Type 2 Diabetes: Why We Are Winning the Battle but Losing the War? 2015 Kelly West Award Lecture

Associations between Type 2 Diabetes Mellitus, Metabolic Traits, and Abdominal Aortic Aneurysm: A Cross-Ethnic Mendelian Randomization Analysis

BACKGROUND

Evidence suggests that type 2 diabetes mellitus (T2DM) may protect from abdominal aortic aneurysm (AAA). However, it is unclear whether a causal relationship exists between these 2 conditions and, if so, whether it remains consistent among racial groups.

METHODS

Cross-ethnic Mendelian randomization (MR) was used to examine the causal relationships between T2DM, metabolic traits, and AAA. Inverse variance weighted (IVW) was the primary analysis tool, supplemented by MR-Egger, weighted median, and MR Pleiotropy RESidual Sum and Outlier. Heterogeneity and horizontal pleiotropy were assessed using the Cochran's Q test and MR-Egger intercept, respectively.

RESULTS

According to IVW, an inverse correlation between T2DM and AAA was detected in Europeans (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.84-0.99; P = 0.034) and East Asians (OR 0.87, 95% CI 0.77-0.99; P = 0.038). Fasting glucose was inversely associated with AAA in Europeans (OR 0.56, 95% CI 0.33-0.96; P = 0.034) but not in East Asians. In Europeans, fasting insulin was a risk factor for AAA (OR 3.03, 95% CI 1.53-6.01; P = 0.001), while 2-hour glucose was protective (OR 0.67, 95% CI 0.49-0.91; P = 0.011). Glycated hemoglobin (HbA1c) had no effect. Insufficient instrumental variables prevented the evaluation of the relationships of fasting insulin, HbA1c, and 2-hour glucose with AAA in East Asians.

CONCLUSIONS

T2DM protects against AAA in Europeans and East Asians. The effects of different glucose metabolism characteristics on AAA may inform AAA treatment.

Diabetes and Cancer: The Perfect Storm and a PRICE to Pay

Diabetes, obesity, cardiovascular diseases, and cancer are noncommunicable diseases representing the main global health challenges of the current century [...].

The association of hypertension among married Indian couples: a nationally representative cross-sectional study

Mounting evidence demonstrates that intimate partners sharing risk factors have similar propensities for chronic conditions such as hypertension. The objective was to study whether spousal hypertension was associated with one's own hypertension status independent of known risk factors, and stratified by socio-demographic subgroups (age, sex, wealth quintile, caste endogamy). Data were from heterosexual married couples (n = 50,023, women: 18-49 years, men: 21-54 years) who participated in the National Family Health Survey-V (2019-2021). Hypertension was defined as self-reported diagnosis of hypertension or average of three blood pressure measurements ≥ 140 systolic or 90 mmHg diastolic BP. Among married adults, the prevalence of hypertension among men (38.8 years [SD 8.3]) and women (33.9 years [SD 7.9]) were 29.1% [95% CI 28.5-29.8] and 20.6% [95% CI 20.0-21.1] respectively. The prevalence of hypertension among both partners was 8.4% [95% CI 8.0-8.8]. Women and men were more likely to have hypertension if their spouses had the condition (husband with hypertension: PR 1.37 [95% CI 1.30-1.44]; wife with hypertension: PR 1.32 [95% CI 1.26-1.38]), after adjusting for known risk factors. Spouse's hypertension status was consistently associated with own status across all socio-demographic subgroups examined. These findings present opportunities to consider married couples as a unit in efforts to diagnose and treat hypertension.

The association of hypertension among married Indian couples: a nationally representative cross-sectional study

Mounting evidence demonstrates that intimate partners sharing risk factors have similar propensities for chronic conditions such as hypertension. The objective was to study whether spousal hypertension was associated with one's own hypertension status independent of known risk factors, and stratified by socio-demographic subgroups (age, sex, wealth quintile, caste endogamy). Data were from heterosexual married couples (n = 50,023, women: 18-49y, men: 21-54y) who participated in the National Family Health Survey-V (2019-21). Hypertension was defined as self-reported diagnosis of hypertension or average of three blood pressure measurements ≥ 140 systolic or 90 mmHg diastolic BP. Among married adults, the prevalence of hypertension among men (38.8 years [SD: 8.3]) and women (33.9 years [SD: 7.9]) were 29.1% [95%CI: 28.5-29.8] and 20.6% [95%CI: 20.0-21.1] respectively. The prevalence of hypertension among both partners was 8.4% [95%CI: 8.0-8.8]. Women and men were more likely to have hypertension if their spouses had the condition (husband with hypertension: PR = 1.37 [95%CI: 1.30-1.44]; wife with hypertension: PR = 1.32 [95%CI: 1.26-1.38]), after adjusting for known risk factors. Spouse's hypertension status was consistently associated with own status across all socio-demographic subgroups examined. These findings present opportunities to consider married couples as a unit in efforts to diagnose and treat hypertension.

Associations of the magnesium depletion score and magnesium intake with diabetes among US adults: an analysis of the National Health and Nutrition Examination Survey 2011-2018

OBJECTIVES

The magnesium depletion score (MDS) is considered more reliable than traditional approaches for predicting magnesium deficiency in humans. We explored the associations of MDS and dietary magnesium intake with diabetes.

METHODS

We obtained data from 18,853 participants in the National Health and Nutrition Examination Survey 2011-2018. Using multivariate regression and stratified analysis, we investigated the relationships of both MDS and magnesium intake with diabetes. To compute prevalence ratios (PRs), we employed modified Poisson or log-binomial regression. We characterized the non-linear association between magnesium intake and diabetes using restricted cubic spline analysis.

RESULTS

Participants with MDS ≥2 exhibited a PR of 1.26 (95% confidence interval [CI], 1.19 to 1.34) for diabetes. Per-standard deviation (SD) increase in dietary magnesium intake was associated with a lower prevalence of diabetes (PR, 0.91; 95% CI, 0.87 to 0.96). Subgroup analyses revealed a positive association between MDS ≥2 and diabetes across all levels of dietary magnesium intake, including the lowest (PR, 1.35; 95% CI, 1.18 to 1.55), middle (PR, 1.23; 95% CI, 1.12 to 1.35), and highest tertiles (PR, 1.25; 95% CI, 1.13 to 1.37; pinteraction<0.001). Per-SD increase in magnesium intake was associated with lower diabetes prevalence in participants with MDS <2 (PR, 0.92; 95% CI, 0.87 to 0.98) and those with MDS ≥2 (PR, 0.91; 95% CI, 0.84 to 0.98; pinteraction=0.030).

CONCLUSIONS

MDS is associated with diabetes, particularly among individuals with low magnesium intake. Adequate dietary magnesium intake may reduce diabetes risk, especially in those with high MDS.

Serum lipoprotein(a), and plasminogen activator inhibitor-1 in uncomplicated type 2 diabetes mellitus: a case-control study

Increased levels of lipoprotein (a) [Lp(a)] are indicative of coronary artery disease (CAD). Dyslipidemia, which is an established risk factor for CAD, is also an additional adverse effect of uncontrolled type 2 diabetes. Procoagulant and fibrinolytic indicators have been linked to the development of type 2 diabetes. Plasminogen activator inhibitor-1 (PAI-1), plays a significant negative regulatory role in fibrinolysis, through its function as the main inhibitor of tissue plasminogen activator. This study was designed to investigate the levels of Lp(a) and PAI-1 in uncomplicated type 2 diabetic patients and their association with healthy controls.

MATERIALS AND METHODS

A case-control study designed for the estimation of Lp(a) and PAI-1 in serum after collecting blood samples from type 2 diabetic patients at the Layla Qasim Diabetic Center in Erbil, Iraq. The study included 90 participants, of whom 30 were healthy controls (15 males and 15 females). The remaining 60 cases were patients with type 2 diabetes with a duration of up to 6 years (30 males and 30 females).

