functional health literacy and cognitive ability were added to the same model, these associations were slightly attenuated. Additionally adjusting for health behaviours and body mass index fully attenuated cross-sectional associations between functional health literacy and cognitive ability with diabetes status, and partly attenuated associations between functional health literacy and cognitive ability with self-reporting diabetes during follow-up.

CONCLUSIONS

Adequate functional health literacy and better cognitive ability were independently associated with lower likelihood of reporting diabetes.

Adolescent Blood Pressure and the Risk for Early Kidney Damage in Young Adulthood

BACKGROUND

Recent guidelines classified blood pressure above 130/80 mm Hg as hypertension. However, outcome data were lacking.

OBJECTIVE

To determine the association between blood pressure in adolescence and the risk for early kidney damage in young adulthood.

METHODS

In this nationwide cohort study, we included 629 168 adolescents aged 16 to 20 who underwent medical examinations before mandatory military service in Israel. We excluded 30 466 adolescents with kidney pathology, hypertension, or missing blood pressure or anthropometric data at study entry. Blood pressure measurements at study entry were categorized according to the Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents: group A (<120/<80 mm Hg; Reference group), group B (120/<80-129/<80 mm Hg), group C (130/80-139/89 mm Hg), and group D (≥140/90 mm Hg). Early kidney damage in young adulthood was defined as albuminuria of ≥30 mg/g with an estimated glomerular filtration rate of 60 mL/(min·1.73 m²) or over.

RESULTS

Of 598 702 adolescents (54% men), 2004 (0.3%) developed early kidney damage during a mean follow-up of 15.1 (7.2) years. The adjusted hazard ratios for early kidney damage in blood pressure group C were 1.17 (1.03-1.32) and 1.51 (1.22-1.86) among adolescents with lean (body mass index <85th percentile) and high body mass index (body mass index ≥85th percentile), respectively. Corresponding hazard ratios for kidney disease in group D were 1.49 (1.15-1.93) and 1.79 (1.35-2.38) among adolescents with lean and high body mass index, respectively.

CONCLUSIONS

Blood pressure of ≥130/80 mm Hg was associated with early kidney damage in young adulthood, especially in adolescents with overweight and obesity.

Adolescent body mass index and changes in pre-pregnancy body mass index in relation to risk of gestational diabetes

BACKGROUND

Pregestational excessive body mass index (BMI) is linked to an increased risk for gestational diabetes mellitus (GDM), but less is known on the effect of adolescent BMI on GDM occurrence. The study aimed to investigate possible associations of adolescent BMI and changes in BMI experienced before first pregnancy, with gestational diabetes risk.

METHODS

This retrospective study was based on linkage of a military screening database of adolescent health status (Israel Defence Forces) including measured height and weight, with medical records (Maccabi Healthcare Services, MHS) of a state-mandated health provider. The latter covers about 25% of the Israeli population; about 90% of pregnant women undergo screening by the two-step Carpenter-Coustan method. Adolescent BMI was categorized according to Center of Disease Control and Prevention percentiles. Only first documented pregnanies were analyzed and GDM was the outcome.

FINDINGS

Of 190,905 nulliparous women, 10,265 (5.4%) developed GDM. Incidence proportions of GDM were 5.1%, 6.1%, 7.3%, and 8.9% among women with adolescent normal BMI, underweight, overweight, and obesity (p<0.001), respectively. In models that accounted for age at pregnancy, birth year, and sociodemographic variables, the adjusted odd ratios (aORs) for developing GDM were: 1.2 (95%CI, 1.1-1.3), 1.5 (1.4-1.6), and 1.9 (1.7-2.1) for adolescent underweight, overweight, and obesity (reference group, normal BMI). Adolescent BMI tracked with BMI notes in the pre-pregnancy period (r=63%). Resuming normal pre-pregnancy BMI from overweight or obesity in adolescence diminished GDM risk, but this diminished risk was not observed among those who returned to a normal per-pre-pregnancy BMI from being underweight in adolescence. Sustained overweight or obesity conferred an aOR for developing GDM of 2.5 (2.2-2.7); weight gain from adolescent underweight and normal BMI to pre-pregnancy excessive BMI conferred aORs of 3.1 (1.6-6.2) and 2.6 (2.2-2.7), respectively.

INTERPRETATION

Change in BMI status from adolescence to pre-pregnancy may contribute to GDM risk. Identifying at-risk populations is important for early preventive interventions.

FUNDING

None.

Asthma in Youth and Early-onset Type 2 Diabetes: A Nationwide Study of 1.72 Million Israeli Adolescents

BACKGROUND

The prevalence of both asthma and early-onset diabetes is on the rise; however, the association between them remains unclear. We examined a possible association of asthma at adolescence with type 2 diabetes in young adulthood.

METHODS

This is a nationwide, population-based study of 1 718 541 Israeli adolescents (57% males; mean age 17.3 years; range 16-19 years), examined before compulsory military service between 1992 and 2016, with data linked to the Israeli National Diabetes Registry. Asthma diagnosis and severity were determined by a board-certified pulmonologist and based on spirometry tests.

RESULTS

Type 2 diabetes developed in 58/9090 (0.64%), 507/97 059 (0.52%), 114/23 332 (0.49%), and 7095/1 589 060 (0.44%) persons with moderate-to-severe, mild, inactive, and no history of asthma, respectively, during a mean follow-up >13 years. The respective odds ratios (ORs) were 1.33 (95% CI, 1.02-1.74), 1.17 (1.06-1.28), and 1.09 (0.9-1.31), considering those without asthma history as the reference, in a model adjusted for birth year, sex, body mass index, and other sociodemographic variables. The association persisted when the analysis accounted for coexisting morbidities, and when persons without asthma, individually matched by age, sex, birth year, and body mass index were the reference. Both mild and moderate-to-severe asthma were associated with type 2 diabetes before age 35 years: ORs 1.18 (1.05-1.34) and 1.44 (1.05-2.00), respectively. The strength of the association was accentuated over time. The effect was unchanged when adjusted for oral and inhaled glucocorticoid use.

CONCLUSION

Adolescents with active asthma have higher risk to develop type 2 diabetes. This seems related to disease severity, independent of adolescent obesity status, apparent before age 35 years, and more pronounced in recent years.

Adolescent cognitive function and incident early-onset type 2 diabetes

BACKGROUND

Cognitive function among apparently healthy adolescents has been associated with cardiovascular morbidity and mortality. We examined the relationship between global and subdomain cognitive scores in adolescence and early-onset type 2 diabetes (T2D) in men and women.

