Weight change and microvascular outcomes in patients with new-onset diabetes: a nationwide cohort study

Trajectories of Body Mass Index and Risk for Diabetes Complications and All-Cause Mortality in Finnish Type 2 Diabetes Patients

Objective

We aimed to assess how longitudinal body mass index (BMI) trajectories are associated with diabetes complications and all-cause mortality in Finnish patients with type 2 diabetes (T2D).

Methods

In this cohort study, electronic health records from public primary and specialized healthcare services in all 13 municipalities of North Karelia, Finland, were utilized. This study included a total of 889 adults with newly diagnosed T2D in 2011 or 2012 (mean age at baseline 62.0 years). Individual BMI trajectories from the T2D diagnosis until 2014 were estimated and grouped by growth mixture modeling (GMM). Hazard ratios (HRs) with 95% confidence intervals (CIs) for microvascular complications, macrovascular complications, any diabetes complications, and all-cause mortality from 2015 to 2022 across BMI trajectory groups were estimated using Cox regression models.

Results

Three distinct BMI trajectory groups were identified using GMM and labeled as follows: "stable" (n = 774, 87.1%), "decreasing" (n = 87, 9.8%), and "increasing" (n = 28, 3.1%). During a median follow-up of 8 years, there were 119 (13.3%) patients with microvascular complications, 187 (21.0%) with macrovascular complications, 258 (29.0%) with any diabetes complications, and 180 (20.2%) deaths. Compared with the "stable" BMI, the "increasing" BMI was associated with an increased risk of microvascular complications (HR = 2.88, 95% CI: 1.32 to 6.28), macrovascular complications (HR = 2.52, 95% CI: 1.17 to 5.43), and any diabetes complications (HR = 2.21, 95% CI: 1.16 to 4.20). The "decreasing" BMI was associated with an increased risk of all-cause mortality (HR = 1.90, 95% CI: 1.14 to 3.15), compared to the "stable" BMI.

Conclusion

Our findings underscore the significance of continuous BMI monitoring and weight management in patients with T2D. Tailored treatments are crucial for efficiently preventing weight gain and reducing the risk of diabetes complications.

Treat Obesity to Treat Type 2 Diabetes Mellitus

Obesity, a multifactorial, relapsing chronic disease, serves as a gateway to a spectrum of metabolic, cardiovascular, mechanical and mental health problems. Over the last few decades, the global prevalence of obesity has surged nearly threefold, mirroring the escalating rates of type 2 diabetes mellitus (T2DM). This parallel trajectory strongly suggests a cause-and-effect relationship between obesity and T2DM. Extensive research indicates that even modest weight gain elevates the risk of T2DM, favoring the notion of obesity being a root cause. This perspective finds robust support in numerous studies demonstrating the preventive effects of obesity management on the onset of T2DM. Beyond prevention, obesity management has been shown to enhance remission in individuals with T2DM and to decrease microvascular complications, cardiovascular risk factors, renal failure and heart failure. This evidence underpins the urgent need for global initiatives aimed at addressing obesity management as a key strategy in the prevention and management of T2DM and its complications.

Excessive generalized and visceral adiposity is associated with a higher prevalence of diabetic retinopathy in Caucasian patients with type 2 diabetes

BACKGROUND AND AIMS

Type 2 Diabetes Mellitus (T2D) has heterogeneous clinical phenotypes related to different risk of developing diabetes complications. We investigated the correlation between generalized and abdominal adiposity and the prevalence of both micro- and macrovascular complications in Caucasian patients with T2D.

METHODS AND RESULTS

We evaluated 769 individuals with T2D consecutively referred to our diabetes center. Body mass index (BMI), waist circumference (WC), waist to hip (W/H) ratio, glycated hemoglobin (HbA1c), systolic and diastolic blood pressure, lipid profile, smoking habit, diabetes therapy, and micro- and macrovascular complications were recorded. Patients were divided into three groups based on BMI and WC: non-obese with normal WC (nWC, n = 220), non-obese with excess of abdominal fat (AF, n = 260) and obese (Ob, n = 289). We found that nWC, compared with AF and Ob individuals, were predominantly males (p<0.01), had lower HbA1c (p<0.01), diastolic blood pressure (p<0.01), triglycerides (p<0.01), and showed a significantly lower prevalence of diabetic retinopathy (DR) (p = 0.01). The rate of proliferative DR was significantly higher in Ob (13.2 %) compared to the other groups (p = 0.03). Multivariate analyses showed a significantly decreased prevalence of DR in nWC compared to both AF (OR 0.58, 95 CI 0.34-0.96; p = 0.03) and Ob (OR 0.57, 95 CI 0.33-0.98; p = 0.04) individuals. Conversely, DR was associated, mainly in women, to higher WC and W/H ratio. The prevalence of the other diabetes-related complications was similar among the studied groups.