RESULTS

Serum Lp(a) and PAI-1 levels were significantly lower in type 2 diabetic patients than in controls (P<0.01), this is an opposite result that usually happen in uncontrolled and complicated diabetic patients.

CONCLUSIONS

The results were clearly stated a beneficial effect of Metformin on the levels of Lp(a) and PAI-1 in type 2 diabetes, so lowering their concentrations would help prevention of CAD, a known cause of death in diabetic patients.

A Strategic Research Framework for Defeating Diabetes in India: A 21st-Century Agenda

Indian people are at high risk for type 2 diabetes (T2DM) even at younger ages and lower body weights. Already 74 million people in India have the disease, and the proportion of those with T2DM is increasing across all strata of society. Unique aspects, related to lower insulin secretion or function, and higher hepatic fat deposition, accompanied by the rise in overweight (related to lifestyle changes) may all be responsible for this unrelenting epidemic of T2DM. Yet, research to understand the causes, pathophysiology, phenotypes, prevention, treatment, and healthcare delivery of T2DM in India seriously lags behind. There are major opportunities for scientific discovery and technological innovation, which if tapped can generate solutions for T2DM relevant to the country's context and make leading contributions to global science. We analyze the situation of T2DM in India, and present a four-pillar (etiology, precision medicine, implementation research, and health policy) strategic research framework to tackle the challenge. We offer key research questions for each pillar, and identify infrastructure needs. India offers a fertile environment for shifting the paradigm from imprecise late-stage diabetes treatment toward early-stage precision prevention and care. Investing in and leveraging academic and technological infrastructures, across the disciplines of science, engineering, and medicine, can accelerate progress toward a diabetes-free nation.

Genetic evidence for a causal relationship between type 2 diabetes and peripheral artery disease in both Europeans and East Asians

BACKGROUND

Observational studies have revealed that type 2 diabetes (T2D) is associated with an increased risk of peripheral artery disease (PAD). However, whether the two diseases share a genetic basis and whether the relationship is causal remain unclear. It is also unclear as to whether these relationships differ between ethnic groups.

METHODS

By leveraging large-scale genome-wide association study (GWAS) summary statistics of T2D (European-based: N_case = 21,926, N_control = 342,747; East Asian-based: N_case = 36,614, N_control = 155,150) and PAD (European-based: N_case = 5673, N_control = 359,551; East Asian-based: N_case = 3593, N_control = 208,860), we explored the genetic correlation and putative causal relationship between T2D and PAD in both Europeans and East Asians using linkage disequilibrium score regression and seven Mendelian randomization (MR) models. We also performed multi-trait analysis of GWAS and two gene-based analyses to reveal candidate variants and risk genes involved in the shared genetic basis between T2D and PAD.

RESULTS

We observed a strong genetic correlation (r_g) between T2D and PAD in both Europeans (r_g = 0.51; p-value = 9.34 × 10^-15) and East Asians (r_g = 0.46; p-value = 1.67 × 10^-12). The MR analyses provided consistent evidence for a causal effect of T2D on PAD in both ethnicities (odds ratio [OR] = 1.05 to 1.28 for Europeans and 1.15 to 1.27 for East Asians) but not PAD on T2D. This putative causal effect was not influenced by total cholesterol, body mass index, systolic blood pressure, or smoking initiation according to multivariable MR analysis, and the genetic overlap between T2D and PAD was further explored employing an independent European sample through polygenic risk score regression. Multi-trait analysis of GWAS revealed two novel European-specific single nucleotide polymorphisms (rs927742 and rs1734409) associated with the shared genetic basis of T2D and PAD. Gene-based analyses consistently identified one gene ANKFY1 and gene-gene interactions (e.g., STARD10 [European-specific] to AP3S2 [East Asian-specific]; KCNJ11 [European-specific] to KCNQ1 [East Asian-specific]) associated with the trans-ethnic genetic overlap between T2D and PAD, reflecting a common genetic basis for the co-occurrence of T2D and PAD in both Europeans and East Asians.

CONCLUSIONS

Our study provides the first evidence for a genetically causal effect of T2D on PAD in both Europeans and East Asians. Several candidate variants and risk genes were identified as being associated with this genetic overlap. Our findings emphasize the importance of monitoring PAD status in T2D patients and suggest new genetic biomarkers for screening PAD risk among patients with T2D.

REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS

Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").

Socioeconomic status and ethnic variation associated with type 2 diabetes mellitus in patients with uncontrolled hypertension in Singapore

INTRODUCTION

The burden of type 2 diabetes mellitus (T2DM) and related vascular complications is particularly high in Asians and ethnic minorities living in the West. However, the association of T2DM with socioeconomic status (SES) and ethnicity has not been widely studied in populations living in Asia. Therefore, we investigated these associations among the multiethnic population with uncontrolled hypertension in Singapore.

RESEARCH DESIGN AND METHODS

In a cross-sectional study using baseline data of a 2-year randomized trial in Singapore, we obtained demographic, SES, lifestyle and clinical factors from 915 patients aged ≥40 years with uncontrolled hypertension. T2DM was defined as having either: (i) self-reported 'physician-diagnosed diabetes confirmed through medical records' or taking antidiabetes medications, (ii) fasting blood glucose levels ≥7.0 mmol/dL or (iii) hemoglobin A1c ≥6.5%. The SES proxies included education, employment status, housing ownership and housing type, and the ethnicities were Chinese, Malays and Indians. Logistic regression analyses were used to evaluate the association of T2DM with SES and ethnicity.

RESULTS

Higher proportion of T2DM was observed in Malays (40.0%) and Indians (56.0%) than Chinese (26.8%) (p<0.001), and in patients with lower SES (ranging from 25.7% to 66.2% using different proxies) than those with higher SES (19.4% to 32.0%). In a multivariate model comprising age, gender, ethnicity and SES, Malay ethnicity (OR 1.59; 95% CI 1.04 to 2.44, p=0.031) or Indian ethnicity (OR 3.65; 95% CI 2.25 to 5.91, p<0.001) versus Chinese and housing type (residing in one to three rooms (OR 2.00; 95% CI 1.16 to 3.43, p=0.012) or four to five rooms public housing (OR 1.86; 95% CI 1.13 to 3.04, p=0.013) vs private housing) were associated with higher T2DM odds. The associations of Indians and one to three rooms public housing with T2DM met the significance after accounting for multiple testing (p≤0.0125).

CONCLUSION

Our study suggests that housing type and ethnic variation are independently associated with higher T2DM risk in patients with uncontrolled hypertension in Singapore. Further studies are needed to validate our results.

TRIAL REGISTRATION NUMBER

NCT02972619.

Impact of blinded retrospective continuous glucose monitoring on clinical decision making and glycemic control in persons with type 2 diabetes on insulin therapy

BACKGROUND AND AIMS

Blinded retrospective continuous glucose monitoring (rCGM) provides detailed information about real-life glycaemic profile. In persons with type 2 diabetes without adequate glycaemic control, the structured introduction of rCGM may be beneficial to sustain improvements in diabetes management.

METHODS AND RESULTS

102 individuals with insulin-treated type 2 diabetes, age less than 66 years old and HbA1c >7.5%, were recruited. Participants performed a 7-day blinded rCGM (iPro2) every four months for one year. Biochemical, anthropometric, and rCGM data was collected. Participants' and healthcare professionals' perceptions were assessed. 90 participants completed the protocol. HbA1c was 9.1 ± 0.1% one year prior to enrolment and 9.4 ± 0.1% at enrolment (p < 0.01). With the rCGM-based intervention, a decrease in HbA1c was achieved at 4 months (8.4 ± 0.1%, p < 0.0001), and 12 months (8.1 ± 0.1%, p < 0.0001). A significant increase in time-in-range was observed (50.8 ± 2.4 at baseline vs 61.5 ± 2.2% at 12 months, for 70-180 mg/dL, p < 0.001), with no difference in exposure time to hypoglycaemia. After 12 months, there was an increase in self-reported diabetes treatment satisfaction (p < 0.05).