METHODS

A nationwide, population-based study of 971,677 Israeli born adolescents (56% men; mean age 17.4 years) who were medically examined and their cognitive performance was assessed before compulsory military service during 1992-2010. Data included global and subdomain cognitive Z-scores (problem-solving, verbal abstraction and categorization, verbal comprehension, and mathematical abilities). Data were linked to the Israeli National Diabetes Registry. The relations between global and subdomain scores and incident T2D was determined using Cox proportional hazard models and logistic regression models. Analyses were conducted separately for men and women.

FINDINGS

During 16,095,122 person-years, 3,570 individuals developed T2D. After adjustment, those in the low compared to the high quintile of global cognitive Z-score had the highest risk for T2D; HR 2.46, (95% CI 2.10-2.88) for men and 2.33 (95% CI 1.88-2.89) for women. A one-unit lower global cognitive Z-score was associated with 1.41 (95% CI 1.34-1.48) and 1.46 (95% CI 1.36-1.56) increased risks for men and women, respectively. The relationship was noted for the cognitive subdomains scores as well as for the global cognitive score, with no heterogeneity across cognitive subdomains.

INTERPRETATION

This large nationally representative cohort suggests relationship between global, as well as subdomain cognitive scores in late adolescence, and incident early onset T2D in both sexes, which was independent of socioeconomic status.

Body Mass Index in 1.9 Million Adolescents and Stroke in Young Adulthood

[Figure: see text].

Educational attainment protects against type 2 diabetes independently of cognitive performance: a Mendelian randomization study

AIMS

Observational studies have reported a negative association between educational attainment and type 2 diabetes (T2D), but the causality remains largely unknown. The aim of this study is to investigate the potential causal effect of educational attainment on T2D and whether such an effect is independent of cognitive performance.

METHODS

We conducted two-sample Mendelian randomization (MR) analysis using genetic variants strongly associated with educational attainment and cognitive performance to estimate the causal associations with T2D, among 61,714 T2D cases and 593,952 controls. We also performed multivariable MR to explore the independent effects of educational attainment and cognitive performance on T2D risk.

RESULTS

In univariable MR, we found evidence that genetically predicted higher educational attainment [odds ratio (OR) 0.53 per 1-standard deviation (SD) increase; 95% confidence interval (CI) 0.47-0.60] and cognitive performance (OR 0.79 per 1-SD increase; 95%CI 0.69-0.91) were related to decreased risk of T2D. Our further multivariable MR results suggested that more years of education led to a reduced likelihood of T2D independently of cognitive performance (OR 0.52; 95%CI 0.42-0.64). However, the protective effect of cognitive performance on T2D was attenuated once educational attainment was controlled for (OR 1.08; 95%CI 0.88-1.32).

CONCLUSIONS

We provided evidence to suggest that educational attainment protects against T2D independently of cognitive performance, but does not support a negative causal association between cognitive performance and T2D independently of educational attainment. Education might represent a potential target for intervention to battle type 2 diabetes risk.

Intelligence, health and death

The field of cognitive epidemiology studies the prospective associations between cognitive abilities and health outcomes. We review research in this field over the past decade and describe how our understanding of the association between intelligence and all-cause mortality has consolidated with the appearance of new, population-scale data. To try to understand the association better, we discuss how intelligence relates to specific causes of death, diseases/diagnoses and biomarkers of health through the adult life course. We examine the extent to which mortality and health associations with intelligence might be attributable to people's differences in education, other indicators of socioeconomic status, health literacy and adult environments and behaviours. Finally, we discuss whether genetic data provide new tools to understand parts of the intelligence-health associations. Social epidemiologists, differential psychologists and behavioural and statistical geneticists, among others, contribute to cognitive epidemiology; advances will occur by building on a common cross-disciplinary knowledge base.

Stuttering and Incident Type 2 Diabetes: A Population-Based Study of 2.2 Million Adolescents

PURPOSE

To investigate the association between stuttering in adolescence and incident type 2 diabetes in young adulthood.

METHODS

This nationwide population-based study included 2 193 855 adolescents of age 16 to 20 years who were assessed for military service between 1980 and 2013. Diagnoses of stuttering in adolescence were confirmed by a speech-language pathologist. Diabetes status for each individual as of December 31, 2016, was determined by linkage to the Israeli National Diabetes Registry. Relationships were analyzed using regression models adjusted for socioeconomic variables, cognitive performance, coexisting morbidities, and adolescent body mass index.

RESULTS

Analysis was stratified by sex (Pinteraction = 0.035). Of the 4443 (0.4%) adolescent men with stuttering, 162 (3.7%) developed type 2 diabetes, compared with 25 678 (2.1%) men without stuttering (adjusted odds ratio [OR] 1.3; 95% CI, 1.1-1.6). This relationship persisted when unaffected brothers of men with stuttering were used as the reference group (adjusted OR = 1.5; 95% CI, 1.01-2.2), or when the analysis included only adolescents with unimpaired health at baseline (adjusted OR = 1.4; 95% CI, 1.1-1.7). The association was stronger in later birth cohorts, with an adjusted OR of 2.4 (1.4-4.1) for cases of type 2 diabetes before age 40. Of the 503 (0.1%) adolescent women with stuttering 7 (1.4%) developed type 2 diabetes, compared with 10 139 (1.1%) women without stuttering (OR = 2.03; 95% CI, 0.48-2.20).

CONCLUSIONS

Adolescent stuttering is associated with an increased risk for early-onset type 2 diabetes among men.

Cognitive Performance and Its Associations with Dental Caries: Results from the Dental, Oral, Medical Epidemiological (DOME) Records-Based Nationwide Study

Relatively few studies have analyzed the association between cognitive performance and dental status. This study aimed to analyze the association between cognitive performance and dental caries. Included were data from the dental, oral, medical epidemiological (DOME) study; cross-sectional records-based research, which integrated large socio-demographic, medical, and dental databases of a nationally representative sample of young to middle-aged military personnel (N = 131,927, mean age: 21.8 ± 5.9 years, age range: 18-50). The cognitive function of draftees is routinely measured at age 17 years using a battery of psychometric tests termed general intelligence score (GIS). The mean number of decayed teeth exhibited a gradient trend from the lowest (3.14 ± 3.58) to the highest GIS category (1.45 ± 2.19) (odds ratio (OR) lowest versus highest = 5.36 (5.06-5.68), p < 0.001). A similar trend was noted for the other dental parameters. The associations between GIS and decayed teeth persisted even after adjusting for socio-demographic parameters and health-related habits. The adjustments attenuated the OR but did not eliminate it (OR lowest versus highest = 3.75 (3.38-4.16)). The study demonstrates an association between cognitive performance and caries, independent of the socio-demographic and health-related habits that were analyzed. Better allocation of resources is recommended, focusing on populations with impaired cognitive performance in need of dental care.