CONCLUSIONS

In our population, nWC subjects showed a lower prevalence of DR. An increased generalized and abdominal adiposity was associated to a higher prevalence of DR, especially among females.

Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study

OBJECTIVE

This study aimed to investigate the associations between concurrent atrial fibrillation and diabetes-related complications among patients with diabetes.

RESEARCH DESIGN AND METHODS

This nationwide observational cohort study used the health checkup database from the Korean National Health Insurance Service. Patients diagnosed with diabetes who underwent health checkups between 2009 and 2012 were investigated. The patients with atrial fibrillation were matched in a 1:5 ratio with those without atrial fibrillation using propensity scores. Study outcomes included macrovascular, microvascular (diabetic retinopathy and diabetic nephropathy), and diabetic foot complications. The risks of clinical outcomes were measured using hazard ratios (HRs) with 95% CIs.

RESULTS

A total of 65,760 patients with diabetes were analyzed (54,800 without atrial fibrillation and 10,960 with atrial fibrillation). After well-balanced propensity score matching, atrial fibrillation was associated with significantly higher risks of macrovascular complications (HR 1.12, 95% CI 1.09-1.16), diabetic nephropathy (HR 1.23, 95% CI 1.16-1.30), and diabetic foot complications (HR 1.13, 95% CI 1.09-1.17) compared with no atrial fibrillation, while the risk of diabetic retinopathy was comparable (HR 0.99, 95% CI 0.96-1.03). Patients with atrial fibrillation had a significantly higher risk of diabetic foot amputation (HR 4.12, 95% CI 1.98-8.56).

CONCLUSIONS

Among patients with diabetes, concurrent atrial fibrillation was associated with increased risks for diabetes-related macrovascular complications, diabetic nephropathy, and diabetic foot. Such patients require holistic management to reduce the risk of adverse outcomes.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Adherence to healthy lifestyle behaviors as a preventable risk factor for severe hypoglycemia in people with type 2 diabetes: A longitudinal nationwide cohort study

AIMS/INTRODUCTION

We investigated the associations between a combination of lifestyle factors and changes to these factors and the subsequent risk of severe hypoglycemia (SH) in type 2 diabetes patients.

MATERIALS AND METHODS

Individuals with adult type 2 diabetes who underwent consecutive 2-year interval health screening programs from 2009 to 2012 from the Korean National Health Insurance Service database were included and followed up until 2018. Information on history of smoking status, alcohol consumption and physical activity, as well as changes to these factors, was obtained. The primary outcome was incident SH.

RESULTS

Of the 1,490,233 type 2 diabetes patients, 30,539 (2.1%) patients developed SH. Current smokers and heavy drinkers had increased risk of SH, compared with non-smokers and non-drinkers, respectively (hazard ratio 1.28, 95% confidence interval 1.23-1.34; hazard ratio 1.22, 95% confidence interval 1.15-1.30). However, regular physical activity was associated with reduced SH risk (hazard ratio 0.79, 95% confidence interval 0.77-0.82). A combination of unhealthy lifestyle habits was associated with increased SH risk in a dose-dependent fashion (P for trend <0.001). Compared with participants without changes in their unhealthy lifestyles, participants who improved lifestyles had decreased risk of SH.

CONCLUSIONS

Greater adherence to healthy lifestyle factors and any improvement in unhealthy lifestyle habits were associated with a substantially lower risk of SH in individuals with type 2 diabetes.

The Risks of Cardiovascular Disease Following Weight Change in Adults with Diabetes: A Cohort Study and Meta-analysis (jc.2022-01089)

CONTEXT

Weight management is recognized as critical in reducing cardio-metabolic risk factors for adults with diabetes, but the effects of weight change on cardiovascular disease in patients with diabetes are unknown.

OBJECTIVE

To evaluate 18-month weight change and subsequent risk of macrovascular and microvascular complications in established individuals with type 2 diabetes.

DESIGN AND SETTING

This study consisted of a cohort study and a meta-analysis. In the cohort study, weight change over 18 months was divided into: gain ≥5%, gain 1%-5%, stable (-1%-1%), loss 1%-5%, and loss ≥5%. Cox regression analyses were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). We then used random-effect models to pool the results combing our study with other relevant studies.

RESULTS

In the cohort study, 8920 participants with valid weight measurements were included. Compared with patients with stable weight, higher risks were seen in those with weight change for total vascular complications (gain ≥5%: HR=1.43, 95% CI: 1.10-1.85; gain 1-5%: HR=1.44, 95% CI: 1.02-2.03; loss ≥5%: HR=1.58, 95% CI: 1.20-2.08), macrovascular complications (gain ≥5%: HR=1.84, 95% CI: 1.16-2.91; loss 1-5%: HR=1.91, 95% CI: 1.06-3.43; loss ≥5%: HR=2.18, 95% CI: 1.36-3.49) and microvascular complications (loss ≥5%: HR=1.48, 95% CI: 1.06-2.06). Meta-analysis also showed similar results.