CONCLUSION

In persons with type 2 diabetes and poor metabolic control, specific data from blinded rCGM informed therapeutic changes and referral to targeted education consultations on nutrition and insulin administration technique. Therapeutic changes were made more frequently and targeted to changes in medication dose, timing, and/or type, as well as to lifestyle. Together, these brought significant improvements in clinical outcomes, effective shared decision-making, and satisfaction with treatment.

REGISTRATION NUMBER

NCT04141111.

Efficacy of liraglutide on glycemic endpoints in people of Western European and South Asian descent with T2DM using multiple daily insulin injections: results of the MAGNA VICTORIA studies

AIMS

Data on the effect of liraglutide on glycemic endpoints in people with T2DM using multiple daily insulin injections (MDI) are scarce, especially in the context of ethnicity.

METHODS

This is a secondary analysis of the placebo-controlled randomized clinical "MAGNA VICTORIA" trials in Western European (WE) and South Asian (SA) people with T2DM. Participants had inadequate glycemic control despite using metformin and/or sulfonylurea derivatives and/or insulin. Participants were assigned to liraglutide (1.8 mg) or placebo for 6 months, in addition to standard care. The primary endpoint number of participants reaching target HbA1c was compared for liraglutide versus placebo in the complete dataset and MDI-treated participants using Chi-square test. Liraglutide's efficacy in WE and SA was compared using a generalized linear model.

RESULTS

Forty-five subjects were randomized to liraglutide and 51 to placebo. In each group, one participant did not complete the study. Liraglutide-treated patients reached target HbA1c more frequently: 23/45 (51%) vs 11/51 (22%), relative probability 2.4 (1.3-4.3), p = 0.002. Subgroup analysis in 43 MDI participants showed that the proportion reaching target HbA1c using liraglutide was significantly higher than in placebo: 9/22 (41%) vs 1/21 (5%), p = 0.005. There was no difference between WE and SA in terms of liraglutide efficacy (p = 0.18).

CONCLUSIONS

Liraglutide treatment resulted in increased chance of reaching target HbA1c as compared to placebo. Liraglutide efficacy was sustained in participants using MDI regimens and those of SA descent. Liraglutide should be considered for T2DM people with inadequate glycemic control despite MDI.

HLA-DRB1 genes and the expression dynamics of HLA CIITA determine the susceptibility to T2DM

Type 2 diabetes mellitus (T2DM) is a disease with polygenic inheritance. The expression of major histocompatibility complex class II genes are regulated by several trans-activators. We have studied the expression of HLA-DRB1, RFX, CIITA-P1, PIV transactivators, immunophenotyping of cells, SNPs in CIITA-168 (A/G) and IFN-γ + 874 (T/A) in T2DM patients and controls (n = 201 each). We observed increased frequencies of DRB1*03, DRB1*04 and DRB1*07 and decreased frequencies of DRB1*10, DRB1*14, and DRB1*15 alleles among patients. Significant up-regulations of HLA-DRB1 genes were observed in patients (p < 0.0001). Down-regulated expressions were documented in DRB1*03-homo (p < 0.002) and DRB1*04-homo (p < 0.009) patients. No significant differences were observed for CIITA-P1 expression except DRB1*04-pooled (p < 0.0113). The CIITA-PIV was up-regulated in overall (p < 0.0001), DRB1*03-pooled (p < 0.0006), DRB1*03-hetero (p < 0.0006) and DRB1*03-homo (p < 0.001) T2DM patients. However, significant down-regulations were documented for DRB1*04-pooled (p < 0.040), DRB1*04-hetero (p < 0.060), and DRB1*04-homo (p < 0.027) combinations. Further, significant down-regulations of RFX5 were observed in overall (p < 0.0006), DRB1*04-pooled (p < 0.0022), and DRB1*04-hetero (p < 0.0004) combinations. Immunophenotyping studies revealed significant increase of CD45⁺ CD14^-, CD19⁺, CD14^- and CD8 cells and elevated level of expression of IFN-γ (p < 0.0001) in patients. A significant increase of TT (p < 3.35 × 10^-6) and decrease of TA (p < 4.57 × 10^-4) genotypes of IFN-γ + 874 (T/A) and an increase of GG (p < 0.001) and decrease of AG (p < 8.24 × 10^-5) genotypes of CIITA-168 A/G SNPs were observed. The combinatorial analysis revealed susceptible associations for DRB1*03 + AA, *03 + AG, *03 + GG and *04 + GG and protective associations for DRB1*10 + AG, *10 + GG, *15 + AG, and *14 + GG combinations. Thus, the present study corroborated the effect of differential expressions of promoters of risk alleles in the pathogenesis of T2DM.

Incidence of diabetes in South Asian young adults compared to Pima Indians

INTRODUCTION

South Asians (SA) and Pima Indians have high prevalence of diabetes but differ markedly in body size. We hypothesize that young SA will have higher diabetes incidence than Pima Indians at comparable body mass index (BMI) levels.

RESEARCH DESIGN AND METHODS

We used prospective cohort data to estimate age-specific, sex, and BMI-specific diabetes incidence in SA aged 20-44 years living in India and Pakistan from the Center for Cardiometabolic Risk Reduction in South Asia Study (n=6676), and compared with Pima Indians, from Pima Indian Study (n=1852).

RESULTS

At baseline, SA were considerably less obese than Pima Indians (BMI (kg/m²): 24.4 vs 33.8; waist circumference (cm): 82.5 vs 107.0). Age-standardized diabetes incidence (cases/1000 person-years, 95% CI) was lower in SA than in Pima Indians (men: 14.2, 12.2-16.2 vs 37.3, 31.8-42.8; women: 14.8, 13.0-16.5 vs 46.1, 41.2-51.1). Risk of incident diabetes among 20-24-year-old Pima men and women was six times (relative risk (RR), 95% CI: 6.04, 3.30 to 12.0) and seven times (RR, 95% CI: 7.64, 3.73 to 18.2) higher as compared with SA men and women, respectively. In those with BMI <25 kg/m², however, the risk of diabetes was over five times in SA men than in Pima Indian men. Among those with BMI ≥30 kg/m², diabetes incidence in SA men was nearly as high as in Pima men. SA and Pima Indians had similar magnitude of association between age, sex, BMI, and insulin secretion with diabetes. The effect of family history was larger in SA, whereas that of insulin resistance was larger in Pima Indians CONCLUSIONS: In the background of relatively low insulin resistance, higher diabetes incidence in SA is driven by poor insulin secretion in SA men. The findings call for research to improve insulin secretion in early natural history of diabetes.

NDSP 09: Risk Assessment of Pakistani Individual for Diabetes (RAPID) - Findings from Second National Diabetes Survey of Pakistan (NDSP) 2016-2017

OBJECTIVE

To elucidate the effectiveness of Risk Assessment of Pakistani individuals with diabetes (RAPID) tool in epidemiological and population-based second National Diabetes Survey of Pakistan (NDSP) 2016-2017 for identifying risk of developing type 2 diabetes.

METHODOLOGY

This observational study was a sub-analysis of the second National Diabetes Survey of Pakistan (NDSP) 2016-2017 conducted from February 2016 to August 2017 in all four provinces of Pakistan. Ethical approval was obtained from National Bioethics Committee Pakistan. RAPID score, a validated and published scoring scale to assess risk of diabetes, originally developed from community-based surveys was used. The risk score is assessed by parameters namely: age, waist circumference, and positive family history of diabetes. Subjects with score greater ≥4 were considered at risk of diabetes.