Adolescent Nonalcoholic Fatty Liver Disease and Type 2 Diabetes in Young Adulthood

CONTEXT

The long-term risk of type 2 diabetes in adolescents with nonalcoholic fatty liver disease (NAFLD) is unclear.

OBJECTIVE

To assess type 2 diabetes risk among adolescents with NAFLD.

DESIGN AND SETTING

A nationwide, population-based study of Israeli adolescents who were examined before military service during 1997-2011 and were followed until December 31, 2016.

PARTICIPANTS

A total of 1 025 796 normoglycemic adolescents were included.

INTERVENTIONS

Biopsy or radiographic tests were prerequisite for NAFLD diagnosis. Data were linked to the Israeli National Diabetes Registry.

MAIN OUTCOME MEASURES

Type 2 diabetes incidence.

RESULTS

During a mean follow-up of 13.3 years, 12 of 633 adolescents with NAFLD (1.9%; all with high body mass index [BMI] at baseline) were diagnosed with type 2 diabetes compared with 2917 (0.3%) adolescents without NAFLD. The hazard ratio (HR) for type 2 diabetes was 2.59 (95% confidence interval [CI], 1.47-4.58) for the NAFLD vs. the non-NAFLD group after adjustment for BMI and sociodemographic confounders. The elevated risk persisted in several sensitivity analyses. These included an analysis of persons without other metabolic comorbidities (adjusted HR, 2.75 [95% CI, 1.48-5.14]) and of persons with high BMI; and an analysis whose outcome was type 2 diabetes by age 30 years (adjusted HR, 2.14 [95% CI, 1.02-4.52]). The results remained significant when a sex-, birth year-, and BMI-matched control group was the reference (adjusted HR, 2.98 [95% CI, 1.54-5.74]).

CONCLUSIONS

Among normoglycemic adolescents, NAFLD was associated with an increased adjusted risk for type 2 diabetes, which may be apparent before age 30 years.

Adolescent BMI and early-onset type 2 diabetes among Ethiopian immigrants and their descendants: a nationwide study

Background

We assessed in a nationwide cohort the association between adolescent BMI and early-onset (< 40 years) type 2 diabetes among Israelis of Ethiopian origin.

Methods

Normoglycemic adolescents (range 16–20 years old), including 93,806 native Israelis (≥ 3rd generation in Israel) and 27,684 Israelis of Ethiopian origin, were medically assessed for military service between 1996 and 2011. Weight and height were measured. Data were linked to the Israeli National Diabetes Registry. Incident type 2 diabetes by December 31, 2016 was the outcome. Cox regression models stratified by sex and BMI categories were applied.

Results

226 (0.29%) men and 79 (0.18%) women developed diabetes during 992,980 and 530,814 person-years follow-up, respectively, at a mean age of 30.4 and 27.4 years, respectively. Among native Israeli men with normal and high (overweight and obese) BMI, diabetes incidence was 9.5 and 62.0 (per 10⁵ person-years), respectively. The respective incidences were 46.9 and 112.3 among men of Ethiopian origin. After adjustment for sociodemographic confounders, the hazard ratios for type 2 diabetes among Ethiopian men with normal and high BMI were 3.4 (2.3–5.1) and 15.8 (8.3–30.3) respectively, compared to third-generation Israelis with normal BMI. When this analysis was limited to Israeli-born Ethiopian men, the hazard ratios were 4.4 (1.7–11.4) and 29.1 (12.9–70.6), respectively. Results persisted when immigrants of other white Caucasian origin were the reference; and among women with normal, but not high, BMI.

Conclusions

Ethiopian origin is a risk factor for early-onset type 2 diabetes among young men at any BMI, and may require selective interventions.

Height as a risk factor in meningioma: a study of 2 million Israeli adolescents

BACKGROUND

Meningiomas are the most common primary central nervous system tumors. Potential risk factors include obesity, height, history of allergy/atopy, and autoimmune diseases, but findings are conflicting. This study sought to assess the role of the different risk factors in the development of meningioma in adolescents/young adults.

METHODS

The cohort included 2,035,915 Jewish men and women who had undergone compulsory physical examination between 1967 and 2011, at age 16 to 19 years, prior to and independent of actual military enlistment. To determine the incidence of meningioma, the military database was matched with the Israel National Cancer Registry. Cox proportional hazard models were used to estimate the hazard ratios for meningioma according to sex, body mass index (BMI), height, and history of allergic or autoimmune disease.

RESULTS

A total of 480 subjects (328 females) were diagnosed with meningioma during a follow-up of 40,304,078 person-years. Median age at diagnosis was 42.1 ± 9.4 years (range 17.4-62.6). On univariate analysis, female sex (p < 0.01) and height (p < 0.01) were associated with risk of meningioma. When the data were stratified by sex, height remained a significant factor only in men. Spline analysis of the male subjects showed that a height of 1.62 m was associated with a minimum disease risk and a height of 1.85+ meters, with a significant risk.

CONCLUSIONS

This large population study showed that sex and adolescent height in males (> 1.85 m) were associated with an increased risk of meningioma in adulthood.

Adolescent Obesity and Early-Onset Type 2 Diabetes

OBJECTIVE

Type 2 diabetes (T2D) is increasingly diagnosed at younger ages. We investigated the association of adolescent obesity with incident T2D at early adulthood.

RESEARCH DESIGN AND METHODS

A nationwide, population-based study evaluated 1,462,362 adolescents (59% men, mean age 17.4 years) during 1996-2016. Data were linked to the Israeli National Diabetes Registry. Weight and height were measured at study entry. Cox proportional models were applied.