CONCLUSIONS

Weight gain and loss over 18 months among patients with type 2 diabetes, especially weight change ≥5%, may be a warning sign of adverse cardiovascular outcomes.

Duration of diabetes mellitus and risk of kidney and bladder cancer: a longitudinal nationwide cohort study

Previous studies have suggested that diabetes mellitus (DM) may increase the risk of kidney and bladder cancer; however, little is known about the duration of DM. We aimed to analyze the risk of kidney and bladder cancer according to the duration of DM in a longitudinal nationwide cohort. This study was conducted in a cohort of 9,773,462 participants ≥ 20 years old who underwent a National Health Examination in 2009 and were followed up until December 2017. Cox-proportional hazard models were used to evaluate the risk of kidney and bladder cancer in relation to the duration of DM. During follow-up (mean 7.3 years), kidney and bladder cancer occurred in 11,219 and 13,769 participants, respectively. DM was associated with an increased risk of kidney and bladder cancer (hazard ratio (HR), 95% confidence interval (95% CI); 1.14, 1.09-1.20 and 1.23, 1.17-1.28, respectively). Compared to fasting glucose < 100 mg/dL, impaired fasting glucose (IFG) and longer DM duration were associated with increased risks (HR, 95% CI): IFG (1.05, 1.01-1.10), new-onset DM (1.13, 1.03-1.24), DM < 5 years (1.11, 1.02-1.20), and DM ≥ 5 years (1.25, 1.15-1.36) in kidney cancer; IFG (1.05, 1.01-1.09), new-onset DM (1.10, 1.01-1.19), DM < 5 years (1.26, 1.18-1.35), and DM ≥ 5 years (1.34, 1.26-1.43) in bladder cancer, respectively. Our findings suggest that the subjects with IFG and longer duration of DM had a higher risk for kidney and bladder cancer than those without DM.

Underweight and Weight Change Increases End-Stage Renal Disease Risk in Patients with Diabetes: A Nationwide Population-Based Cohort Study

Weight variability has known as a risk factor for cardiovascular events and mortality. However, its effect on end-stage renal disease (ESRD) development remains controversial. We investigated the relationship between weight change and ESRD risk. Overall, 97,029 patients with DM aged >20 years were selected from the Korean National Health Screening Program 2009–2012. Weight change was defined as differences in body weight from the index year to 2 years later. Newly diagnosed ESRD was observed until 2017 end. Over a 5.1-year median follow-up period, ESRD was newly diagnosed in 7932 (4.81%) DM patients. BMI < 18.5 kg/m² and waist circumferences <85/80 and >100/95 cm were ESRD risk factors. ESRD risk increased with increasing weight change; ≥10% weight loss (hazard ratio [HR], 1.247) followed by ≥10% weight gain (1.247) was associated with a higher HR than ≤5% weight change after adjusting for several confounding factors. The association between weight change and ESRD risk in a subgroup analysis was significantly stronger in patients aged <65 years, without proteinuria, with BMI ≥ 25, with DM duration <5 years, and prescribed less than 3 classes of DM medication. Underweight patients showed higher ESRD risks than overweight patients. Weight loss >10% was associated with the fastest decline in renal function.

Chronic venous disease and diabetic microangiopathy: pathophysiology and commonalities

Chronic venous disease and diabetes mellitus are highly prevalent and debilitating conditions affecting millions of individuals globally. Although these conditions are typically considered as separate entities, they often co-exist which may be important in both understanding their pathophysiology and determining the best treatment strategy. Diabetes mellitus is twice as common in patients with chronic venous disease compared with the general population. Notably, a large proportion of patients with diabetes mellitus present with venous disorders, although this is often overlooked. The etiology of chronic venous disease is multifactorial, involving hemodynamic, genetic, and environmental factors which result in changes to the venous endothelium and structural wall as well as inflammation. Inflammation, endothelial dysfunction and hyperfiltration or leakage, are commonly observed in diabetes mellitus and cause various diabetic microvascular complications. Both diseases are also influenced by the increased expression of adhesion molecules, chemokines, and cytokines, and are characterized by the presence of vessel hypertension. Consequently, despite differences in etiology, the pathophysiology of both chronic venous disease and diabetic microangiopathy appears to be driven by endothelial dysfunction and inflammation. Treatment strategies should take the co-existence of chronic venous disease and diabetic microangiopathy into account. Compression therapy is recommended in inflammatory conditions that have an edema component as seen in both chronic venous disease and diabetes mellitus. Lifestyle changes like weight loss and exercise, will improve metabolic state and lower inflammation and should be promoted in these patients. Additionally, both patient populations may benefit from venoactive drugs.