RESULTS

A total of 4904 individuals were assessed (2205 males and 2699 females). Mean age of participants was 41.8±14.2 years. Positive family history of diabetes was seen in 1379 (28.1%) people. According to RAPID score 1268 (25.9%) individuals scored ≥4 and were at risk of diabetes. OGTT status of people at risk of diabetes according to RAPID score showed that 18.1% people with diabetes and 29.2% were prediabetic. Whereas, OGTT status of people not at risk of diabetes showed that only 7.6% people with diabetes, 20% were prediabetic.

CONCLUSION

A simple diabetes risk score can be used for identification of high-risk individuals for diabetes so that timely intervention can be implemented. Community-based awareness programs are needed to educate people regarding healthy lifestyle in order to reduce risk of diabetes.

Association between duration of residence and prevalence of type 2 diabetes among male South Asian expatriate workers in the United Arab Emirates: a cross-sectional study

Expatriates account for about 80% of the total population in the United Arab Emirates (UAE). This study aimed to evaluate the hypothesis that prevalence of type 2 diabetes in male South Asian expatriates increases with increased length of residence in the UAE.

DESIGN, SETTINGS AND PARTICIPANTS

This cross-sectional study recruited a representative sample (n=1375) of male South Asian expatriates aged ≥18 years in Al Ain, UAE. Sociodemographic, anthropometric and lifestyle data were obtained using a pilot-tested adapted version of the WHO STEPS instrument.

MAIN OUTCOME MEASURES

Duration of residence was used as a marker for acculturation. Type 2 diabetes was defined as a self-reported physician diagnosis of diabetes or a glycosylated haemoglobin blood level ≥6.5%.

RESULTS

Mean (±SD) age of participants was 34.0±9.9 years. Overall, the prevalence of type 2 diabetes was 8.3% (95% CI 6.8% to 9.8%). Diabetes prevalence was positively associated with longer duration of residence in the UAE, 2.7%, <5 years; 8.2%, 5-10 years; and 18.8%, >10 years. After adjusting for age, nationality, and income and age, expatriates were more likely to develop diabetes if residing in the UAE for 5-10 years (OR=2.18; 95% CI 1.02 to 4.67) or >10 years (OR=3.23; 95% CI 1.52 to 6.85) compared with those residing for <5 years.

CONCLUSIONS

After controlling for potential confounding factors, longer duration of residence was significantly associated with a higher prevalence of type 2 diabetes in male South Asian expatriate workers in the UAE.

Classification of diabetes. World Health Organization 2019. What’s new?

The review focuses on the new WHO classification published in 2019. Unlike the previous classification, this classification does not recognize subtypes of T1DM and T2DM and offers new types of diabetes: “hybrid types of diabetes” and “unclassified diabetes”. This classification provides practical guidance to clinicians for assigning a type of diabetes to individuals and choose appropriate treatment (whether or not to start treatment with insulin), particularly at the time of diagnosis. This review presents the variety of forms of diabetes, the features of their clinical picture, and also emphasizes the importance of molecular genetic and immunological studies to identify types of diabetes and determine personalized therapy. The selection of “hybrid forms” of diabetes is due to the fact that the treatment of these types of diabetes has its own characteristics associated with the specific pathogenesis of diseases. However, it is obvious that further studies should relate to the study of the mechanisms of damage and decrease in the function of в-cells. Perhaps future classification systems and, as a consequence, personalized treatment will focus on various mechanisms of damage to β-cells.

Inducing remission of Type 2 diabetes in the Caribbean: findings from a mixed methods feasibility study of a low-calorie liquid diet-based intervention in Barbados

AIM

In a high proportion of people with recently diagnosed Type 2 diabetes, a short (2-3-month) low-calorie diet is able to restore normal glucose and insulin metabolism. The aim of this study was to determine the feasibility of this approach in Barbados.

METHODS

Twenty-five individuals with Type 2 diabetes diagnosed within past 6 years, not on insulin, BMI ≥ 27 kg/m² were recruited. Hypoglycaemic medication was stopped on commencement of the 8-week liquid (760 calorie) diet. Insulin response was assessed in meal tests at baseline, 8 weeks and 8 months. Semi-structured interviews, analysed thematically, explored participants' experiences. 'Responders' were those with fasting plasma glucose (FPG) < 7 mmol/l at 8 weeks.

RESULTS

Ten men and 15 women (mean age 48, range 26-68 years) participated. Mean (sd) BMI was 34.2 kg/m² (6.0); FPG 9.2 mmol/l (2.2). Mean weight loss at 8 weeks and 8 months was 10.1 kg [95% confidence interval (CI) 8.1, 12.0] and 8.2 kg (95% CI 5.8, 10.6); FPG was lower by 2.2 mmol/l (95% CI 1.2, 3.2) and 1.7 mmol/l (95% CI 0.8, 2.7) respectively. Nine of 11 (82%) of those who lost ≥ 10 kg were 'responders' compared with 6 of 14 (43%) who lost < 10 kg (P = 0.048). The 30-min insulin increment was higher in responders at baseline and follow-up (P ≤ 0.01). A food culture based on starchy foods and pressures to eat large amounts at social events were among the challenges identified by participants.

CONCLUSIONS

The feasibility of this approach to weight loss and diabetes remission in a predominantly black population in Barbados was demonstrated.

Outcomes of metabolic surgery in obese patients with type 2 diabetes with respect to impact on beta cell function, insulin sensitivity and diabetes remission - A study from south India

BACKGROUND AND AIMS

Metabolic surgery is gaining popularity as a procedure for the treatment of morbid obesity among patients with type 2 diabetes (T2DM). The aim of the study was to evaluate the effects of metabolic surgery on beta cell function, insulin sensitivity and glycemic status in obese Asian Indian patients.

METHODS

This is a prospective study of 26 patients with T2DM who underwent metabolic surgery. Complete diabetes remission was defined as FPG<100 mg/dl and HbA1c < 6%, without antidiabetic medications one-year post surgery. Anthropometry, HOMA-IR (insulin resistance), HOMA-insulin sensitivity, beta cell function and antidiabetic drug usage were measured at baseline, 6 months and 12 months post-surgery.

RESULTS

The overall duration of diabetes was 10.3 ± 5.4 years. At one year, 7 (27%) of 26 T2DM patients, achieved diabetes remission while the other 19 had improvement in diabetes status. ROC curves showed that those who had diabetes duration <8.5 years achieved remission. There was a significant decrease in HOMA-IR [3.7 ± 1.8 vs 1.4 ± 0.9 vs1.2 ± 0.6, p < 0.001] and improvement in HOMA-Insulin sensitivity [34 ± 17 vs 93 ± 50 vs 112 ± 62, p < 0.001] from baseline to 6 and 12 months post-surgery respectively. There was a significant (p < 0.001) reduction in the usage of anti-diabetes medications post-surgery. The limitations of this study are small sample size and limited follow up period of 1 year.

CONCLUSIONS

Among T2DM patients, metabolic surgery resulted in significant improvement in beta cell function and insulin sensitivity along with reduction in anti-diabetes medication. Diabetes remission was mainly seen in those who had duration of diabetes <8.5 years.

Why are South Asians prone to type 2 diabetes? A hypothesis based on underexplored pathways

South Asians have a high prevalence of type 2 diabetes, even at a lower BMI. This review sets out our perspective and hypothesis on the reasons for this. Emerging data from epidemiological studies indicate that South Asians may have a lower ability to secrete insulin, and thus may have less compensatory reserves when challenged with unhealthy lifestyles. Thus, insulin resistance may not be the primary driver of type 2 diabetes in this population. Furthermore, data also suggest that South Asians, on average, have lower muscle mass, and may have a specific propensity to ectopic hepatic fat accumulation and for intramyocellular fat deposition, which cause further disruption in insulin action. We hypothesise that the high diabetes susceptibility in South Asians is evolutionarily set through dual parallel and/or interacting mechanisms: reduced beta cell function and impaired insulin action owing to low lean mass, which is further accentuated by ectopic fat deposition in the liver and muscle. These areas warrant further research.