RESULTS

During 15,810,751 person-years, 2,177 people (69% men) developed T2D (mean age at diagnosis 27 years). There was an interaction among BMI, sex, and incident T2D (P _interaction = 0.023). In a model adjusted for sociodemographic variables, the hazard ratios for diabetes diagnosis were 1.7 (95% CI 1.4-2.0), 2.8 (2.3-3.5), 5.8 (4.9-6.9), 13.4 (11.5-15.7), and 25.8 (21.0-31.6) among men in the 50th-74th percentile, 75th-84th percentile, overweight, mild obesity, and severe obesity groups, respectively, and 2.2 (1.6-2.9), 3.4 (2.5-4.6), 10.6 (8.3-13.6), 21.1 (16.0-27.8), and 44.7 (32.4-61.5), respectively, in women. An inverse graded relationship was observed between baseline BMI and mean age of T2D diagnosis: 27.8 and 25.9 years among men and women with severe obesity, respectively, and 29.5 and 28.5 years among low-normal BMI (5th-49th percentile; reference), respectively. The projected fractions of adult-onset T2D that were attributed to high BMI (≥85th percentile) at adolescence were 56.9% (53.8-59.9%) and 61.1% (56.8-65.2%) in men and women, respectively.

CONCLUSIONS

Severe obesity significantly increases the risk for incidence of T2D in early adulthood in both sexes. The rise in adolescent severe obesity is likely to increase diabetes incidence in young adults in coming decades.

Quality of Life in Type 2 Diabetes Mellitus Patients with Neuropsychological Deficits

OBJECTIVE

We investigated: (i) the cognitive performance of type 2 diabetes mellitus (T2DM) patients compared to healthy control participants and (ii) the Health-related Quality of life (HRQOL) of type 2 diabetics with neuropsychological deficits.

METHOD

We conducted a prospective study in (N = 44) T2DM patients and (N = 28) demographically matched healthy controls. All participants were assessed with a flexible comprehensive neuropsychological battery of tests that have been standardized in Greece and found to be sensitive in detecting cognitive deficits in type 2 diabetics. They were additionally assessed on measures of general intelligence, general mental state, and depression. They were also administered the WHO QOL-BREF self-report questionnaire to evaluate perceived health-related quality of life.

RESULTS

Groups were well matched on baseline demographic characteristics and estimated premorbid intelligence. The groups did not differ on general mental state but varied in the encoding of verbal material, total verbal learning, delayed recall of verbal information, mental information processing speed, phonological and semantic verbal fluency and executive functions, set-shifting. Glycosylated hemoglobin levels and an interaction of age, education, and premorbid intelligence were the most important predictors of domain-specific neuropsychological performance. T2DM patients with deficits in verbal learning, executive functions, set-shifting, and semantic verbal fluency, had significantly lower QOL in the domains of psychological and environmental health, social relationships, and general health, respectively.

CONCLUSION

T2DM patients have cognitive deficits on several domains compared to healthy participants. Domain specific neuropsychological deficits in middle aged T2DM patients have a significant impact on HRQOL.

Triad of impairment in older people with diabetes-reciprocal relations and clinical implications

Frailty is emerging as a new category complication of diabetes in older people. Clinically, frailty is still not well defined and mostly viewed as a decline in solely the physical domain. However, frailty is a multidimensional syndrome and the newly introduced concept of "triad of impairment" (physical, cognitive and emotional) may be a more representative of the broad nature of frailty. The components of the triad of impairment (TOI) commonly coexist and demonstrate a reciprocal relation. Diabetes in old age appears to increase the risk of the triad of impairment, which may eventually progress to disability. Therefore, older people with diabetes should be regularly assessed for the presence of these three key components. Adequate nutrition and regular resistance exercise training have been shown to have a positive impact on the long-term outcome in this population. However, the role of good glycaemic control and the use of current hypoglycaemic medications in reducing the incidence of this triad are less clear. Future research is needed to develop novel hypoglycaemic medications that not only focus on glycaemic control and cardiovascular safety but also on reducing the risk of the triad of impairment.

Myopia and Childhood Migration: A Study of 607 862 Adolescents

PURPOSE

Immigration studies can shed light on myopia development and reveal high-risk populations. To this end, we investigated the association among immigration, age at immigration, and myopia occurrence during adolescence.

DESIGN

Population-based, retrospective, cross-sectional study.

PARTICIPANTS

Six hundred seven thousand eight hundred sixty-two adolescents, Israeli born and immigrants, with origins in the former Union of Soviet Socialist Republics (USSR), Ethiopia, or Israel, assessed for medical fitness for mandatory military service at 17 years of age between 1993 and 2016.

METHODS

Myopia and high myopia were defined based on right eye refractive data. Age at immigration was categorized into 0 to 5 years of age, 6 to 11 years of age, and 12 to 19 years of age. Univariate and multivariate logistic regression models were created. Myopia odds ratios (ORs) were calculated according to immigration status, with Israeli-born natives as controls. Next, myopia ORs were calculated according to age at immigration, with Israeli-born of same origin as controls.

MAIN OUTCOME MEASURES

Myopia prevalence and ORs.

RESULTS

Myopia was less prevalent among immigrants than Israeli-born controls. When stratified according to age at immigration, a decrease in myopia prevalence and ORs with increasing age at migration were observed, most prominent in immigrants arriving after 11 years of age, who also showed lower high-myopia ORs. The immigrants from the USSR and Ethiopia arriving after 11 years of age showed a myopia OR of 0.65 (95% confidence interval [CI], 0.63-0.67; P < 10^-205) and 0.52 (95% CI, 0.46-0.58; P < 10^-27) compared with the Israeli-born controls. Notably, Ethiopians arriving earlier than 5 years of age showed a 2-fold higher myopia OR than those migrating after 11 years of age.

CONCLUSIONS

Immigrants arriving after 11 years of age showed markedly lower ORs for myopia and high myopia relative to Israeli-born controls or those arriving during early childhood, likely because of environmental and lifestyle changes. Differences between immigrants arriving up to 5 years of age and those arriving between 6 and 11 years of age were relatively smaller, suggesting exposures at elementary school age play a greater role in this population.

Childhood Pancreatitis and Risk for Incident Diabetes in Adulthood

OBJECTIVE

The relationship between acute pancreatitis and incident diabetes is unclear. We assessed whether a resolved single event of acute pancreatitis in childhood was associated with incident diabetes in adulthood.

RESEARCH DESIGN AND METHODS

A nationwide, population-based study of 1,802,110 Israeli adolescents (mean age 17.4 years [range 16-20]) who were examined before compulsory military service between 1979 and 2008 and whose data were linked to the Israeli National Diabetes Registry (INDR). Resolved pancreatitis was defined as a history of a single event of acute pancreatitis with normal pancreatic function at enrollment. Logistic regression analysis was applied.

RESULTS

Incident diabetes developed in 4.6% of subjects with resolved pancreatitis (13 of 281; none of these cases were identified as type 1 diabetes) and 2.5% among the unexposed group (44,463 of 1,801,716). Resolved acute pancreatitis was associated with incident diabetes with an odds ratio (OR) of 2.23 (95% CI 1.25-3.98) with adjustment for age, sex, and birth year. Findings persisted after further adjustments for baseline BMI and sociodemographic confounders (OR 2.10 [95% CI 1.15-3.84]). Childhood pancreatitis was associated with a diagnosis of diabetes at a younger age, with 92% of diabetes case subjects diagnosed before 40 years of age compared with 47% in the unexposed group (P = 0.002). The association accentuated when the study sample was limited to individuals of unimpaired health or normal BMI at baseline.

CONCLUSIONS

A history of acute pancreatitis in childhood with normal pancreatic function in late adolescence is a risk factor for incident type 2 diabetes, especially at young adulthood.

The neuroprotective effect and action mechanism of polyphenols in diabetes mellitus-related cognitive dysfunction

BACKGROUND

Diabetes mellitus (DM) is a complex and prevalent metabolic disorder worldwide. Strong evidence has emerged that DM is a risk factor for the accelerated rate of cognitive decline and the development of dementia. Though traditional pharmaceutical agents are efficient for the management of DM and DM-related cognitive decrement, long-term use of these drugs are along with undesired side effects. Therefore, tremendous studies have focused on the therapeutic benefits of natural compounds at present. Ample evidence exists to prove that polyphenols are capable to modulate diabetic neuropathy with minimal toxicity and adverse effects.

PURPOSE

To describe the benefits and mechanisms of polyphenols on DM-induced cognitive dysfunction. In this review, we introduce an updated overview of associations between DM and cognitive dysfunction. The risk factors as well as pathological and molecular mechanisms of DM-induced cognitive dysfunction are summarized. More importantly, many active polyphenols that possess preventive and therapeutic effects on DM-induced cognitive dysfunction and the potential signaling pathways involved in the action are highlighted.

CONCLUSIONS

The therapeutic effects of polyphenols on DM-related cognitive dysfunction pave a novel way for the management of diabetic encephalopathy.

The effect of the Suicide Prevention Program (SPP) on the characteristics of Israeli soldiers who died by suicide after its implementation

BACKGROUND

Suicide is major cause of death in the IDF. The Suicide Prevention Program (SPP) led to significant reduction in yearly rates of suicide. A study regarding demographic changes of those who died by suicide was done to further investigate its affect.

METHOD

Nested case control retrospective study based on medical and HR data gathered between 1992 and 2016. Participants were divided into four groups: soldiers who died by suicide and non-suicidal soldiers, before and after SPP implementation.

RESULTS

Multivariate analysis with suicide as the binary logistic dependent variable before and after implementation of the SPP among four groups revealed that before SPP the OR was higher for males (OR, 7.885; 95% CI, 5.071-12.259;p < 0.001) compared to after (OR, 3.281; 95% CI, 1.600-6.726; p = 0.001). For support unit soldiers the values before SPP were OR, 14.962 and 95% CI, 8.427-26.563 (p < 0.001) while after SPP they were OR, 6.304 and 95% CI, 3.334-11.919 (p < 0.001). After SPP, OR was higher for psychiatric diagnosis at recruitment (OR, 5.830; 95% CI, 2.046-16.612; p =  0.001) than before SPP (OR, 2.422; 95% CI, 1.526-3.842; p < 0.001).For soldiers from Ethiopian ethnicity, after SPP values were higher (OR, 8.130 and 95% CI, 2.868-23.047 (p < 0.001) compared to before (OR, 3.522; 95% CI, 1.2891-6.650; p < 0.001). For those of Druse religion before values (OR, 4.027; 95% CI, 2.211-7.331; p < 0.001) were significant but not after.

CONCLUSIONS

While the SPP succeeded in reducing risk of suicide in situational factors, dispositional risk factors were not affected by the SPP. The OR decreased in critical masses and rose in unique and smaller groups.

Personal and psychiatric characteristics among Druze soldiers attempting suicide during military service

BACKGROUND

A non-fatal suicide attempt is a strong predictor of suicide. This study aimed to examine personal characteristics and psychiatric diagnoses among Druze soldiers who attempted suicide during their military service.

METHOD

The research group (n = 180) included all Druze soldiers who had attempted suicide between the years 2008-2012 (This number encompassed 18.4% of all suicide attempts in the IDF during those years). Three control groups were examined: Jewish soldiers who had attempted suicide (n = 155), and two additional groups comprising Druze and Jewish combat soldiers who had not attempted suicide (n = 5,255 and n = 205,819, respectively).

RESULTS

While Druze soldiers were diagnosed with psychiatric conditions less frequently than their Jewish counterparts, the more prolonged time to diagnosis among Druze may account for increased severity at time of diagnosis, thus increasing the risk of suicide attempt. A multivariate analysis revealed that the odds of a suicide attempt among Druze soldiers were much higher than among Jewish soldiers (OR 20.53; p < .001). In addition, it was found that average and high socioeconomic levels, strong Hebrew language skills, and high intelligence levels were protective factors against attempted suicide (p < .001, R² = 0.217).

LIMITATIONS

The three control groups were samples, while the research group (Druze attempters) consisted of all instances of attempted suicide during the study period. Comparing only samples would have offered less statistical power; therefore, using all the records in the research group improved accuracy.

Cognitive function in adolescence and the risk for premature diabetes and cardiovascular mortality in adulthood

Background

Epidemiological studies have demonstrated a relationship between cognitive function in youth and the future risk of death. Less is known regarding the relationship with diabetes related death. This study assessed the relationship between cognitive function in late adolescence and the risk for diabetes, cardiovascular- (CVD) and all-cause mortality in adulthood.

Methods

This retrospective study linked data from 2,277,188 16–19 year olds who had general intelligence tests (GIT) conducted during pre-military recruitment assessment with cause of death as coded by the Israel Central Bureau of Statistics. The associations between cognitive function and cause-specific mortality were assessed using Cox models.