Influence of glucometric 'dynamical' variables on duodenal-jejunal bypass liner (DJBL) anthropometric and metabolic outcomes

BACKGROUND

The endoscopically implanted duodenal-jejunal bypass liner (DJBL) is an attractive alternative to bariatric surgery for obese diabetic patients. This article aims to study dynamical aspects of the glycaemic profile that may influence DJBL effects.

METHODS

Thirty patients underwent DJBL implantation and were followed for 10 months. Continuous glucose monitoring (CGM) was performed before implantation and at month 10. Dynamical variables from CGM were measured: coefficient of variation of glycaemia, mean amplitude of glycaemic excursions (MAGE), detrended fluctuation analysis (DFA), % of time with glycaemia under 6.1 mmol/L (TU6.1), area over 7.8 mmol/L (AO7.8) and time in range. We analysed the correlation between changes in both anthropometric (body mass index, BMI and waist circumference) and metabolic (fasting blood glucose, FBG and HbA1c) variables and dynamical CGM-derived metrics and searched for variables in the basal CGM that could predict successful outcomes.

RESULTS

There was a poor correlation between anthropometric and metabolic outcomes. There was a strong correlation between anthropometric changes and changes in glycaemic tonic control (∆BMI-∆TU6.1: rho = - 0.67, P < .01) and between metabolic outcomes and glycaemic phasic control (∆FBG-∆AO7.8: r = .60, P < .01). Basal AO7.8 was a powerful predictor of successful metabolic outcome (0.85 in patients with AO7.8 above the median vs 0.31 in patients with AO7.8 below the median: Chi-squared = 5.67, P = .02).

CONCLUSIONS

In our population, anthropometric outcomes of DJBL correlate with improvement in tonic control of glycaemia, while metabolic outcomes correlate preferentially with improvement in phasic control. Assessment of basal phasic control may help in candidate profiling for DJBL implantation.

Diabetes and pre-diabetes among adults reaching health centers in Luanda, Angola: prevalence and associated factors

With the lack of surveys, surveillance program and/or statistical data, epidemiologic studies can provide a better understanding of diabetes in Sub-Saharan Africa. This was a cross-sectional survey to determine prevalence of diabetes and impaired fasting glucose (IFG) among adults attending six health centres in six different districts of Luanda (Angola) during August-November 2018, followed by a case-control study to assess the risk factors for IFG and diabetes in a subgroup of subjects not receiving treatment for diabetes. Factors associated with diabetes/IFG were assessed using a generalized ordered logit model and the effects were expressed as odds ratios (OR₁ for IFG/diabetes vs. no IFG/diabetes; OR₂ for diabetes vs. no diabetes) with 95% CI (confidence interval). Some 1,803 participants were included in the survey. Prevalence of diabetes was 12.0% (95%CI 10.5% to 13.5%) and prevalence of IFG was 9.0% (95%CI 7.7% to 10.4%). Older age (OR₁ = OR₂ 1.03, 95%CI 1.02 to 1.04), higher weight (OR₁ = OR₂ 1.01, 95%CI 1.01 to 1.03), having measured glycaemia before (OR₂ 2.07, 95%CI 1.29 to 3.31), feeling polyuria (OR₁ 1.93, 95%CI 1.13 to 3.28; OR₂ 2.18, 95%CI 1.32 to 3.59), feeling polydipsia (OR₁ 1.92, 95%CI 1.16 to 3.18), feeling weakness (OR₁ = OR₂ 2.22, 95%CI 1.39 to 3.55), consumption of free-sugars food/beverages (OR₁ = OR₂ 2.34, 95%CI 1.44 to 3.81) and time spent seated (OR₁ 1.80, 95%CI 1.17 to 2.76) were associated with increased likelihood of diabetes and/or IFG, while eating vegetables was associated with decreased likelihood of IFG or diabetes (OR₁ = OR₂ 0.69, 95%CI 0.47 to 0.99). In conclusion, the high prevalence of diabetes and IFG, with common unawareness of the disease, calls for appropriate interventions in Angolan urban settings. Further research may evaluate the impact of context-specific factors to enhance intervention strategies and feed the results into local health policies. In addition, such information may be useful for selecting high-risk subjects to test.

C1q/TNF-related protein 5 contributes to diabetic vascular endothelium dysfunction through promoting Nox-1 signaling

OBJECTIVE

Dysregulated adipokine profiles contribute to the pathogenesis of diabetic cardiovascular complications. Endothelial cell (EC) dysfunction, a common pathological alteration in cardiovascular disorders, is exaggerated in diabetes. However, it is unclear whether and how dysregulated adipokines may contribute to diabetic EC dysfunction.

METHODS AND RESULTS

Serum C1q/TNF-Related Protein 5 (CTRP5) were determined in control/diabetes patients, and control/diabetic mice (high-fat diet, HFD). We observed for the first time that serum total CTRP5 was increased, high molecular weight (HMW) form was decreased, but the globular form (gCTRP5) was significantly increased in diabetic patients. These pathological alterations were reproduced in diabetic mice. To determine the pathological significance of increased gCTRP5 in diabetes, in vivo, ex vivo and in vitro experiments were performed. Diabetic atherosclerosis and EC dysfunction were significantly attenuated by the in vivo administration of CTRP5 neutralization antibody (CTRP5Ab). EC apoptosis was significantly increased in diabetic EC (isolated from HFD animal aorta) or high glucose high lipid (HGHL) cultured HUVECs. These pathological alterations were further potentiated by gCTRP5 and attenuated by CTRP5Ab. Pathway specific discovery-driven approach revealed that Nox1 expression was one of the signaling molecules commonly activated by HFD, HGHL, and gCTRP5. Treatment with CTRP5Ab reversed HFD-induced Nox1 upregulation. Finally, Nox1siRNA was used to determine the causative role of Nox1 in gCTRP5 induced EC apoptosis in diabetes. Results showed that gCTRP5 activated the mitochondrial apoptotic signal of EC in diabetes, which was blocked by the silencing Nox1 gene.

CONCLUSION

We demonstrated for the first time that gCTRP5 is a novel molecule contributing to diabetic vascular EC dysfunction through Nox1-mediated mitochondrial apoptosis, suggesting that interventions blocking gCTRP5 may protect diabetic EC function, ultimately attenuate diabetic cardiovascular complications.

Impaired compensatory hyperinsulinemia among nonobese type 2 diabetes patients: a cross-sectional study

AIMS

Obesity associated prolonged hyperinsulinemia followed by β-cell failure is well established as the pathology behind type 2 diabetes mellitus (T2DM). However, studies on nonobese T2DM have reported it to be a distinct clinical entity with predominant insulin secretory defect. We, therefore, hypothesized that compensatory hyperinsulinemia in response to weight gain is impaired in nonobese subjects.

METHODS

This was a cross-sectional study from a community-based metabolic health screening program. Adiposity parameters including body mass index (BMI), waist circumference (WC), body fat percentage, plasma leptin concentration and metabolic parameters namely fasting insulin, glucose, total cholesterol, and triglycerides were measured in 650 individuals (73% healthy, 62% nonobese with a BMI <25).

RESULTS

In contrast to obese T2DM, nonobese T2DM patients did not exhibit significant hyperinsulinemia compared with the nonobese healthy group. Age, sex, and fasting glucose adjusted insulin levels, homeostatic model assessment of insulin resistance (HOMA-IR) and HOMA-beta cell function (HOMA-B) were increased in obese T2DM compared with nonobese T2DM. Although adiposity parameters showed strong correlation with fasting insulin in obese healthy (r = 0.38, 0.38, and 0.42, respectively; all p values < 0.001) and T2DM (r = 0.54, 0.54, and 0.66, respectively; all p < 0.001), only BMI and leptin showed a weak correlation with insulin in the nonobese healthy group (0.13 and 0.13, respectively; all p < 0.05) which were completely lost in the nonobese T2DM.