Results

There were 31,268 deaths that were recorded during 41,916,603 person-years of follow-up, with a median follow-up of 19.2 (IQR 10.7, 29.5) years. 3068, 1443, 514 and 457 deaths were attributed to CVD, CHD, stroke, and diabetes, respectively. Individuals in the lowest GIT vs. highest GIT quintiles in unadjusted models had the highest risk for all-cause mortality (HR 1.84, 95% CI 1.78, 1.91), total CVD (HR 3.32, 95% CI 2.93, 3.75), CHD (HR 3.49 95% CI 2.92, 4.18), stroke (HR 3.96 95% CI 2.85, 5.5) and diabetes-related (HR 6.96 95% CI 4.68, 10.36) mortality. These HRs were attenuated following adjustment for age, sex, birth year, body-mass index, residential socioeconomic status, education and country of origin for all-cause (HR 1.23, 95% CI 1.17, 1.28), CVD (HR 1.76, 95% CI 1.52, 2.04), CHD (HR 1.7 95% CI 1.37, 2.11), stroke (HR 2.03, 95% CI 1.39, 2.98) and diabetes-related (HR 3.14 95% CI 2.00, 4.94) mortality. Results persisted in a sensitivity analyses limited to participants with unimpaired health at baseline and that accounted competing risk.

Conclusions

This analysis of over 2 million demonstrates a strong relationship between cognitive function at youth and the risk for diabetes, all-cause and CVD-related mortality independent of adolescent obesity.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0798-5) contains supplementary material, which is available to authorized users.

Risk factors associated with gastroenteropancreatic neuroendocrine tumors in a cohort of 2.3 million Israeli adolescents

We investigated whether obesity and sociodemographic factors at adolescence are associated with incident gastroenteropancreatic neuroendocrine tumors (GEP-NET).Our cohort included 2.3 million Israeli adolescents examined at ages 16 to 19 years between 1967 and 2010. The baseline database included sex, country of birth, residential socioeconomic status (SES), body-mass index (BMI) and height. Participants were followed through linkage with the National Cancer Registry up to 2012. We identified 221 cases of GEP-NET (66 pancreatic, 52 gastric, 39 rectal, 27 appendiceal, 23 small bowel and 14 colonic). Immigration from the Former Soviet Union (FSU) was associated with the risk of small bowel and rectal NET's, [Hazard Ratio (HR) 4.79, 95% Confidence Interval (CI) 1.37-16.76 and 3.43, 95% CI 1.20-9.83, respectively].Height >75th percentile and BMI ≥ 85th percentile were associated with increased risk of gastric NET (HR 2.25 95% CI 1.14-4.42 and HR 2.38, 95% CI 1.19-4.75, respectively). Female sex was associated with appendiceal NET (HR 2.30, 95% CI 1.06-4.96) while male gender was associated with an increased risk for NET of the small bowel [HR 4.72 (95% CI 1.10-20.41)].In conclusion, our findings suggest different risk factor associations with the various GEP-NETS: immigrants from the FSU were at increased risk for small bowel and rectal NET; increased height and weight were associated with the risk of gastric NET and females were at increased risk for appendiceal NET. Further focus on the FSU population is indicated in addition to studies verifying the association of BMI and height with gastric NET.

The chicken or the egg? Does glycaemic control predict cognitive function or the other way around?

The association between type 2 diabetes and cognitive dysfunction is well established. Prevention of the development of type 2 diabetes and its complications, as well as cognitive dysfunction and dementia, are leading goals in these fields. Deciphering the causality direction of the interplay between type 2 diabetes and cognitive dysfunction, and understanding the timeline of disease progression, are crucial for developing efficient prevention strategies. The prevailing perception is that type 2 diabetes leads to cognitive dysfunction and dementia. There is substantial evidence showing that accelerated cognitive decline in type 2 diabetes starts in midlife (mean age 40-60 years) and that it may even begin at the prediabetes stage. However, in this issue of Diabetologia, Altschul et al (doi: https://doi.org/10.1007/s00125-018-4645-8 ) show evidence for the reverse causality hypothesis, i.e. that lower cognitive function precedes poor glycaemic control. They found that cognitive function at early adolescence (age 11 years) predicts both HbA_1c levels and cognitive function at age 70 years. Moreover, they found that lower cognitive function at age 70 is associated with an increase in HbA_1c from age 70 to 79 years. Based on these findings, future studies should explore whether developing prevention strategies that target young adolescents with lower cognitive function will result in prevention of type 2 diabetes, breaking the vicious cycle of type 2 diabetes and cognitive dysfunction.

The association between caries related treatment needs and socio-demographic variables among young Israeli adults: a record based cross sectional study

Backgroud

The need for dental treatments, especially those related to dental caries, may be associated with and influenced by a wide range of demographic variables. The aim of this study was to describe caries related treatment needs among young Israeli adults and the association with several socio-demographic factors, including socio-economic cluster (SEC), intellectual capabilities, ethnicity and other variables.

Methods

Data were collected from dental records of army recruits between 2012 and 2013. We cross-examined data regarding dental treatment needs with socio-demographic variables: age, gender, SEC, intellectual capability score (ICS), birth place of participant and parents, education and immigration.

Results

Data received regarding 13,398 combat recruits during their first four months of military training. Most subjects were males (92.4%), with a mean age of 18.9 years. 10.8% were immigrants, with 12.2 years living in Israel before their recruitment. Only 17.7% had no dental treatment needs. Mean number of teeth needing treatment was: for restorations 1.96 ± 2.59, for root canal therapies 0.07 ± 0.44 and for extractions 0.05 ± 0.28. Low ICS scores and low SEC group were significantly associated with higher treatment needs (P < 0.001). Statistically significant higher treatment needs were observed among participants who originated from immigrant families. In a multivariate analysis (Generalized Linear Model), gender, age, ICS score, SEC group and country of birth were found as independent predictors for number of restorations needed.

Conclusion

Socio-demographic variables significantly influence dental treatment needs and should be taken into account when preparing intervention programs in this population.

Practical considerations for managing patients with diabetes and dementia

Diabetes and dementia appear to be linked epidemiologically and share a common pathogenetic mechanism. The development of dementia in older people with diabetes will have a significant impact on diabetes self-care and will increase the risk of hypoglycaemia and frailty which ultimately lead to disability and poor outcome. Areas covered: We performed a Medline and Embase search from 1997 to present on relevant dementia and diabetes studies published in English language. Expert commentary: Older people with comorbid diabetes and dementia are functionally heterogeneous and interventions should be proportionate to patients 'functional capacity. Metabolic targets can be tightened in fit persons and relaxed when cognitive abilities continue to decline and overall function deteriorates. A holistic multidisciplinary team approach that involves patients, their carers and integrated primary and secondary care services at one point of care that focuses on improving function and maintaining quality of life is needed.

Sex Differences in the Impact of Thinness, Overweight, Obesity, and Parental Height on Adolescent Height

PURPOSE

The secular trend of increasing weight may lead to a decline in height gain compared with the genetic height potential. The impact of weight on height in healthy male and female adolescents compared with their genetic height was assessed.

METHODS

Height and weight were measured in Israeli adolescent military recrutees aged 16-19 years between 1967 and 2013. The study population comprised 355,229 recrutees for whom parental height measurements were documented. Subjects were classified into four body mass index percentile groups according to the U.S. Centers for Disease Control and Prevention body mass index percentiles for age and sex:<5th (underweight), 5th-49th (low-normal), 50th-84th (high-normal), and ≥85th (overweight-obese). Short stature was defined as height ≤ third percentile and tall stature as height ≥ 90th percentile for age and sex.

RESULTS

Overweight-obese females had a 73% increased risk for short stature (odds ratio [OR]: 1.73, 95% confidence interval [CI] = 1.51-1.97, p < .001). Conversely, underweight females had a 56% lower risk of short stature (OR: .44, 95% CI = .28-.70, p = .001) and a twofold increased risk for being tall (OR: 2.08, 95% CI = 1.86-2.32, p < .001). Overweight-obese males had a 23% increased risk of being short (OR: 1.23, 95% CI = 1.10-1.37, p < .001). Underweight females were on average 4.1 cm taller than their mid-parental height.

CONCLUSIONS

Overweight-obese males and females had an increased risk of being short, and underweight females were significantly taller compared with their genetic height. The significantly increased height among underweight healthy females may reflect a potential loss of height gain in overweight-obese females.

Brain function and structure and risk for incident diabetes: The Atherosclerosis Risk in Communities Study

INTRODUCTION

Diabetes is prospectively associated with cognitive decline. Whether lower cognitive function and worse brain structure are prospectively associated with incident diabetes is unclear.

METHODS

We analyzed data for 10,133 individuals with cognitive function testing (1990-1992) and 1212 individuals with brain magnetic resonance imaging (1993-1994) from the Atherosclerosis Risk in Communities cohort. We estimated hazard ratios for incident diabetes through 2014 after adjustment for traditional diabetes risk factors and cohort attrition.

RESULTS

Higher level of baseline cognitive function was associated with lower risk for diabetes (per 1 standard deviation, hazard ratio = 0.94; 95% confidence interval = 0.90, 0.98). This association did not persist after accounting for baseline glucose level, case ascertainment methods, and cohort attrition. No association was observed between any brain magnetic resonance imaging measure and incident diabetes.

DISCUSSION

This is one of the first studies to prospectively evaluate the association between both cognitive function and brain structure and the incidence of diabetes.

Self-Perceived Emotional Distress and Diabetes Risk Among Young Men

INTRODUCTION

There are mixed data regarding the effect of emotional distress on diabetes risk, especially among young adults. This study assessed the effect of self-perceived emotional distress on diabetes incidence among young men.

METHODS

Incident diabetes during a mean follow-up of 6.3 (4.3) years was assessed among 32,586 men (mean age, 31.0 [5.6] years) of the Metabolic, Lifestyle, and Nutrition Assessment in Young Adults cohort with no history of diabetes between 1995 and 2011. Emotional distress was assessed by asking participants as part of a computerized questionnaire: Are you preoccupied by worries or concerns that affect your overall wellbeing? Time-dependent Cox models were applied. Data analysis took place between 2014 and 2015.

RESULTS

There were 723 cases of diabetes during 206,382 person-years. The presence of distress was associated with a 53% higher incidence of diabetes (95% CI=1.08, 2.18, p=0.017) after adjustment for age, BMI, fasting plasma glucose, family history of diabetes, triglyceride and high-density lipoprotein cholesterol levels, education, cognitive performance, white blood cell count, physical activity, and sleep quality. These results persisted when distress, BMI, physical activity, and smoking status were treated as time-dependent variables (hazard ratio=1.66, 95% CI=1.21, 2.17, p=0.002). An adjusted hazard ratio of 2.14 (95% CI=1.04, 4.47, p=0.041) for incident diabetes was observed among participants persistently reporting emotional distress compared with those persistently denying it.

CONCLUSIONS

Sustained emotional distress contributes to the development of diabetes among young and apparently healthy men in a time-dependent manner. These findings warrant awareness by primary caregivers when stratifying diabetes risk.

Sleep quality and risk of diabetes and coronary artery disease among young men

AIMS

To assess the time-dependent effect of sleep quality on diabetes and coronary artery disease (CAD) incidence among young adults.

METHODS

Incident rates of diabetes and CAD during a mean follow-up of 6.4 ± 4.1 years were assessed among 26,023 men (mean age 30.9 ± 5.6 years) of the Metabolic Lifestyle and Nutrition Assessment in Young Adults stratified by sleep quality at baseline, as assessed by the Mini-Sleep Questionnaire (MSQ). Incident diabetes and CAD were analyzed using a Cox proportional hazard model.

RESULTS

There were 445 cases of diabetes and 92 cases of CAD during 151,312 person-years. An abnormal MSQ score was associated with a 53 % higher incidence of diabetes (95 % CI 1.22-1.94, p < 0.001) compared to those with a normal score, after adjustment for clinical and biochemical diabetes risk factors. The increased risk associated with abnormal sleep quality remained when MSQ was modeled as a continuous time-dependent variable in a multivariable model (HR = 1.036, 95 % CI 1.024-1.049, p < 0.001). The increased risk was higher among overweight or obese participants (BMI and MSQ interaction p = 0.046). Sustained abnormality in MSQ score resulted in higher HR for diabetes (2.35; 95 % CI 1.564-3.519, p < 0.001). In addition, abnormal sleep quality was associated with a 2.38 higher incidence of CAD (95 % CI 1.38-4.11, p = 0.002), after adjustment for traditional clinical and biochemical risk factors.

CONCLUSIONS

Sleep quality contributes to the development of diabetes and CAD in apparently healthy young adults in a time-dependent manner. The use of a simple questionnaire to assess sleep quality may be a useful tool for risk stratification in this population.

Hypertension in late adolescence and cardiovascular mortality in midlife: a cohort study of 2.3 million 16- to 19-year-old examinees

BACKGROUND

The effect of early hypertension on midlife cardiovascular (CV) mortality remains controversial. We assessed the association of established hypertension in late adolescence with subsequent CV mortality.