CONCLUSIONS

Compensatory hyperinsulinemia in response to weight gain is impaired in the nonobese population making insulin secretory defect rather than IR the major pathology behind nonobese T2DM.

Racial/Ethnic Disparities in the Prevalence of Diabetes and Prediabetes by BMI: Patient Outcomes Research To Advance Learning (PORTAL) Multisite Cohort of Adults in the U.S

OBJECTIVE

To examine racial/ethnic disparities in the prevalence of diabetes and prediabetes by BMI category.

RESEARCH DESIGN AND METHODS

In a consortium of three U.S. integrated health care systems, 4,906,238 individuals aged ≥20 years during 2012-2013 were included. Diabetes and prediabetes were ascertained by diagnosis and laboratory results; antihyperglycemic medications were also included for diabetes ascertainment.

RESULTS

The age-standardized diabetes and prediabetes prevalence estimates were 15.9% and 33.4%, respectively. Diabetes but not prediabetes prevalence increased across BMI categories among all racial/ethnic groups (P for trend < 0.001). Racial/ethnic minorities reached a given diabetes prevalence at lower BMIs than whites; Hawaiians/Pacific Islanders and Asians had a diabetes prevalence of 24.6% (95% CI 24.1-25.2%) in overweight and 26.5% (26.3-26.8%) in obese class 1, whereas whites had a prevalence of 23.7% (23.5-23.8%) in obese class 2. The age-standardized prediabetes prevalence estimates in overweight among Hispanics (35.6% [35.4-35.7%]), Asians (38.1% [38.0-38.3%]), and Hawaiians/Pacific Islanders (37.5% [36.9-38.2%]) were similar to those in obese class 4 among whites (35.3% [34.5-36.0%]), blacks (36.8% [35.5-38.2%]), and American Indians/Alaskan Natives (34.2% [29.6-38.8%]). In adjusted models, the strength of association between BMI and diabetes was highest among whites (relative risk comparing obese class 4 with normal weight 7.64 [95% CI 7.50-7.79]) and lowest among blacks (3.16 [3.05-3.27]). The association between BMI and prediabetes was less pronounced.

CONCLUSIONS

Racial/ethnic minorities had a higher burden of diabetes and prediabetes at lower BMIs than whites, suggesting the role of factors other than obesity in racial/ethnic disparities in diabetes and prediabetes risk and highlighting the need for tailored screening and prevention strategies.

Tale of two Indians: Heterogeneity in type 2 diabetes pathophysiology

AIMS

Type 2 diabetes is a heterogeneous disease and may manifest from multiple disease pathways. We examined insulin secretion and insulin resistance across two ethnicities with particularly high risk for diabetes yet with widely different distributions of weight class.

MATERIALS AND METHODS

In this population-based, cross-sectional study, Pima Indians from Southwestern United States (n = 865) and Asian Indians from Chennai, India (n = 2374) had a 75-g oral glucose tolerance test. We analysed differences in plasma glucose, plasma insulin, insulin resistance (HOMA-IR), and insulin secretion (ΔI0-30 /ΔG0-30 ) across categories of body mass index (BMI) and glycemic status per American Diabetes Association criteria.

RESULTS

Pima Indians were younger (mean 27.4 ± SD 6.6, Asian: 33.9 ± 6.7 years) and had higher BMI (33.6 ± 8.1, Asian: 25.7 ± 4.9 kg/m2 ). Among normal weight participants (mean BMI: Pima 22.4 SE 0.2; Asian 22.2 SE 0.06 kg/m2 ), fasting glucose was higher in Asian Indians (5.2 vs Pima: 4.8 mmol/L, P = .003), adjusted for age and sex. Pima Indians were three times as insulin resistant as Asian Indians (HOMA-IR: 7.7 SE 0.1, Asian: 2.5 SE 0.07), while Asian Indians had three times less insulin secretion (Pima: 2.8 SE 1.0 vs Asian: 0.9 SE 1.0 pmol/mmol), a pattern evident across age, BMI, and glycemic strata.

CONCLUSIONS

Metabolic differences between Pima and Asian Indians suggest heterogeneous pathways of type 2 diabetes in the early natural history of disease, with emphasis of insulin resistance in Pima Indians and emphasis of poor insulin secretion in Asian Indians.

Circulating Oxidative Stress Biomarkers in Clinical Studies on Type 2 Diabetes and Its Complications

Type 2 diabetes (T2DM) and its complications constitute a major worldwide public health problem, with high rates of morbidity and mortality. Biomarkers for predicting the occurrence and development of the disease may therefore offer benefits in terms of early diagnosis and intervention. This review provides an overview of human studies on circulating biomarkers of oxidative stress and antioxidant defence systems and discusses their usefulness from a clinical perspective. Most case-control studies documented an increase in biomarkers of oxidative lipid, protein, and nucleic acid damage in patients with prediabetes and in those with a diagnosis of T2DM compared to controls, and similar findings were reported in T2DM with micro- and macrovascular complications compared to those without. The inconsistence of the results regarding antioxidant defence systems renders difficulty to draw a general conclusion. The clinical relevance of biomarkers of oxidative lipid and protein damage for T2DM progression is uncertain, but prospective studies suggest that markers of oxidative nucleic acid damage such as 8-hydroxy-2'-deoxyguanosine and 8-hydroxyguanosine are promising for predicting macrovascular complications of T2DM. Emerging evidence also points out the relationship between serum PON1 and serum HO1 in T2DM and its complications. Overall, enhanced oxidative damage represents an underlying mechanism of glucose toxicity in T2DM and its related micro- and macrovascular complications suggesting that it may be considered as a potential additional target for pharmacotherapy. Therefore, further studies are needed to understand whether targeting oxidative stress may yield clinical benefits. In this view, the measurement of oxidative stress biomarkers in clinical trials deserves to be considered as an additional tool to currently used parameters to facilitate a more individualized treatment of T2DM in terms of drug choice and patient selection.

Precision Diabetes Is Slowly Becoming a Reality

The concept of precision medicine is becoming increasingly popular. The use of big data, genomics and other "omics" like metabolomics, proteomics and transcriptomics could make the dream of personalised medicine become a reality in the near future. As far as polygenic forms of diabetes like type 2 and type 1 diabetes are concerned, interesting leads are emerging, but precision diabetes is still in its infancy. However, with regard to monogenic forms of diabetes like maturity-onset diabetes of the young and neonatal diabetes mellitus, rapid strides have been made and precision diabetes has already become part of the clinical tools used at advanced diabetes centres. In patients with some monogenic form of diabetes, if the appropriate gene defects are identified, insulin injections can be stopped and be replaced by oral sulphonylurea drugs. In the coming years, rapid advances can be expected in the field of precision diabetes, thereby making the control of diabetes more effective and hopefully leading to prevention of its complications and improvement of the quality of life of people afflicted with diabetes.

Cardiovascular disease in diabetes type 2: current concepts

Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.