METHODS

Of 2,298,130 Israeli adolescents (60% males; age 17.4 ± 0.3 years) who underwent a compulsory medical examination prior to military service between 1967 and 2010, 8720 teenagers (0.4%) were formally diagnosed with persistent hypertension. Using Cox proportional hazards modeling, we compared the hypertensive group to the large normotensive group with regard to time to event analysis of midlife mortality due to cerebrovascular accidents (CVA), coronary heart disease (CHD), sudden death (SD) and their summation as cardiovascular disease (CVD).

RESULTS

During 45,729,521 person-years of follow-up, we identified 2918 CV deaths-2879 and 39 among the 2,289,410 normotensive and 8720 hypertensive adolescents, respectively. Hypertension at a young age was associated with a threefold elevation of stroke mortality compared to normotension when adjusted for sex, age at examination, birth year, country of origin, socioeconomic status, education, body mass index (BMI) and height [hazard ratio (HR) 3.12; 95% confidence interval (CI) 1.76-5.54; p < 0.001]. There was no significant association of hypertension with CHD mortality or SD. An increased risk for overall CVD mortality among hypertensive youngsters (HR 1.51; 95 % CI 1.10-2.07) was attenuated after adjusting for BMI and other covariates (HR 1.24; 95% CI 0.90-1.72).

CONCLUSIONS

Established hypertension at a young age was independently associated with elevated stroke mortality in midlife. This finding warrants confirmatory large-scale long-term follow-up studies to address the distant effects of adolescent hypertension.

A socioeconomic and behavioral survey of patients with difficult-to-control type 2 diabetes mellitus reveals an association between diabetic retinopathy and educational attainment

BACKGROUND

We have recently reported that the attitude of patients toward risk could be a factor in the progression of diabetic complications. In general, risk preference is closely related to socioeconomic status (SES), which includes factors such as age, sex, income, and educational attainment.

OBJECTIVE

We aimed to determine the effect of SES and behavioral propensity on the progress of diabetic complications in patients with type 2 diabetes mellitus (T2DM).

METHODS

We conducted a survey of 238 patients with difficult-to-control T2DM treated at a hospital in Japan using a modified behavioral economics questionnaire that included questions related to SES. The patients had been referred by general practitioners or other departments in the hospital because of poor metabolic control or unstable complications.

RESULTS

Educational attainment was significantly associated with progression of retinopathy in patients <65 years of age. Educational attainment of a high school diploma (12 years of education) or lower was a significant risk factor, but there were no differences among levels of attainment beyond high school (13-16 years or more of education). Behavioral propensities were also weakly associated with complications, but not as much as educational attainment. Personal income level and economic status did not show an association with the retinopathy levels.

CONCLUSION

Lower educational attainment is a strong risk factor for diabetic retinopathy, and it is independent of the economic status. The result suggests that cognitive function may play an important role in the progression of diabetic retinopathy in patients with T2DM.

Cognitive Performance at Late Adolescence and the Risk for Impaired Fasting Glucose Among Young Adults

CONTEXT

Although dysglycemia is a risk factor for cognitive decline, it is unknown whether cognitive performance among young and apparently healthy adults affect the risk for impaired fasting glucose (IFG).

OBJECTIVE

This study aimed to characterize the relationship between cognitive function and the risk for IFG among young adults.

DESIGN AND SETTING

This was a retrospective cohort study utilizing data collected at pre-military recruitment assessments with information collected at the screening center of Israeli Army Medical Corps.

PARTICIPANTS

Normoglycemic adults (n = 17 348) (free of IFG and diabetes; mean age 31.0 ± 5.6 y; 87% men) of the Metabolic Lifestyle and Nutrition Assessment in Young Adults (MELANY) cohort with data regarding their General Intelligence Score (GIS), a comprehensive measure of cognitive function, at age 17 y.

INTERVENTIONS

Fasting plasma glucose was assessed every 3-5 y at scheduled visits. Cox proportional hazards models were applied.

MAIN OUTCOMES MEASURES

The main outcome of the study was incident IFG (≥ 100 mg/dL and <126 mg/dL) at scheduled visits.

RESULTS

During a median followup of 6.6 y, 1478 cases of IFG were recorded (1402 men). After adjustment for age and sex, participants in the lowest GIS category had a 1.9-fold greater risk for incident IFG compared with those in the highest GIS category. In multivariable analysis adjusted for age, sex, body mass index, fasting plasma glucose, family history of diabetes, country of origin, socioeconomic status, education, physical activity, smoking status, alcohol consumption, breakfast consumption, triglyceride level, white blood cell count, the risk for IFG was nearly doubled in the lowest GIS category compared with the highest GIS category (hazard ratio, 1.8; 95% confidence interval, 1.4-2.3; P < .001). These results persisted when GIS was treated as a continuous variable and when the model was adjusted also for body mass index at the end of followup.

CONCLUSIONS

This study demonstrates that lower cognitive function at late adolescence is independently associated with an elevated risk IFG in both men and women.

Height at Late Adolescence and Incident Diabetes among Young Men

Background

Short stature was suggested as a risk factor for diabetes onset among middle age individuals, but whether this is the case among young adults is unclear. Our goal was to assess the association between height and incident diabetes among young men.

Methods and Findings

Incident diabetes was assessed among 32,055 men with no history of diabetes, from the prospectively followed young adults of the MELANY cohort. Height was measured at two time points; at adolescence (mean age 17.4±0.3 years) and grouped according to the US-CDC percentiles and at young adulthood (mean age 31.0±5.6 years). Cox proportional hazards models were applied. There were 702 new cases of diabetes during a mean follow-up of 6.3±4.3 years. There was a significant increase in the crude diabetes incidence rate with decreasing adolescent height percentile, from 4.23 cases/10⁴ person-years in the <10^th percentile group to 2.44 cases/10⁴ person-years in the 75^th≤ percentile group. These results persisted when clinical and biochemical diabetes risk factors were included in multivariable models. Compared to the 75^th≤ percentile group, height below the 10^th percentile was associated with a hazard ratio (HR) of 1.64 (95%CI 1.09–2.46, p = 0.017) for incident diabetes after adjustment for age, body mass index (BMI), fasting plasma glucose, HDL-cholesterol and triglyceride levels, white blood cells count, socioeconomic status, country of origin, family history of diabetes, sleep quality and physical activity. At age 30 years, each 1-cm decrement in adult height was associated with a 2.5% increase in diabetes adjusted risk (HR 1.025, 95%CI 1.01–1.04, p = 0.001).

Conclusions

Shorter height at late adolescence or young adulthood was associated with an increased risk of incident diabetes among young men, independent of BMI and other diabetes risk factors.