What the oncologist can learn from diabetes studies: Epidemiology, prevention, management, cure

Notwithstanding massive efforts and investment in improving cancer therapy, the limited progress made in reducing overall mortality has mostly been achieved through early diagnosis. Mortality rates for cardiovascular disease are in decline, a success attributable in large part to an active prevention approach coupled with identification of risk factors and biomarkers. Promising natural and synthetic molecules including numerous flavonoids have the potential to be used in diabetes care and in prevention of cardiovascular pathologies. These concepts should also be applied to cancer, the incidence of which continues to increase. In cancer chemoprevention low toxicity drugs or dietary constituents are used to prevent or delay onset of malignancy. Evidence is accumulating that cancer chemoprevention is a valuable weapon against human cancer. For example, doubling of fruit and fiber intake is associated with reduction of colorectal cancer whereas fat food consumption appears to increase malignant progression of certain tumors. Breast, colorectal and prostate cancer are the most suitable cancers for dietary prevention and scientists have strong data in these cancers at basic, translational, clinical and epidemiological levels, due to experimental evidence and the large EPIC study. Physical activity is also crucial. Yet, cancer chemoprevention research in oncology is largely underrepresented and lags far behind the efforts dedicated to therapy; it is important to close this gap. Few European phase III clinical trials are ongoing and systematic development of novel agents for cancer prevention is rare in Europe.

Islet-like clusters derived from skeletal muscle-derived stem/progenitor cells for autologous transplantation to control type 1 diabetes in mice

A population of muscle-derived stem/progenitor cells (MDSPCs) contained in skeletal muscle is responsible for muscle regeneration. MDSPCs from mouse muscle have been shown to be capable of differentiating into pancreatic islet-like cells. However, the potency of MDSPCs to differentiate into functional islet-like cluster remains to be confirmed. The therapeutic potential of autologous MDSPCs transplantation on type 1 diabetes still remains unclear. Here, we investigated a four-stage method to induce the differentiation of MDSPCs into insulin-producing clusters in vitro, and tested the autologous transplantation to control type 1 diabetes in mice. MDSPCs isolated from the skeletal muscles of mice possessed the ability to form islet-like clusters through several stages of differentiation. The expressions of pancreatic progenitor-related genes, insulin, and islet-related genes were significantly upregulated in islet-like clusters determined by the quantitative reverse transcription polymerase chain reaction. The autologous islet-like clusters transplantation effectively improved hyperglycaemia and glucose intolerance and increased the survival rate in streptozotocin-induced diabetic mice without the use of immunosuppressants. Taken together, these results provide evidence that MDSPCs from murine muscle tissues are capable of differentiating into insulin-producing clusters, which possess insulin-producing ability in vitro and in vivo, and have the potential for autologous transplantation to control type 1 diabetes.

New insights from continuous glucose monitoring into the route to diabetes

AIM

Type 2 diabetes mellitus (T2DM) is preceded by a period of impaired glucoregulation. We investigated if continuous glucose monitoring system (CGMS) (1) could improve our capacity to predict the development of T2DM in subjects at risk. (2) Find out if impaired fasting glucose/impaired glucose tolerance differentiation through CGMS would also elucidate differences in clinical phenotypes.

MATERIAL AND METHODS

Observational study of 209 hypertensive patients, aged 18 to 85 years who wore at entry a CGMS. Two CGMS metrics, percent of time under the 100 mg/dL glycaemic threshold (TU100) (impaired fasting glucose surrogate phenotype) and area above the 140 mg/dL glycemic threshold (AO140) (impaired glucose tolerance surrogate phenotype) were measured. The median follow-up was 32 months (6-72 mo), and there were 17 new cases of T2DM.

RESULTS

In a multivariate Cox proportional hazard survival analysis including the conventional prediabetes-defining criteria and the 2 CGMS-derived variables, only TU100 and HbA_1c were significant and independent variables in predicting T2DM development. An increase in 0.1 in TU100 resulted in a 0.69 (95% CI, 0.54-0.88; P < .01) odds ratio of developing T2DM. With cut-off points of 0.5 for TU100 and 5.7% for HbA_1c , the test "TU < 0.5 and HbA_1c  > 5.7%" had a sensitivity of 0.81 (SD, 0.10), a specificity of 0.83 (SD, 0.03), and a likelihood ratio of 4.82 (SD, 1.03) for T2DM development.

CONCLUSIONS

Continuous glucose monitoring system allows for a better T2DM risk-development categorization than fasting glucose and HbA_1c in a high-risk population. Continuous glucose monitoring system-derived phenotyping reveals clinical differences, not disclosed by conventional fasting plasma glucose/HbA_1c categorization. These differences may correlate with distinct pathophysiological mechanisms.

Diabetes and pancreatic neuroendocrine tumours: Which interplays, if any?

Pancreatic neuroendocrine tumours (PanNETs) represent an uncommon type of pancreatic neoplasm, whose incidence is increasing worldwide. As per exocrine pancreatic cancer, a relationship seems to exist between PanNETs and glycaemic alterations. Diabetes mellitus (DM) or impaired glucose tolerance often occurs in PanNET patients as a consequence of hormonal hypersecretion by the tumour, specifically affecting glucose metabolism, or due to tumour mass effects. On the other hand, pre-existing DM may represent a risk factor for developing PanNETs and is likely to worsen the prognosis of such patients. Moreover, the surgical and/or pharmacological treatment of the tumour itself may impair glucose tolerance, as well as antidiabetic therapies may impact tumour behaviour and patients outcome. Differently from exocrine pancreatic tumours, few data are available for PanNETs as yet on this issue. In the present review, the bidirectional association between glycaemic disorders and PanNETs has been extensively examined, since the co-existence of both diseases in the same individual represents a further challenge for the clinical management of PanNETs.

Diabetes in South Asians: Phenotype, Clinical Presentation, and Natural History

PURPOSE OF REVIEW

South Asia is one of the epicenters of the global diabetes pandemic. Diabetes in south Asians has certain peculiar features with respect to its pathophysiology, clinical presentation, and management. This review aims to summarize some of the recent evidence pertaining to the distinct diabetes phenotype in south Asians.

RECENT FINDINGS

South Asia has high incidence and prevalence rates of diabetes. The progression from "pre-diabetes" to diabetes also occurs faster in this population. Pancreatic beta cell dysfunction seems to be as important as insulin resistance in the pathophysiology of diabetes in south Asians. Recent evidence suggests that the epidemic of diabetes in south Asia is spreading to rural areas and to less affluent sections of society. Diabetes in south Asians differs significantly from that in white Caucasians, with important implications for prevention, diagnosis, and management.

Phenotypic and metabolic dichotomy in obesity: clinical, biochemical and immunological correlates of metabolically divergent obese phenotypes in healthy South Asian adults

INTRODUCTION

Metabolic heterogeneity among obese individuals is thought to translate into variations in cardiovascular risk. Identifying obese people with an unfavourable metabolic profile may allow preventive strategies to be targeted at high-risk groups. This study aimed to identify clinical, biochemical and immunological differences between insulin-sensitive and insulin-resistant obese subgroups, to understand the population-specific pathophysiological basis of the adverse cardiovascular risk profile in the latter group.

METHODS

Cardiovascular risk indicators, including anthropometric parameters, blood pressure, acanthosis nigricans area, and related biochemical, endocrine and inflammatory markers, were determined in 255 healthy South Asian volunteers aged 18-45 years, with a 2:1 ratio of obese/overweight to normal-weight individuals. Lifetime atherosclerotic cardiovascular disease (ASCVD) risk was also calculated.

RESULTS

Body mass index (BMI) and insulin sensitivity-based tertiles independently showed incremental trends in waist-hip ratio, skinfold thickness, acanthosis nigricans area, blood pressure, serum lipids, hepatic enzymes, adipokines, inflammatory markers and ten-year ASCVD risk. The anthropometric, biochemical and inflammatory parameters of obese insulin-sensitive and obese insulin-resistant groups differed significantly. Extreme group analysis after excluding the middle tertiles of both insulin resistance and BMI also showed significant difference in anthropometric indicators of cardiovascular risk and estimated lifetime ASCVD risk between the two obese subgroups.

CONCLUSION

Obese insulin-sensitive individuals had a favourable metabolic profile compared to the obese insulin-resistant group. The most consistent discriminative factor between these phenotypic classes was anthropometric parameters, which underscores the importance of clinical parameters as cardiovascular risk indicators in obesity.

Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Globally, the number of people with diabetes mellitus has quadrupled in the past three decades, and diabetes mellitus is the ninth major cause of death. About 1 in 11 adults worldwide now have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Asia is a major area of the rapidly emerging T2DM global epidemic, with China and India the top two epicentres. Although genetic predisposition partly determines individual susceptibility to T2DM, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic; early developmental factors (such as intrauterine exposures) also have a role in susceptibility to T2DM later in life. Many cases of T2DM could be prevented with lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation. Most patients with T2DM have at least one complication, and cardiovascular complications are the leading cause of morbidity and mortality in these patients. This Review provides an updated view of the global epidemiology of T2DM, as well as dietary, lifestyle and other risk factors for T2DM and its complications.

Association between the ratio of triglyceride to high-density lipoprotein cholesterol and incident type 2 diabetes in Singapore Chinese men and women

BACKGROUND

Increased triglycerides (TG) and decreased high-density lipoprotein cholesterol (HDL-C) are risk factors for type 2 diabetes (T2D). The relationship between TG:HDL-C ratio and T2D risk is not clear, and it is not known whether the association is modified by gender, body mass index, or fasting status. This study examined the relationship between TG:HDL-C ratio and risk of incident T2D, and the predictive ability of the ratio on top of other diabetes risk factors.

METHODS

Blood biomarkers were determined in 571 T2D cases and 571 controls nested within a prospective, population-based cohort study, the Singapore Chinese Health Study. Participants were free of diagnosed diabetes, cardiovascular disease, and cancer at the time of blood collection (1999-2004). Incident self-reported T2D cases were identified at follow-up interview (2006-10). Controls were matched 1:  1 for age, sex, dialect group, and date of blood collection. Multivariable logistic regression was used to compute the odds ratio (OR) and 95 % confidence interval (CI).

RESULTS

The ORs (95 % CI) of T2D per 1-SD increment in TG and TG:  HDL-C ratio were 1.70 (1.39-2.09) and 1.72 (1.37-2.17), respectively. The relationships were stronger among females than males (P_interaction  = 0.028 and 0.017, respectively), and stronger among lean (<23 kg/m² ) than overweight/obese participants (P_interaction  = 0.051 and 0.046, respectively). Both TG and TG:  HDL-C improved T2D prediction to a similar degree.

CONCLUSIONS

Both TG and TG:HDL-C ratio are independent risk factors for incident T2D, and confer greater risk in women and lean participants. The TG:  HDL-C ratio is not a better predictor of diabetes than TG alone.

Risk factors for low high-density lipoprotein among Asian Indians in the United States

AIM

To examine the differences in metabolic risk factors (RFs) by gender in the Asian Indian (AI) population in the United States.

METHODS

Using cross-sectional data from 1038 randomly selected Asian Indians, we investigated the relationship between metabolic syndrome (MetS) RFs, cardiovascular disease, and diabetes.

RESULTS

A greater percent of women in this group had increased waist circumference and low high density lipoprotein (HDL) levels than men, but AI males had increased blood glucose, increased blood pressure, and increased triglycerides compared to females. Those individuals who met the MetS criteria had increased cardiovascular disease. One of the biggest single RFs for cardiovascular disease and diabetes reported in the literature for AIs is low HDL.

CONCLUSION

Our results show that lack of knowledge about diabetes, low physical activity, increased body mass index, and age were the factors most significantly correlated with low HDL in this population. Future studies and prospective trials are needed to further elucidate causes of the MetS and diabetes in AIs.

Type 2 Diabetes: Demystifying the Global Epidemic

Type 2 diabetes (T2D) has attained the status of a global pandemic, spreading from affluent industrialized nations to the emerging economies of Asia, Latin America, and Africa. There is significant global variation in susceptibility to T2D, with Pacific Islanders, Asian Indians, and Native Americans being considerably more prone to develop the disorder. Although genetic factors may play a part, the rapidity with which diabetes prevalence has risen among these populations reflects the far-ranging and rapid socioeconomic changes to which they have been exposed over the past few decades. Traditionally, obesity and its correlate, insulin resistance, have been considered the major mediators of T2D risk; however, recent evidence shows that early loss of β-cell function plays an important role in the pathogenesis of T2D, especially in nonobese individuals such as South Asians. Knowledge of the modifiable risk factors of T2D is important, as it forms the basis for designing cost-effective preventive and therapeutic strategies to slow the epidemic in populations at increased risk. Lessons learned from randomized prevention trials need to be implemented with appropriate cultural adaptations, accompanied by empowerment of the community, if the diabetes epidemic is to be slowed or halted.

Primary care for diabetes mellitus patients from the perspective of the care model for chronic conditions

Objective

to assess the health care Primary Health Care professionals provide to diabetes mellitus patients from the perspective of the Modelo de Atenção às Condições Crônicas.

Method

qualitative study, using the theoretical framework of Complex Thinking and the Modelo de Atenção às Condições Crônicas and the methodological framework of assessment research. To collect the data, 38 interviews were held with health professionals and managers; observation of the activities by the health teams; and analysis of 25 files of people who received this care. The data analysis was supported by the software ATLAS.ti, using the directed content analysis technique.

Results

at the micro level, care was distant from the integrality of the actions needed to assist people with chronic conditions and was centered on the biomedical model. At the meso level, there was disarticulation among the professionals of the Family Health Strategy, between them and the users, family and community. At the macro level, there was a lack of guiding strategies to implement public policies for diabetes in care practice.

Conclusion

the implementation of the Modelo de Atenção às Condições Crônicas represents a great challenge, mainly needing professionals and managers who are prepared to work with chronic conditions are who are open to break with the traditional model.

Macular thicknesses and their associations with ocular and demographic variables in black South Africans

Purpose: To determine normal macular thicknesses and their associations with demographic and ocular variables in healthy eyes of black South Africans.Methods: Six hundred healthy subjects (N = 600) underwent height and weight measurements followed by a complete ophthalmic examination, which included auto-refraction, subjective refraction, slit-lamp biomicroscopy, ocular biometric measurements and tonometry. Intraocular pressure (IOP) was measured with the Nidek NT530P (Tonopachy™) and the axial length (AL) thickness with the Nidek Echoscan. The central corneal thickness (CCT) and macular thickness were measured using iVue-100 spectral-domain optical coherence tomography (Optovue, Inc.). The macular thickness map protocol that divides the macular area into nine regions of the Early Treatment Diabetic Retinopathy Study (ETDRS) fields was used. Variations in macular thickness measurements with body mass index (BMI), age, gender, refraction, AL, CCT and IOP were determined with partial correlation analysis.Results: The 600 subjects had a mean age of 28.15 ± 13.09 years (range = 10–66 years), with 305 (50.83%) being males and 295 (49.17%) females. The thickness values of the central, inner and outer maculae were normally distributed, with means of 235.89 µm ± 20.04 µm, 303.56 µm ± 18.68 µm and 287.81 µm ± 14.61 µm, respectively. Mean total macular thickness for all subjects was 268.72 ± 15.04 µm. The temporal quadrant was markedly thinner than all other quadrants for both inner and outer macular regions. Macular thicknesses were greater in men than in women (p < 0.05). The thickness of mean central, mean inner and mean outer maculae increased significantly with increasing BMI (p < 0.001). Central, inner and outer maculae were significantly associated (p < 0.001) with a high hyperopic spherical equivalent refraction. AL was associated with a thin inner macula (p < 0.05) and an outer macula (p < 0.001), but not with a thinner central macula (p > 0.05). Age, CCT and IOP were not associated with macular thickness values in any quadrant (p > 0.05).Conclusion: The macular values were thinner in women than in men and were related to BMI, gender, hyperopic spherical refraction and AL with regional variations. These differences should be considered when interpreting optical coherence tomography results for accurately diagnosing and managing retinal abnormalities.